Prostate cancer is currently the most prevalent form of cancer in men and the second leading cause of can-cer death in the United States, and the third most common cancer in men worldwide. Increasing mor-tality rates due to Prostate carcinoma have been ob-served worldwide. This disease usually progresses im-perceptibly; thus, patients are unlikely to seek medi-cal help during the early stages. For these reasons, screening programs aimed at early detection have been developed. The Prostate-specific antigen (PSA) test is among the best screening tools available in medicine today and is recognized as the best marker for its early detection. Prostate cancers detected by DRE method alone are clinically localized only 50% to 60% of the time, whereas PSA-detected tumors are clinically localized 90% of the time and pathologi-cally confined to the Prostate as determined at Prostatectomy about two thirds of the time. Recently, the detection of localized Prostate cancers has improved, owing to the development of various new Biopsy methods. However, a standard Biopsy method, including number of cores, has not yet been established at present. When screening results indi-cate the possibility of Prostate cancer, a pathologic diagnosis may be pursued by ultrasound guided trans-rectal needle Biopsy. Prostate Biopsy is usually ad-vised if serum PSA is >4 ng/mL, and this procedure remains the gold standard for Prostate cancer diagno-sis. Fine needle Biopsy is less painful than core bi-opsy, but also less diagnostically accurate. Systematic Biopsy protocols: In 1989, Hodge et al. coined the sextant Biopsy method that is still the standard of reference in Prostate cancer detection. The Prostate is bilaterally divided into three regions (apex, midgland, and base), all of which are system-atically biopsied once. Although Hodge et al. first proposed sextant Biopsy under transrectal ultrasound guidance, some recent reports have indicated that systematic sextant Biopsy might be inadequate for cancer detection. In a standard transrectal ultrasonography (TRUS)-guided Biopsy, a specimen is removed with a Biopsy gun from any suspicious areas, followed by tissue cores from the base, mid-zone, and apical areas of the right and left lobes (sextant Biopsy). However, de-pending on Prostate volume, up to 18 cores can be obtained covering all Prostate areas. Analysis of tumor histology using the Gleason grad-ing system provides some index of prognosis and may also guide local therapy. However, the sensitivity of the standard sextant Biopsy may be suboptimal with false negative rates of approximately 20%. Accord-ingly, to further increase the diagnostic accuracy of Prostate cancer, several investigators have recom-mended more extensive sampling of Biopsy cores; however, there are several issues to be elucidated for establishing optimal Biopsy strategy, such as the number and regions of Biopsy cores to be taken. It has been reported that 20-30% of Prostate cancers origi-nate the transition zone. Currently, it is well accepted that TRUS-guided transition zone biopsies are useful in patients exhibiting elevated serum PSA levels with an enlarged, non-nodular Prostate and patients un-dergoing prior sextant biopsies. In general, the most common procedure for Prostate cancer detection is the transrectal approach. Al-though the transperineal approach is not commonly used worldwide, some groups perform Prostate Biopsy using only this approach especially in European and Asian countries, but there are few data on transperin-eal Prostate Biopsy. Several studies have suggested that microvascularity is an essential requirement in the progression of Prostate carcinoma. Trans-rectal ultrasound (TRUS)-guided systematic Biopsy of the Prostate is the standard technique for the diagnosis of Prostate cancer. Tumors larger than 1 mm in diame-ter must form new blood vessels to grow larger. This neovascularity is expected to give rise to detectable flow using the Doppler principle. Focal peripheral zone hypervascularity at color Dop-pler ultrasonography is associated with an increased likelihood of Prostate cancer or inflammation at bi-opsy, often without a focal gray-scale abnormality. Color Doppler ultrasonography may help identify an appropriate site for Biopsy. A negative color Doppler ltrasonography scan, however, should not preclude Biopsy, as color Doppler ultrasonography has a lim-ited sensitivity in the detection of all sites of cancer. Targeting of hypoechoic lesions Gray-scale imaging allows for an excellent anatomical delineation of the Prostate gland in relation to the surrounding fat tis-sue, rectum, neurovascular bundles, and venous plex-us, as well as a clear division between the inner gland (transition and central zone) and outer gland (periph-eral zone) of the Prostate. In the early 1980s, hypoechoic nodules were seen as the main presentation of Prostate cancer, and solely these nodules were targeted at Biopsy. The hypoechoic appearance is believed to be due to the increased microvessel density. However, up to 30% of all Prostate cancers are isoechoic, and it is estimated that a hypoechoic nodule has a 17-57% chance of being identified as Prostate cancer. Presently, in the PSA era, this percentage is reported to be as low as 9%. Contrast-enhanced US of the Prostate with ultra-sound contrast agents can improve sensitivity for the detection of cancers in the outer gland, but it can also demonstrate focal enhancement in areas of benign hyperplasia. Contrast-enhanced transrectal ultrasonography im-proves the sonographic detection of malignant foci in the Prostate. The performance of multiple biopsies of suspicious enhancing foci significantly improves the detection of cancer. The purpose of this review is to describe the various techniques of TRUS-guided Prostate Biopsy that are currently applied in radiological practice and to com-pare the diagnostic performance of systematic Biopsy with imaging-guided techniques such as gray-scale, color, and power Doppler as well as contrast-enhanced imaging.

Background and Aims: Trans-rectal ultrasound guided Prostate Biopsy (TRUS) remains the gold standard to diagnose patients with Prostate cancer. The purpose of this study is to prospectively evaluate the efficacy of diclofenac suppository versus diclofenac patch as compared to placebo, on pain reduction during Prostate Biopsy.Methods: A prospective, randomized, single-blind, placebo controlled study was performed in 73 patients requiring transrectal ultrasound guided Prostate Biopsy (TRUS). Patients were randomly allocated to receive 100 mg diclofenac suppository or 100 mg diclofenac patch or matching placebo 1 hour prior to the procedure.They were asked to indicate on a 10 cm visual analogue scale the degree of discomfort during probe insertion, needle penetration and four hours post Biopsy. Statistical analysis was done using one way ANOVA. The data was analyzed using SPSS version 10.0.Results: Patients given diclofenac suppository and diclofenac patch had statistically significant lower four hour pain scores than those who were given placebo. There was no statistically significant difference in the pain scores between the three groups during probe insertion and needle penetration. The three groups were similar in regards to age, Prostate volume, Biopsy number, Prostate specific antigen levels, histological diagnosis and complication rate.Conclusions: Diclofenac in the form of a patch or suppository does not confer a superior intraprocedural analgesic effect compared to the placebo, but it reduces post procedural pain to a significant extent. We do not recommend its use as a single agent analgesic for Prostate Biopsy and it should be used as an adjunctive analgesic for reducing post procedural pain.

Purpose: We have previously demonstrated that transperineal template Prostate Biopsy (TPTPB) has a significantly higher cancer detection rate compared to transrectal ultrasound guided (TRUS) Biopsy in Biopsy naive men with a PSA < 20 ng/mL. We, therefore, performed a prospective study to determine whether TPTPB is still superior to TRUS Biopsy in the detection of Prostate cancer in men with persistently elevated PSA after one previous negative set of TRUS biopsies. Materials and Methods: 42 patients with a background of one previous negative set of TRUS Biopsy, persistently elevated PSA (but < 20 ng/mL) and benign feeling digital rectal examination (DRE) underwent simultaneous standard 12-core TRUS Biopsy and 36-core TPTPB under general anaesthesia. We determined the Prostate cancer detection rate between the two diagnostic modalities. Results: Mean age was 65 years (range: 50-75), mean Prostate volume was 59 cc (range: 21-152), mean PSA is 8. 3 ng/L (range: 4. 4-19), mean time difference between the study and the previous TRUS Biopsy was 33 months (range: 1-150) with mean PSA velocity of 0. 7 ng/mL/year (range: 0-8). Out of the 42 patients, 22 (52%) had benign pathology. Of the 20 patients (48%) diagnosed with Prostate cancer, 4 (10%) had positive results in both TRUS Biopsy and TPTPB, 1 (2%) had positive result in TRUS Biopsy with negative TPTPB, while 15 (36%) had negative TRUS Biopsy with positive TPTPB. Hence, TRUS Biopsy detected cancer in 5/42 (12%) patients versus (19/42) 45% detected by TPTPB (P < 0. 01). 13/19 (68%) of cancers detected by TPTPB had Gleason score ≥ 7. A total of 82/141 (58%) of positive cores was found in the anterior zone. One patient (2%) experienced urosepsis, 2 (5%) temporary urinary retention, 14 (34%) mild haematuria and 13 (32%) haematospermia. Conclusion: TPTPB still shows a significantly higher Prostate cancer detection rate compared to TRUS Biopsy (12% versus 45%, P < 0. 01) in men with a previous set of negative TRUS Biopsy, persistently elevated PSA (but < 20 ng/mL) and benign feeling Prostate on DRE.

Purpose: To examine the effect of routine sampling anterior apical cores in the initial Prostate Biopsy among patients that 14-cores of Prostate Biopsy (PB) planned. Materials and Methods: Five-hundred twenty-eight patients with increased Prostate-specific antigen (PSA) levels and/or abnormal digital rectal examination underwent transrectal ultrasound and initial PB between November 2012 and October 2013. We performed routine 12-cores extended PB, plus 2 anterior apex samples that were taken from the junction of urethra and apex of the Prostate. Site-specific and unique cancer detection rate, tumor characteristics, the presence of clinically insignificant Prostate cancer (PCa) (clinical stage ≤ T1, serum PSA level of < 10 ng/mL, Biopsy Gleason score ≤ 6, number of positive Biopsy cores ≤ 3 and no core with > 50% involvement) and Biopsy-related pain were evaluated. Results: PCa was detected in 147 of 451 patients (32. 6%). The lateral base of the Prostate was the most affected area with 128 of 451 patients (28. 3%), followed by unique cancer detection, with 17 of 40 patients (43. 5%). Anterior apex (n = 6) was in third place after the lateral apex (n = 8). The patients diagnosed by anterior apex cores were all clinically insignificant PCa. The cancer diagnosis rate would be 31% if 12-cores Biopsy was used, but the rate was found to be 32. 6% in 14-cores Biopsy (P =. 016). Average Biopsy pain, right anterior apex Biopsy pain, and left anterior apex Biopsy pain were found to register at 0. 61, 1. 06 and 1. 08 points in the visual analog scale pain score, respectively. When right and left anterior apex Biopsy pain is compared to average Biopsy pain, the pain level was found to be statistically significantly higher in the biopsies of right and left anterior apex (P =. 040 and P =. 042, respectively). Conclusion: The gold standard for the diagnosis of PCa is at least 8 cores PB. According to our results, although most PCa diagnosis is carried out with 14-cores PB, it should not be forgotten that these patients might have clinically insignificant PCa.