Prostate Biopsies and the Vienna Nomograms

Introduction and objective: Discordant data still persists regarding the optimal prostate biopsy scheme to be used, the correct timing for performing repeat biopsy in high risk patients as well as the ability of clinical variables to predict prostate cancer. The aim of this review is to provide a comprehensive assessment of different prostate biopsy approaches and to evaluate the role of clinical variables in predicting the presence of prostate cancer (PCa) at biopsy. Methods: Analysis of published full-length papers that were identified through Medline search from January 1980 through January 2006. Abstracts published in peer-reviewed journals from the same period were also considered. Results: Several groups have proposed new biopsy strategies, often increasing the number of biopsies and the sectors to be sampled or performing biopsies more laterally. However, controversial data have been reported about the real advantage of these new techniques. Moreover, several studies report that sextant biopsies still do not represent an appropriate tool for PCa detection, especially in large prostates. Our nomogram based on patient age and gland volume provides the minimum number of cores needed to accurately detect cancer and it is associated with a 90% sensistivity of PCa detection. Furthermore, several evidences report that, in case of negative initial biopsy, cancers detected on repeat biopsy have similar stage, grade distribution and total PSA values compared to cancers found on initial biopsy. On the contrary, cancers detected on third and fourth systematic biopsy show characteristics of ‘‘insignificant’’ cancers. Among the available clinical predictors, % free PSA and PSATransition Zone showed to be the best markers for repeat prostate biopsy, increasing sensitivity and specificity for prostate cancer detection. Conclusions: Traditional sextant biopsies might become obsolete in future designed trials since a body of evidence supports the findings that this technique is far from optimal in patients with large prostates. The combination of prostate size and patient age can help physicians in determining the most appropriate prostate biopsy sampling for PCa detection. Due to the high rate of insignificant prostate cancer detected, a systematic repeat biopsy after the second negative biopsy in a PSA range of 2.5–10 ng/ml is not indicated and PSA based watchful waiting should be advocated. Finally, % free PSA and PSATransition Zone should be included in predicting models for prostate cancer detection at repeat biopsy. # 2006 Published by Elsevier B.V.