Diagnostic yield of repeated transrectal ultrasound-guided biopsies stratified by specific histopathologic diagnoses and prostate-specific antigen levels

Objectives. To determine the diagnostic yield of secondary and tertiary transrectal ultrasound (TRUS)-guided biopsies of the prostate in men suspected of having carcinoma of the prostate because of an elevated serum prostate-specific antigen (PSA) level or an abnormal digital rectal examination (DRE). Methods. The pathology database at the Dallas Veterans Affairs Medical Center was retrospectively searched for patients who had undergone at least two TRUS-guided biopsies of the prostate within a 6-month time span. Pertinent demographic data, serum PSA, outcomes of the two (or more) biopsies stratified in six distinct histopathologic diagnoses, and Gleason grade if carcinoma of the prostate was identified, were entered into a database and analyzed. Results. A total of 123 men had at least two TRUS- guided biopsies, of which 22 had three biopsies. Mean age of this group was 68.5 ± 0.51 (SE), and mean PSA was 11.5 ± 1.07 (SE). Of 123 patients, 28 had a positive second biopsy following a negative first biopsy, for a positive biopsy rate of 23%. Only 2 of 22 patients who underwent a third biopsy were found to have carcinoma of the prostate, for a positive biopsy rate of 9%. The positive biopsy rate for the second biopsy was 19% (3 of 16) if the PSA was 4.0 ng/mL or less, 15% (10 of 66) if the PSA was between 4 and 10.0 ng/mL independent of the DRE findings, and 37% (15 of 41) if the PSA was 10.0 ng/mL or higher. Benign prostatic hyperplasia (59 of 123 [48%]) and atypia (38 of 123 [31%]) were the most common histopathologic diagnoses on the first biopsy, and the positive re-biopsy rates were similar for these two groups (25% versus 21%). Conclusions. An overall positive biopsy rate of 23% in our retrospective series of 123 men with a mean PSA of 11.5 ng/mL warrants the performance of a second biopsy independent of the histopathologic diagnosis made on the first (negative) biopsy, if the outcome of such biopsy would have therapeutic consequences for the patient. This policy should not be restricted to men with a PSA above the cutoff level of 4.0 ng/mL alone. Patients with atypia should be pursued aggressively, as even on a third biopsy the positive biopsy rate was 29%.