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EDITORIAL COMMENT

The original sextant biopsy technique described by Hodge et alcompared a sextant biopsy technique to directed biopsies in patientswith palpable abnormalities of the prostate (reference 1 in article).The overall detection rate was 66% and in 9% of cases the sextanttechnique discovered cancer that ultrasound directed biopsies didnot. This technique was then transferred to the larger population ofpatients with a palpably normal prostate and has been the mostcommonly used biopsy strategy for the last 10 years.

Urologists have traditionally taught and been taught that prostatecancer originates in the posterior portion of the prostate gland. It isnow clear that a significant number of tumors do not originate in theposterior gland. All too often patients present after undergoing mul-tiple sextant biopsies of the posterior peripheral zone of the prostateonly to have large volume, sometimes locally advanced cancer dis-covered in the anterior gland. It should not be too surprising inretrospect that most cancer noted has been in the posterior prostate.After all, it was only that portion of the prostate that we havescreened by rectal examination and it was that portion that we havebiopsied, whether with ultrasound directed or sextant biopsies. In ananalysis of Babaian using computer simulated biopsies of radicalprostatectomy specimens standard sextant biopsies missed 27% oftumors greater than 0.5 ml. in volume with those tumors located inthe transition zone, anterior horn of the lateral peripheral zone andmidline.1 There are now multiple lines of evidence that challenge thetraditional concept of the posterior origin of prostate tumors anddemonstrate the pitfalls of the sextant approach, including the series

of these authors. It is also now clear that obtaining more biopsiesyields a higher cancer detection rate, larger prostates need moreextensive sampling, and somewhere between 15% and 30% of tumorsreside in the far lateral and anterior horns of the peripheral zone orin the anterior prostate and transition zone. Regardless of the biopsytechnique, obtaining additional biopsies seems to increase the cancerdetection rate.

The technique used by these authors is limited because it fails tosample the more anterior portions of the prostate and it may in factbe over sampling the prostate of men with a smaller prostate glandor larger tumors. Eskew et al reported that increasing sampling byobtaining biopsies from the lateral and anterior horn of the prostatesignificantly increased the cancer detection rate in men with non-palpable disease and a PSA of 4 to 10 ng./ml. (reference 14 in article).It did not make a difference in men with larger volume disease, asdetermined by PSA, whether or not it was palpable. Large tumorsare simply easier to detect. Consequently it is my opinion thatroutinely obtaining 12 biopsies is not indicated in men with highPSA, a large palpable tumor or small prostate. In addition, samplingthe more anterior gland should be routinely considered. Obtainingextensive samples of the posterior peripheral zone would most cer-tainly detect a few additional tumors and also most likely detectsome small and potentially insignificant posterior tumors. Theseauthors did not report the size of the tumors detected by this tech-nique.

Whether transrectal or transperineal, the actual technique used isprobably much less important than where the needles are placed inthe prostate. I agree with the authors that extensive transrectalbiopsies may be uncomfortable for the patient and also agree thatadministering local anesthesia, as described by Soloway and Obek,may significantly decrease patient discomfort (reference 42 in arti-cle). Most urologists in the United States may continue to use thetransrectal approach because the available technology lends itself tothis approach. The transperineal approach seems to work well in theexperience of these authors.

At this point there would appear to be sufficient evidence thatmost urologists should no longer be routinely doing only sextantbiopsies, but instead more extensively sampling the posterior pros-tate in larger prostate glands, including far lateral and anterolateralbiopsies as well as transition zone biopsies in cases highly suspiciousfor cancer. The current series further confirms that the traditionalsextant technique under samples most prostate glands. Urologistsmust consider the whole prostate gland at risk for prostate cancerand approach the sampling techniques accordingly.

Michael O. KochDepartment of UrologyIndiana Cancer PavilionIndianapolis, IN 46202

1. Chen, M. E., Troncoso, P., Johnston, D. A. et al: Optimization ofprostate biopsy strategy using computer based analysis.J Urol, 158: 2168, 1997

REPLY BY AUTHORS

We agree that sextant biopsy technique cannot be considered thegold standard for prostate cancer detection anymore. We are awarethat 12 core transperineal biopsy provides excellent sampling of theperipheral zone, including far lateral areas, but it gives no informa-tion on anterior zone. We have experienced a few cases of negativebiopsy and extensive cancer at subsequent transurethral resection ofthe prostate or minimal disease at biopsy and large anterior cancerat radical prostatectomy. Our policy is now to add cores from theanterior zone when there is a hypoechoic area or routinely at secondbiopsy after a first negative biopsy in patients whose PSA is stillincreased. The anterior zone is easily reached by the transperinealapproach. However, it should be emphasized that transperineal bi-opsy requires a longer learning curve. Again, we agree that in smallprostates 12 cores are not strictly necessary but our aim was toevaluate the results of a standardized procedure.

VALUE OF BIOPSY WITH 12 TRANSPERINEAL CORES FOR DETECTING PROSTATE CANCER850