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Gleason underestimation is predicted by prostate biopsy core length



To evaluate whether core length impacts biopsy accuracy and Gleason score underestimation compared to radical prostatectomy (RP) specimens.


From 2010 to 2011, 8,928 cores were trans-rectal obtained from 744 consecutive patients (178 RP, 24 %), 557 by an experienced performer (>250/year) and 187 (25 %) by in-training urology residents. Prospectively analyzed variables were core length, age, prostate volume, free and total prostate-specific antigen (PSA), PSA density and free/total PSA ratio.


Mean core length for Gleason upgrading on RP (42.7 %, n = 76) was 11.61 (±2.5, median 11.40) compared to 13.52 (±3.2, median 13.70), p < 0.001 for perfect biopsy-RP Gleason agreement (57.3 %, n = 102). In multivariate analysis, for each unit of core length increment in millimeter, the Gleason upgrading risk decreased 89.9 %, p = 0.049 [odds ratio (OR) 0.10, 95 % confidence interval (CI) 0.01–0.99]. Biopsy positivity between experienced (35.5 %) and in-training performer (30.1 %) was not significantly different (p = 0.20), with comparable mean patient age (65.1 vs. 64.1), prostate volume (52.3 vs. 50.7) and median PSA (5.2 vs. 5.1), respectively. Denoting wider variability in terms of core length, in-training performers obtained significantly larger cores for positive biopsies (11.33 ± 3.42 vs. 10.83 ± 3.68), p = 0.043, compared to experienced performer (11.39 ± 3.36 vs. 11.37 ± 3.64), p = 0.30. In multivariate analysis, PSA density (OR 1.14, 95 % CI 1.02–1.28) and age (OR 1.04, 95 % CI 1.01–1.07) were significantly associated with biopsy positivity, p = 0.021 and p = 0.011, respectively.


While core length on trans-rectal biopsy independently affects Gleason upgrading on RP specimens, performer experience has minor impact on Gleason discordance or biopsy positivity due to a sharp learning curve.

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Fig. 1



Radical prostatectomy


Prostate volume


Prostate-specific antigen


American urological association


European association of urology


International society of urological pathology


European randomized study of screening for prostate cancer


Digital rectal examination


Odds ratio


Confidence interval


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We would like to thank Wagner França for help with data collection.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standard

Performed in accordance with the institutional ethical guidelines ethical standards laid down in the 1964 Declaration of Helsinki its later amendments.

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Correspondence to Leonardo O. Reis.

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Reis, L.O., Sanches, B.C.F., de Mendonça, G.B. et al. Gleason underestimation is predicted by prostate biopsy core length. World J Urol 33, 821–826 (2015).

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  • Prostate
  • Trans-rectal biopsy
  • Technique optimization
  • Cancer
  • Staging
  • Diagnosis
  • Gleason
  • Pathology report
  • Radical prostatectomy
  • Needle
  • Learning curve
  • Upgrading
  • Downgrading