Editing Prostate Biopsy (section)

=== Number and location of cores ===
* '''Approach'''
**'''Transrectal'''
***The extended 12-core systematic biopsy that incorporates apical and far-lateral cores is the current recommended method.
**** Previously, the standard number of cores was 6. However, it has been shown that increasing the number of cores from 6 to 12 significantly increases cancer detection rate.
***** Increasing the number of cores to 18 or 21 (often termed saturation biopsy) as an initial biopsy strategy does not appear to result in a similar increase from 6 to 12. Saturation biopsy is more likely to be considered in the setting of a prior negative biopsy, though in the era of MRI this may not be relevant.
**'''Transperineal'''
***20 cores (2 cores (different locations) taken from 5 sites on each side)[https://pubmed.ncbi.nlm.nih.gov/34048827/]
****5 sites
****#Posterior medial
****#Anterior medial
****#Posterior lateral
****#Anterior lateral
****#Base
**'''<span style="color:#ff0000">≥2 needle biopsy cores per target should be obtained in patients with suspicious prostate lesion(s) on MRI.[https://pubmed.ncbi.nlm.nih.gov/23659877/]</span>'''
***≥2 cores per target provides the most reproducible and accurate cancer detection rate.
**** The optimal number of biopsy cores per MRI target may differ based on multiple factors including
*****Patient characteristics (e.g., age, PSA, biopsy naïve versus prior biopsy)
*****Target characteristics (e.g., size, location, PIRADS classification)
*****Biopsy approach/technique (e.g., software fusion versus cognitive fusion, transrectal vs. transperineal).
****The incremental value in cancer detection is diminished after obtaining >3 cores per target.
***For prostate cancer risk group stratification, all cores from the same MRI target should be considered as a single core.
*'''The transitional zone and seminal vesicles are not routinely sampled because these regions have been shown to have consistently low yields for cancer detection at initial biopsy'''
** '''Isolated transition zone tumors without peripheral zone involvement occur < 5% of the time.'''
** '''Transitional zone and anteriorly directed biopsies may occasionally prove necessary to diagnose prostate cancer in those patients with persistently elevated PSA levels and prior negative biopsies. More recently, MRI is often used to detect and guide biopsies of these anterior tumors that may escape standard TRUS prostate biopsy'''
** The seminal vesicles are not routinely performed unless there is a palpable abnormality, with some authors recommending seminal vesicle biopsy when the PSA is > 30 or if brachytherapy is being considered
* '''When biopsy specimens are taken from different sextant areas of the prostate, they should be submitted to pathology in separate containers'''
** ''An AUA white paper recently outlined the recommended processing of prostate biopsy samples, and the review did not provide compelling evidence that individual site–specific labeling of cores benefits clinical decision making regarding the management of prostate cancer (Bjurlin et al, 2013). [still relevant?]''