When is a Negative Prostate Biopsy Really Negative? Repeat Biopsies in Detection and Active Surveillance.

REPEAT biopsies are commonly performed in the encouraged to reduce the morbidity of prostate diagnostic setting and increasingly for men on active surveillance. A prior study using SEER (Surveillance, Epidemiology, and End Results)Medicare data reported that 11.8% of men with a negative prostate biopsy underwent repeat biopsy within 1 year and 38% did so within 5 years. A major problem is the significant sampling error with the traditional random systematic biopsy and the resulting lack of confidence that a negative biopsy is really negative. This sampling error also results in staging inaccuracies that affect decision making about prostate cancer management for newly diagnosed patients. Indeed, a recent review shows that a third or more of patients with very low or low risk prostate cancer at diagnosis have disease upgraded upon resampling within 6 months. For men who opt for active surveillance, most protocols recommend repeat biopsy within the first year and then every 1 to 5 years thereafter. It is noteworthy that despite the inaccuracy of diagnostic prostate biopsy, new data from the PLCO (Prostate, Lung, Colorectal and Ovarian) Cancer Screening Trial in this issue of The Journal (page 1014) show that men with an initial negative prostate biopsy have a low risk of prostate cancer specific mortality (1.1% at 12.9 years median followup). Nevertheless, the frequent scenario of a man undergoing 1 or multiple repeat biopsies during a lifetime represents a significant source of morbidity and cost. Although repeat biopsy procedures have a risk of infection similar to that of the initial biopsy, a new study from the New York Statewide Planning and Research Cooperative System, also in this issue of The Journal (page 1020), shows that the risk of these complications continues to increase with time. Meanwhile, techniques to reduce biopsy risks such as the transperineal approach and rectal swab cultures were rarely used. The American Urological Association recently issued an updated white paper on the prevention of prostate biopsy complications and increasing use of these strategies should be