Elevated serum prostate specific antigen levels in conjunction with an initial prostatic biopsy negative for carcinoma: who should undergo a repeat biopsy?

Objective To determine the outcome of repeated prostatic biopsies in men at tending with suspected prostate cancer but an initial negative biopsy, Patients and methods Patients who had undergone two or more transrectal ult rasonography (TRUS)-guided prostate biopsies were identified from the Hospi tal Information Support System database. Indications for TRUS were a raised prostate-specific antigen (PSA) level (>4.0 ng/mL), with or without an abn ormal digital rectal examination (DRE). Sextant prostate biopsies plus biop sies of any suspicious hypoechoic area or area of DRE abnormality were obta ined for histology. Forty-eight patients underwent repeat TRUS-guided prost atic biopsies (mean age 67.5, SD 7.25, range 53-82 years). Results The mean (SD, median, range PSA level was 16.9 (13.5, 11.6, 5.2-61. 8) ng/mL. Fifteen patients (31%) had carcinoma on repeat biopsy, II after t he second and four after a third biopsy. The positive repeat biopsy rate wa s 24% where the PSA level was 4.0-9.9 ng/mL, 33% if the level was 10.0-19.9 ng/mL and 39% if it was greater than or equal to 20.0 ng/mL. There was no significant difference in age or initial PSA concentration between those me n with positive and those with negative repent biopsies. However, patients with cancer had significantly higher PSA levels before repeat biopsy than a t first biopsy (P = 0.0043 and had greater PSA velocities than had patients with no diagnosis of cancer (P = 0.0067). Conclusion Where sufficient clinical suspicion exists, despite an initial n egative biopsy, repeat TRUS-guided prostate biopsies should be carried out to exclude carcinoma of the prostate.