Repeat Prostate Biopsies and the Vienna Nomograms

  • Bob Djavan
  • Sibylle Marihart
Part of the Current Clinical Urology book series (CCU)


Based on the Vienna nomograms, repeat prostate biopsy is indicated in patients with negative initial findings who have high-grade prostatic intraepithelial neoplasia, continue to have increasing abnormal prostate-specific antigen levels, or prostate volumes >45 cc and/or transition zone volumes >25 cc. The Vienna nomograms evaluate the minimum number of cores based on patient’s age and prostate gland volume required to ensure 90% certainty of cancer detection. The authors found that more than six biopsy cores are needed and that biopsies should be directed more laterally. Location and density measurements suggest that repeat biopsy should be directed in a more apico-dorsal location which is rather spared during initial biopsy. Current data suggest that cancers detected on repeat biopsy have a similar stage and grade distribution and total prostate-specific antigen values compared with cancers found on initial biopsy. Patients younger than 60 years of age need to be counseled regarding higher pain and discomfort during repeat biopsy. Local or topical anesthesia should be offered.


nomograms biopsy strategy repeat biopsy 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Djavan B, Susani M, Bursa B, Basharkhah A, Simak R, Marberger M. Predictability and significance of multifocal prostate cancer in the radical prostatectomy specimen. Tech Urol 1999;5(3):139–142.PubMedGoogle Scholar
  2. 2.
    Stamey TA. Making the most out of six systematic sextant biopsies. Urology 1995;45(1):2–12.CrossRefPubMedGoogle Scholar
  3. 3.
    Billebaud T, Villers A, Astier L, et al. Advantage of systematic random ultrasound-guided biopsies, measurement of serum specific antigen levels and determination of prostate volume in the early diagnosis of prostate cancer. Eur Urol 1992;21:6–14.PubMedGoogle Scholar
  4. 4.
    Vashi AR, Wojno KJ, Gillespie B, Oesterling JE. A model for the number of cores per prostate biopsy based on patient age and prostate gland volume. J Urol 1998;159:920–924.CrossRefPubMedGoogle Scholar
  5. 5.
    Karakiewicz PI, Aprikian AG, Meshref AW, Bazinet M. Computer-assisted comparative analysis of four-sector and six section biopsies of the prostate. Urology 1996;48:747–750.CrossRefPubMedGoogle Scholar
  6. 6.
    Karakiewicz PI, Hanley JA, Bazinet M. Three-dimensional computer-assisted analysis of sector biopsy of the prostate. Urology 1998;52:208–212.CrossRefPubMedGoogle Scholar
  7. 7.
    Ravery V, Billeband T, Toublanc M, et al. Diagnostic value of the systematic TRUS-guided prostate biopsies. Eur Urol 1999;35:298–303.CrossRefPubMedGoogle Scholar
  8. 8.
    Eskew AL, Bare RL, McCullongh DL. Systematic 5-region prostate biopsy is superior to sextant method for diagnosing carcinoma of the prostate. J Urol 1997;157:199–202.CrossRefPubMedGoogle Scholar
  9. 9.
    Bauer JJ, Zeng J, Weir J, et al. Three-dimensional computer-simulated prostate models: lateral prostate biopsies increase the detection rate of prostate cancer. Urology 1999;53:961–967.CrossRefPubMedGoogle Scholar
  10. 10.
    Chang JJ, Shinohara K, Bhargava V, Presti JC Jr. Prospective evaluation of lateral biopsies of the peripheral zone for prostate cancer detection. J Urol 1998;160:2111–2114.CrossRefPubMedGoogle Scholar
  11. 11.
    Norberg M, Egevad L, Holmberg L, Sparen P, Norlen BJ, Busch C. The sextant protocol for ultrasound-guided core biopsies of the prostate underestimates the presence of cancer. Urology 1997;50:562–566.CrossRefPubMedGoogle Scholar
  12. 12.
    Djavan B, Zlotta AR, Ekane S, et al. Is one set of sextant biopsies enough to rule out prostate cancer? Influence of transition and total prostate volumes on prostate cancer yield. Eur Urol 2000;38(2):218–224.CrossRefPubMedGoogle Scholar
  13. 13.
    Uzzo RG, Wei JT, Waldbaum RS, Perlmutter AP, Byrne JC, Vaughan ED. The influence of prostatic size on cancer detection. Urology 1995;46:831–836.CrossRefPubMedGoogle Scholar
  14. 14.
    Chen ME, Troncoso P, Johnston DA, Tang K, Babaian RJ. Optimization of prostate biopsy strategy using computer based analysis. J Urol 1997;158:2168–2175.CrossRefPubMedGoogle Scholar
  15. 15.
    Djavan B, Zlotta AR, Remzi M, et al. Total and transition zone prostate volume and age: how do they affect the utility of PSA based diagnostic parameters for early prostate cancer detection? Urology 1999;54(5):846–852.CrossRefPubMedGoogle Scholar
  16. 16.
    Djavan B, Zlotta AR, Byttebier G, et al. Prostate specific antigen density of the TZ for early detection of prostate cancer. J Urol 1998;160(2):411–418.CrossRefPubMedGoogle Scholar
  17. 17.
    Zlotta AR, Djavan B, Marberger M, Schulmann CC. Prostate specific antigen density of the transition zone: a new effective parameter for prostate cancer prediction. J Urol 1997;157:1315–1321.CrossRefPubMedGoogle Scholar
  18. 18.
    Levine MA, Ittman M, Melamed J, Lepor H. Two consecutive sets of transrectal ultrasound guided sextant biopsies of the prostate for the detection of prostate cancer. J Urol 1998;159:471–476.CrossRefPubMedGoogle Scholar
  19. 19.
    Letran JL, Meyer GE, Loberiza FR, Brawer MK. The effect of prostate volume on the yield of needle biopsy. J Urol 1998;160(5):1718–1721.CrossRefPubMedGoogle Scholar
  20. 20.
    Vashi AR, Wojno KJ, Gillespie B, Oesterling JE. A model for the number of cores per prostate biopsy based on patient age and prostate gland volume. J Urol 1998;159:920–924.CrossRefPubMedGoogle Scholar
  21. 21.
    Catalona WJ, Smith DS, Ratliff TD, et al. Measurement of prostate specific antigen in serum as a screening test for prostate cancer. New Engl J Med 1991;324:1156–1161.PubMedGoogle Scholar
  22. 22.
    Brawer MK, Chetner MP, Beatie J, Buchner DM, Vessella RL, Lange PH. Screening for prostatic carcinoma with prostate specific antigen. J Urol 1992;147(2):841–845.PubMedGoogle Scholar
  23. 23.
    Keetch DW, Catalona WJ. Prostatic TZ biopsies in men with previous negative biopsies and persistently elevated serum prostate specific antigen values. J Urol 1995;154:1795–1797.CrossRefPubMedGoogle Scholar
  24. 24.
    Djavan B, Zlotta AR, Remzi M, et al. Optimal predictors of prostate cancer in repeat prostate biopsy: a prospective study in 1051 men. J Urol 2000;163(4):1144–1148.CrossRefPubMedGoogle Scholar
  25. 25.
    Zlotta AR, Djavan B, Roumeguere T, Marberger M, Schulmann CC. Transition zone volume on transrectal ultrasonography is more accurate and reproducible than the total prostate volume. Br J Urol 1997;Suppl 80:A926.Google Scholar
  26. 26.
    Catalona WJ, Partin AW, Slawin KM, et al. Use of the percentage of free prostate-specific antigen to enhance differentiation of prostate cancer from benign prostatic disease. JAMA 1998;279:1542–1547.CrossRefPubMedGoogle Scholar
  27. 27.
    Chan DW, Sokoll LJ, Partin AW, et al. The use of %free PSA to predict prostate cancer probabilities: an eleven center prospective study using an automated immunoassay system in a population with nonsuspicious DRE. J Urol 1999;161(Suppl 4):A353.Google Scholar
  28. 28.
    Horninger W, Reissigl A, Klocker H, et al. Improvement of specificity in PSA-based screening by using PSA transition zone density and percent free PSA in addition to total PSA levels. Prostate 1998;37:133–139.CrossRefPubMedGoogle Scholar
  29. 29.
    Ukimura O, Durrani O, Babaian J. Role of PSA and its indices in determining the need for repeat prostate biopsies. Urology 1997;50:66–72.CrossRefPubMedGoogle Scholar
  30. 30.
    Letran JL, Blasé AB, Loberiza FR, et al. Repeat ultrasound guided prostate needle biopsy: use of free to total PSA ratio in predicting prostatic carcinoma. J Urol 1998;60:426–429.Google Scholar
  31. 31.
    Morgan TO, McLeod DG, Leifer ES, Murphy GP, Moul JW. Prospective use of free prostate-specific antigen to avoid repeat prostate biopsies in men with elevated total prostate-specific antigen. Urology 1996;48:76–80.CrossRefPubMedGoogle Scholar
  32. 32.
    Fleshner NE, O’Sullivan M, Fair WR. Prevalence and predictors of a positive repeat transrectal ultrasound guided needle biopsy of the prostate. J Urol 1997;158:505–509.CrossRefPubMedGoogle Scholar
  33. 33.
    Catalona WJ, Beiser JA, Smith DS. Serum free prostate specific antigen and prostate specific antigen density measurements for predicting cancer in men with prior negative prostatic biopsies. J Urol 1997;158:2162–2167.CrossRefPubMedGoogle Scholar
  34. 34.
    Keetch DW, McMurtry JM, Smith DS, Andriole GL, Catalona WJ. Prostate specific antigen density versus prostate specific antigen slope as predictors of prostate cancer in men with initially negative prostatic biopsies. J Urol 1996;156:428–431.CrossRefPubMedGoogle Scholar
  35. 35.
    Rietbergen JBW, Boeken Kruger AE, Hoedemaeker RF, Bangma CH, Kirkels WJ, Schröder FH. Repeat screening for prostate cancer after 1-year followup in 984 biopsied men: clinical and pathological features of detected cancer. J Urol 1998;160:2121–2125.CrossRefPubMedGoogle Scholar
  36. 36.
    Durkan GC, Greene DR. Elevated serum prostate specific antigen levels in conjunction with an initial prostatic biopsy negative for carcinoma: who should undergo a repeat biopsy? BJU Int 1999;83:34–38.CrossRefPubMedGoogle Scholar
  37. 37.
    Noguchi M, Yahara J, Koga H, Nakashima O, Noda S. Necessity of repeat biopsies in men for suspected prostate cancer. Int J Urol 1999;6:7–12.CrossRefPubMedGoogle Scholar
  38. 38.
    Keetch DW, Catalona WJ, Smith DS. Serial prostatic biopsies in men with persistently elevated serum prostate specific antigen values. J Urol 1994;151:1571–1574.PubMedGoogle Scholar
  39. 39.
    Stamey TA, McNeal JE, Yemoto CM, Sigal BM, Johnstone IM. Biological determinants of cancer progression in men with prostate cancer. JAMA 1999;281:1395–1400.CrossRefPubMedGoogle Scholar
  40. 40.
    Hodge KK, McNeal JE, Terris MK, et al. Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol 1989;142:71–74.PubMedGoogle Scholar
  41. 41.
    Presti JR, Chang JJ, Bhargava V, Shinohara K. The optimal systematic prostate biopsy scheme should include 8 rather than 6 biopsies: results of a prospective clinical trial. J Urol 2000;163:163–167.CrossRefPubMedGoogle Scholar
  42. 42.
    McNeal JE, Redwine EA, Freiha FS, Stamey TA. Zonal distribution of prostatic adenocarcinoma: correlation with histologic pattern and direction of spread. Am J Surg Pathol 1988;12:897–906.PubMedCrossRefGoogle Scholar
  43. 43.
    Bazinet M, Karakiewicz PI, Aprikian AG, et al. Value of systematic TZ biopsies in the early detection of prostate cancer. J Urol 1996;155:605–606.CrossRefPubMedGoogle Scholar
  44. 44.
    Terris MK, Pham TQ, Issa MM, Kabalin JN. Routine TZ and seminal vesicle biopsies in all patients undergoing transrectal ultrasound guided prostate biopsies are not indicated. J Urol 1997;157:204–206.CrossRefPubMedGoogle Scholar
  45. 45.
    Morote J, Lopes M, Encabo G, de Torres I. Value of routine TZ biopsies in patients undergoing ultrasound-guided sextant biopsies for the first time. Eur Urol 1999;35:294–297.CrossRefPubMedGoogle Scholar
  46. 46.
    Epstein JI, Walsh PC, Sauvageot J, Carter HB. Use of repeat sextant and transition zone biopsies for assessing extent of prostate cancer. J Urol 1997;158:1886–1890.CrossRefPubMedGoogle Scholar
  47. 47.
    Orozco R, O’Dowd GJ, Kunnel B, et al. Observations on pathology trends in 62,537 prostate biopsies obtained from urology private practices in the United States. Urology 1998;51:186–195.CrossRefPubMedGoogle Scholar
  48. 48.
    Bostwick DG, Qian J, Frankel K. The incidence of high grade prostatic intraepithelial neoplasia in needle biopsies. J Urol 1995;154:1791–1794.CrossRefPubMedGoogle Scholar
  49. 49.
    Green J, Feneley MR, Young M, Peeling B, Kirby R, Parkinson C. The prevalence of prostatic intraepithelial neoplasia (PIN) in biopsies from hospital practice and pilot screening: clinical implications. J Urol 1996;155(Supp1):A1260.Google Scholar
  50. 50.
    Raviv G, Janssen TH, Zlotta AR, Descamps F, Verhest A, Schulman CC. Prostatic intraepithelial neoplasia: influence of clinical and pathological data on the detection of invasive prostate cancer, in patients initially diagnosed on previous needle biopsy. J Urol 1996;156:1050–1055.CrossRefPubMedGoogle Scholar
  51. 51.
    Raviv G, Zlotta AR, Janssen TH, Descamps F, Verhest A, Schulman CC. Does prostate-specific antigen and prostate-specific antigen density enhance the detection of prostate cancer in patients initially diagnosed to have prostatic intraepithelial neoplasia? Cancer 1996;77:2103–2108.CrossRefPubMedGoogle Scholar
  52. 52.
    Zlotta AR, Raviv G, Schulman CC. Clinical prognostic criteria for later diagnosis of prostate carcinoma in patients with initial isolated prostatic intraepithelial neoplasia. Eur Urol 1996;30:249–255.PubMedGoogle Scholar
  53. 53.
    Weinstein MH, Epstein JI. Significance of high grade prostatic intraepithelial neoplasia on needle biopsy. Hum Pathol 1993;24:624–629.CrossRefPubMedGoogle Scholar
  54. 54.
    Cooner WH, Mosley BR, Rutherford CL, et al. Prostate cancer detection in a clinical urological practice by ultrasonography, digital rectal examination and prostate specific antigen. J Urol 1990;143:1146–1152.PubMedGoogle Scholar
  55. 55.
    Irani J, Fournier F, Bon D, et al. Patient tolerance of transrectal ultrasound-guided biopsy of the prostate. Br J Urol 1997;79(4):608–610.PubMedGoogle Scholar
  56. 56.
    Collins GN, Lloyd SN, Hehir M, et al. Multiple transrectal ultrasound-guided prostatic biopsies: true morbidity and patient acceptance. Br J Urol 1993;71:460–463.CrossRefPubMedGoogle Scholar
  57. 57.
    Clements R, Aideyan OU, Griffiths GJ, et al. Side effects and patient acceptability of transrectal biopsy of the prostate. Clin Radiol 1993;47:125–126.CrossRefPubMedGoogle Scholar
  58. 58.
    Rodriguez LV, Terris MK. Risks and complications of transrectal ultrasound guided prostate needle biopsy: a prospective study and review of the literature. J Urol 1998;160:2115–2120.CrossRefPubMedGoogle Scholar
  59. 59.
    Crawford ED, Haynes AL Jr, Story MW, et al. Prevention of urinary tract infection and sepsis following transrectal prostatic biopsy. J Urol 1982;127:449–4451.PubMedGoogle Scholar
  60. 60.
    Davison P, Malament M. Urinary contamination as a result of transrectal biopsy of the prostate. J Urol 1971;105:545–546.PubMedGoogle Scholar
  61. 61.
    Fawcett DP, Eykyn S, Bultidue MI. Urinary tract infection following transrectal biopsy of the prostate. Br J Urol 1975;47:679–681.CrossRefPubMedGoogle Scholar
  62. 62.
    Ashby EC, Rees M, Dowding CH. Prophylaxis against systemic infection after transrectal biopsy for suspected prostatic carcinoma. Br Med J 1978;2:1263–1264.CrossRefPubMedGoogle Scholar
  63. 63.
    Thompson PM, Talbot RW, Packham DA, et al. Transrectal biopsy of the prostate and bacteremia. Br J Surg 1980;67:127–128.CrossRefPubMedGoogle Scholar
  64. 64.
    Thompson PM, Prior JP, Williams JP, et al. The problem of infection after prostatic biopsy: the case for the transperineal approach. Br J Urol 1982;54:736.CrossRefPubMedGoogle Scholar
  65. 65.
    Gustafsson O, Norming U, Nyman CR, et al. Complications following combined transrectal aspiration and core biopsy of the prostate. Scand J Urol Nephrol 1990;24:249–251.PubMedGoogle Scholar
  66. 66.
    Sieber PR, Rommel FM, Agusta VE, et al. Antibiotic prophylaxis in ultrasound guided transrectal prostate biopsy. J Urol 1997;157:2199–2200.CrossRefPubMedGoogle Scholar

Copyright information

© Humana Press, a part of Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Bob Djavan
    • 1
  • Sibylle Marihart
    • 1
  1. 1.Department of UrologyUniversity of ViennaViennaAustria

Personalised recommendations