Is an Initial Saturation Prostate Biopsy Scheme Better than an Extended Scheme for Detection of Prostate Cancer? A Systematic Review and Meta-analysis

Context: The optimal initial prostate biopsy core number is still an issue with many unanswered questions and significant controversy. Objective: To compare diagnostic values of initial saturation prostate biopsy scheme and extended scheme with respect to prostate-specific antigen (PSA) levels, prostate volume (PV), and PSA density (PSAD). Evidence acquisition: Electronic databases including Medline, Web of Knowledge, and the Cochrane Library were searched through November 1, 2012. Experts were consulted, and references from relevant articles were scanned. The meta-analysis was conducted with RevMan 5.1, according to the PRISMA guidelines. Mantel-Haenszel estimates were calculated and pooled under a fixed or random effect model, with data expressed as risk difference (RD) and 95% confidence interval (CI). Evidence synthesis: We analyzed eight trials with a total of 11 997 participants who underwent transrectal ultrasound guided prostate biopsies for the first time and met inclusion criteria. Studies consisted of one paired design study, two randomized clinical trials, and five nonrandomized studies. Saturation biopsy scheme showed a significant advantage in prostate cancer (PCa) detection over an extended scheme (RD: 0.04; 95% CI, 0.01-0.08; p = 0.02). In addition, subgroup analyses found a saturation protocol to be superior to an extended protocol in the detection of PCa in men with PSA < 10 ng/ml (RD: 0.04; 95% CI, 0.01-0.07; p = 0.002), PV > 40 ml (RD: 0.05; 95% CI, 0.01-0.09; p = 0.02), or PSAD < 0.25 ng/ml per gram (RD: 0.04; 95% CI, 0.00-0.09; p = 0.04). Conclusions: The existing evidence indicates that an initial saturation biopsy scheme is more efficient than an extended scheme for PCa detection, especially for those men with lower PSA levels, higher PV, or lower PSAD, without increasing complications and the amount of insignificant cancer. (C) 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.