POWER DOPPLER ULTRASONOGRAPHY-DIRECTED PROSTATE BIOPSY IN MEN WITH ELEVATED SERUM PSA LEVELS: AN EVALUATION OF THE CLINICAL UTILITY AND LIMITATIONS SATORU TAKAHASHI, YUKIO YAMADA, YUKIO HOMMA, SHIGEO HORIE, YOSHIO HOSAKA, AND TADAICHI KITAMURA ABSTRACT Objectives. To determine the utility and limitations of power Doppler ultrasonography (PDU)-directed prostate biopsy in patients with elevated serum prostate-specific antigen (PSA) levels. Methods. A total of 108 men (mean age 67.7 years, range 50 to 86) with serum PSA levels of greater than 4.0 ng/mL were assessed using digital rectal examination (DRE), gray-scale transrectal ultrasonography (TRUS), and PDU. Prostate vasculature identified on PDU was judged using a grading system. Subsequently, these patients underwent systematic six-core transperineal biopsy and additional biopsies for positive sites on DRE, gray-scale TRUS, and PDU. Results. A hypervascular site and prostate cancer on PDU was identified in 43 (40%) and 40 (37%) cases, respectively. PDU-directed and systematic six-core biopsies could independently detect 36 and 30 cancer cases, respectively. The sensitivity of PDU for cancer detection was 90%, specificity 90%, positive predictive value 84%, negative predictive value 94%, and accuracy 90%. High test performance was also observed in 53 cases with serum PSA levels of 4.1 to 10 ng/mL (sensitivity 77%, specificity 88%, positive predictive value 67%, negative predictive value 92%, and accuracy 85%). These values were superior or comparable to those of DRE and gray-scale TRUS. Inflammatory reactions and prostatic calculi were probable major causes of false-positive and false-negative results on PDU, respectively. Conclusions. PDU can identify appropriate sites for biopsy and improve the cancer detection rate. However, PDU-directed biopsy does not appear to identify prostate cancer with sufficient accuracy to omit the systematic biopsy, and combined use of these methods should be preferable. UROLOGY 60: 248–252, 2002. © 2002, Elsevier Science Inc. T he detection of prostate cancer is generally based on digital rectal examination (DRE) and transrectal ultrasonography (TRUS) findings and serum prostate-specific antigen (PSA) determina- tion. 1,2 However, the frequency of positive biopsies for prostate cancer has remained low. Although TRUS is widely used to guide needle biopsy, its clinical utility has been compromised by an unsat- isfactory positive predictive value (PPV). 3 System- atic sextant biopsy under ultrasound monitoring generally demonstrates prostate cancer in 20% to 30% of men with serum PSA levels of 4.1 to 10 ng/mL and in 50% to 67% with PSA levels of more than 10 ng/mL. 4,5 In an attempt to overcome the limitations of the standard diagnostic methods, new techniques have been developed. Among them, color Doppler ultrasound (CDU) has been reported to be more sensitive than gray-scale im- aging. 6 However, fine blood flows in small cancer- ous lesions are difficult to identify. 7,8 Power Dopp- ler ultrasonography (PDU) has a theoretical advantage over CDU and allows for a better detec- tion of lower speed blood flow. 9 Several investiga- tions have suggested that PDU may better charac- terize hypoechoic lesions in the peripheral zone 10 and help identify appropriate sites for biopsy. 11–14 The present study was designed to investigate fur- From the Department of Urology, University of Tokyo Faculty of Medicine, Tokyo, Japan Reprint requests: Satoru Takahashi, M.D., Department of Urology, University of Tokyo Faculty of Medicine, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan Submitted: July 6, 2001, accepted (with revisions): March 11, 2002 ADULT UROLOGY © 2002, ELSEVIER SCIENCE INC. 0090-4295/02/$22.00 248 ALL RIGHTS RESERVED PII S0090-4295(02)01702-8