Transrectal Ultrasonography and
Ultrasound-Guided Biopsies of the Prostate
Gland: How, When, and Where
Athanasios Papatheodorou, MD,a Panagiotis Ellinas, MD,a
Savvas Tandeles, MD,a Fotios Takis, MD,a Hercules Poulias, MD,b
Irene Nikolaou, MD,c and Nikolaos Batakis, MD, PhDa
Transrectal ultrasound (TRUS) has revolutionized
prostate biopsy technique and plays a central part in
diagnosis of prostate cancer. Nevertheless TRUS is an
inherently operator-dependent modality and its perfor-
mance varies significantly due to equipment quality.
Thus it is of great importance to the detailed knowl-
edge of the complex 3D prostate anatomy, the inte-
grated scanning procedure, the evaluation of every
zone for chronic or suspicious change, and the perfor-
mance of ultrasound-guided biopsies.1
Anatomy
The prostate is an exocrine gland lying just below the
bladder neck and surrounding the urethra. Superolat-
erally to it lay the seminal vesicles and the vas
deferens. The lateral venous plexus intermixed with
arteries and nerves comprise the neurovascular bun-
dles that pass from above to below along the postero-
lateral aspects of the prostate, piercing the capsule.
Vessels, connective tissue, and fat surround the pros-
tate. Histologically the prostate is composed of four
zones: anterior fibromuscular stroma, periurethral
transition zone (TZ), posterior peripheral zone (PZ),
and posterosuperior central zone (CZ).
From the aRadiology Department, Hellenic Red Cross Hospital, Athens,
Greece; bUrology Department, Hellenic Red Cross Hospital, Athens,
Greece; and cHistopathology Department, Hellenic Red Cross Hospital,
Athens, Greece.
Reprint requests: Athanasios Papatheodorou, MD, Radiology Department,
Hellenic Red Cross Hospital, 19 Sigrou Street, GR-151 26 Marousi,
Greece. E-mail: athpapatheodorou@yahoo.gr.
Curr Probl Diagn Radiol 2005;34:76-83.
© 2005 Elsevier Inc. All rights reserved.
0363-0188/2005/$30.00 ⫹ 0
doi:10.1067/j.cpradiol.2004.12.003
76
Since the majority of patients referred for TRUS
examination are middle aged or older, almost all of
them have a hyperplastic transition zone. Peripheral
and central zones are usually thin and compressed in a
posterolateral position. This process is described as
benign prostatic hyperplasia (BPH).2
The previously described middle lobe consists of
part of the transition zone that protrudes in the urinary
bladder base. Anteriorly lying fibromuscular stroma is
nonglandular tissue. Virtually all BPH arise in the
transitional zone. Seventy percent of adenocarcinomas
arise in the peripheral zone, 20% arise in the transi-
tional zone, and 10% arise within the central zone.2
TRUS
Technique
The main workload of TRUS evaluation comprises
patients with abnormal digital rectal examination (DRE)
and/or elevated prostatic-specific antigen (PSA) levels
that are candidates for ultrasound-guided biopsy. Infer-
tility, clinical suspicion of acute or chronic prostatitis,
and prostate abscess drainage are also indications for
TRUS.
When the patient arrives in the ultrasound depart-
ment, every effort should be made to reassure him and
explain to him the various steps of the procedure. An
informed consent form is obtained. Urinary bladder
should not be empty, to create a clear interface with
prostate superior margin. The patient is placed in a
right lateral decubitus position and a DRE is per-
formed. If biopsy is considered, a needle guide should
be secured on the transducer in advance. Then the
patient is turned to a left lateral decubitus position and
Curr Probl Diagn Radiol, March/April 2005
a broad bandwidth transducer of 5 to 7 MHz is inserted
in the rectum (Fig 1). The patient is instructed to take
a deep breath and relax to facilitate transducer’s
insertion into the rectum. Some patients with hemor-
rhoids complain of anal discomfort.
The entire gland is examined and every abnormality
should be imaged in both axial and sagittal planes.3
The gland volume is measured using the formula:
0.52 ⫻ W ⫻ L ⫻ H. The width is easily defined on
axial scanning. The length is measured in the midline
sagittal plane and is the distance between bladder neck
and the apex of the gland. The height is measured
perpendicularly to the length measurement (Fig 2).
Consequently grayscale axial scanning is performed
from apex to base including the seminal vesicles. Care
should be taken that all parts of the prostate and
periprostatic tissues are sufficiently scanned (espe-
cially fat planes in apical region, and middle lobe in
large glands). Grayscale sagittal scanning is then
performed from left to right. Color Doppler interroga-
tion is performed in the axial plane from apex to base.
The mode could be either color or Power Doppler and
the color window must cover the entire gland. Every
suspicious hypoechoic or hypervascular area is exam-
ined both in comparison to the opposite side and
independently in the center of the image. Some au-
thors warn that a lateral decubitus position of the
patient could increase the color Doppler flow detected
in the dependent part of the gland.4 Finally, biopsies
are performed. After the procedure, the patient is given
detailed written instructions. TRUS as well as TRUS-
guided biopsy are performed in an outpatient setting.
Findings
While 8 to 10% of men have histologic evidence of
BPH by their 40s, almost 90% demonstrate it by the
age of 90.
In men with BPH, the transition zone is enlarged
sometimes asymmetrically. Middle lobe may protrude
in the urinary bladder. TZ appears hypoechoic with a
heterogeneous nodular pattern, while PZ and CZ are
compressed and distorted. TZ nodules may be hypo-,
iso-, or hyperechoic compared with the surrounding
PZ. Hyperechoic foci without acoustic shadowing
usually coexist. Some patients do not exhibit discrete
nodular pattern. There is also increased incidence of
small cysts in TZ (Fig 3). Color Doppler findings are
unremarkable.3,5
Chronic prostatitis is demonstrated as TZ inhomo-
geneity with dystrophic calcifications. Color Doppler
Curr Probl Diagn Radiol, March/April 2005
interrogation is usually normal. Frequently chronic
prostatitis is a histological finding and TRUS does not
provide important information.5
Chronic granulomatous prostatitis is generally pre-
sented as a very hypoechoic nodular area with clear
margins. Periprostatic fat planes are intact and color
Doppler interrogation is normal3 (Fig 4).
Prostate abscess and hematoma are rare pathologic
entities. Predisposing factors are diabetes, previous
TRUS with biopsy, and hemorrhagic disorders. Ab-
scess appears as a hypoechoic area within the gland
with indistinct margins. The gland is sometimes en-
larged and color Doppler shows hypervascularity in
adjacent parts of prostate. Hematoma shows ill-de-
fined borders and color Doppler flow is not increased
(Fig 5).
Prostate cancer is the most common noncutaneous
cancer diagnosed in American men. In 2003 approxi-
mately 220,900 men were diagnosed with this cancer
and 28,900 have died from it in the United States
alone.6,7
Acinar prostatic adenocarcinoma constitutes 95%
of all malignant prostatic neoplasms. Eighty percent of
cancers occur in the peripheral and central zone.
TRUS imaging has no role in early detection of
confined prostate cancer, beyond biopsy guidance and
tumor staging. Small cancers appear as hypoechoic
areas in the peripheral zone.8 Differential diagnosis for
hypoechoic areas in the peripheral zone is prostatic
atrophy, prostatitis, granulomatous prostatitis, lym-
phoma, and ductal ectasia. Cancer may appear as focal
nodule (30%), nodule with infiltrative component
(50%), and predominantly infiltrative pattern (20%)5
(Fig 6A). Prostate cancer may also be multifocal. As
neoplasms enlarge, they tend to become isoechoic.
Rarely tumors may appear hyperechoic.
Any focal area in the peripheral zone should be
evaluated by Doppler interrogation. Normal blood
flow is normally detected in periurethral and pericap-
sular areas.8 Typically an area of cancer demonstrates
hypervascularity (Fig 6B). Hypervascular areas may
exist independently of the grayscale hypoechoic areas.
Also not all tumors demonstrate increased vascularity.
Current imaging technology is unable to detect very
slow flow and demonstrate neovascularity associated
with tumors.3,8
The prostatic contour is a very important landmark
in the evaluation of extracapsular extension (ECE) of
prostate cancer, especially near the superior and infe-
rior neurovascular bundles. An irregular capsular
77

FIG 1. The patient assumes left lateral decubitus position and the
transrectal transducer is inserted in the rectum. (Simulated examina-
tion.) (Color version of figure is available online.)
bulge and/or tumor extension into the periprostatic fat
demonstrated as hypoechoic strands are signs of ECE
(Fig 7). Seminal vesicle (SV) invasion is suggested by
soft-tissue echogenicity and loss of normal SV “beak”
at prostatic base in sagittal image.9
Five percent (5%) of all prostatic malignancies are
rare variants such as comedocarcinoma, mucinous
adenocarcinoma, squamous cell and signet-ring carci-
nomas, neuroendocrine neoplasms, sarcomas, and
metastatic neoplasms.10,11 Comedocarcinoma appears
as multiple hyperechoic lesions within a larger hypo-
echoic area.5 Sarcomas are usually large infiltrating
tumors. Lymphomas tend to appear as large hypo-
echoic areas within the prostate and sometimes beyond
its confines.8
There is limited literature concerning the imaging
characteristics of TZ cancers.12,13 No specific sono-
graphic characteristics have been reported and further
investigation is needed in this area. Currently TZ
cancers are found only by systematic biopsies (Fig 8).
Two general rules apply: a normal-appearing gland
does not exclude the presence of cancer and every
hypoechoic hypervascular peripheral zone lesion is not
necessarily cancer. Tumor grade describes the meta-
static and invasive potential in prostate cancer. Glea-
78
son tumor grading system is the most widespread one.
Gleason score is the sum of a primary and a secondary
grade (each one ranging from 1 to 5), thus ranging
from 2 to 10. The pathologist assigns the first grade to
the most commonly observed cancer pattern in biopsy
specimens and the second grade to the second pattern.9
Ultrasound Microbubble Contrast Agents
(USCA)
The potential role of USCA in the detection of
prostate cancer is currently being investigated. There
are reports that after the IV administration of either
first- or better second-generation USCA, the sensitiv-
ity of TRUS for cancer detection may be improved,
because tumors show enhancement.5,14,15 Such appli-
cation of USCA requires that the ultrasound equip-
ment have harmonic capabilities and USCA applica-
tion software. Nonetheless areas of BPH can also
demonstrate enhancement and small, low Gleason
score tumors may demonstrate no enhancement.16 A
simple application that requires no special equipment
is the IV bolus injection of a USCA that results in a
substantial increase of color Doppler signal intensity
of prostatic vasculature.
Ultrasound-Guided Biopsies
The main contribution of TRUS in prostate cancer
diagnosis is to guide systematic biopsies of the gland.
The superiority of TRUS versus digitally guided
prostate biopsies has been well demonstrated.17
Indications for First Biopsies
TRUS-guided biopsies are performed on patients
over age 50, when DRE is abnormal (presence of
induration, palpable nodule, asymmetry) and/or serum
PSA is more than 4 ng/mL.18 The presence of suspi-
cious TRUS findings is also an indication for biopsy
(hypoechoic or hypervascular peripheral zone nodule).
For younger patients (age 40 to 49) the PSA
decision level is 2.5 ng/mL.3
There are several risk factors for prostate cancer
that have to be taken into consideration when biopsy is
considered,3,5,18 as follows:
● A positive family history (father, grandfather,
brother, uncle with prostate cancer)
● Black race
● PSA refinements such as PSA velocity and free
PSA/total PSA ratio.
Curr Probl Diagn Radiol, March/April 2005

FIG 2. (A) Grayscale axial image, middle. Width measurement.
Enlarged prostate due to BPH. (B) Same patient. Grayscale sagittal
image, midline. Length and height measurement.
An increase of PSA more than 0.75 to 1 ng/mL/year
(PSA velocity) is a risk parameter. At least three PSA
measurements over a 2-year period are required.
A lower fraction of unbound or free PSA is seen
more frequently in cancer patients than in BPH pa-
tients. The decision level is when the free PSA/total
PSA ratio is less than 25%.
Other PSA refinements such as PSA density, com-
plexed PSA,19 and ultrasensitive PSA are under clin-
ical trials and further assessment.
Therefore, younger patients (age 40 to 49) with
some risk factors (increased PSA velocity or low
free/total PSA ratio, etc.) may be considered as can-
didates for early first biopsy. Older patients with
intermediate PSA (4 to 10 ng/mL) with low risk profile
Curr Probl Diagn Radiol, March/April 2005
FIG 3. Grayscale axial image, middle. BPH. TZ is enlarged with
nodular heterogeneous pattern. Middle lobe protrudes in the bladder.
There are also small cystic formations.
FIG 4. Grayscale axial image, middle. There is a hypoechoic area in
the left lateral PZ. Power Doppler showed no increased vascularity.
Biopsy demonstrated chronic granulomatous prostatitis.
(normal free/total PSA ratio, normal PSA velocity, no
family history, advanced age) may decide on a more
conservative follow-up with PSA measurements or to
repeat TRUS rather than immediate biopsy.3
Preparation
A written information and consent form is given to
all patients scheduled for prostate biopsy.
A detailed clinical history is a must. Any medica-
tion that alters bleeding time and blood clotting should
be discontinued 10 days before the biopsy. Aspirin in
small doses is not considered a contraindication. A
recent international normalized ratio (INR) count is
asked as well as all previous PSA counts. A second-
generation quinolone antibiotic is prescribed twice
79
FIG 5. Grayscale axial image, middle. Large hypoechoic avascular
area with the prostate. Prostatic hematoma.

daily for 3 days, the first oral dose given the morning
before the biopsy day. The evening before the biopsy,
patients are asked to administer a low bowel enema
and to have bowel movement. Bisacodyl rectal prep-
aration is an alternative.20 Usually TRUS-guided bi-
opsies are well tolerated with minimal pain reported
by the patients,21 with spring-driven biopsy devices
contributing to this. Younger patients tend to report
more often mild-to-severe discomfort or pain. If an
extended biopsy protocol is considered, the infiltration
of 2 mL of 2% lidocaine around neurovascular bundles FIG 6. (A) Grayscale axial image, apex. There is a hypoechoic area
using a 20-cm-long needle under TRUS guidance in the left PZ. (B) Color Doppler, axial image, apex. There is increased
eliminates pain.22 An 18-gauge 20-cm-long biopsy vascularity in left PZ. Biopsy: adenocarcinoma with Gleason score 7
(4 ⫹ 3) infiltrating left PZ and TZ. (Color version of figure is available
needle (22- to 25-cm-long in large glands) is used. The online.)
right lobe is biopsied first; then the transducer is turned
upside down and the left lobe is also biopsied. Biop-
sies are performed in the axial plane.
All specimens are individually labeled, placed in a reported increased cancer detection rate.26,27 Cur-
10% formalin solution, and sent to the histopathology rently, various extended field biopsy protocols are
department. suggested. They combine laterally directed biopsies,
which sample the lateral aspects of the PZ with
Sites/Protocols posteromedial biopsies of the PZ. Midline biopsies
of the PZ are not widely accepted yet.28 All these
Sextant biopsies (specimens from each prostatic
biopsies are performed in three levels (apex, mid
sextant from right and left lobes at the level of apex,
middle, and base) have been shown to be inadequate level, base) or four levels in large glands (a total
for prostate cancer detection.8,23 Targeted-only bi- number of 15 to 20 biopsies). Additional biopsies
opsies also miss a substantial number of can- may be performed at seminal vesicles. Some proto-
cers.24,25 A modified sextant protocol, consisting of cols recommend as many as 30 biopsies per patient.
the classic sextant biopsies with additional biopsies TZ biopsies are not recommended for the initial
obtained from the lateral aspect of the peripheral biopsy work-up due to their low yield of cancers.
zone at the base and mid gland (10 biopsies), However, they are useful in patients with persis-

80 Curr Probl Diagn Radiol, March/April 2005


FIG 7. (A) Grayscale, axial image, middle. There is a hypoechoic
area in the left PZ. (B) Grayscale sagittal image, middle. There is a
hypoechoic area occupying the left PZ from base to apex. Fat
around apex is hypoechoic, indicating ECE. Biopsy: adenocarci-
noma with Gleason score 8 (4 ⫹ 4) with ECE.
tently elevated PSA and negative initial biopsy
work-up.28,29
The authors perform a version of extended field
protocol consisting of:
Laterally directed PZ biopsies.
Medially directed peripheral and transition zone
biopsies in three levels (a total of 12 biopsies)
(Fig 9).
If the prostate gland is larger than 60 mL, an additional
level with another four biopsies is added. Also, if
there are suspicious focal findings in PZ or in
seminal vesicles, additional targeted biopsies are
performed.
Curr Probl Diagn Radiol, March/April 2005
FIG 8. Grayscale, axial image, middle. Markedly enlarged and
inhomogeneous TZ. Biopsy: there is an adenocarcinoma with Gleason
score 4 (2 ⫹ 2) well differentiated in the left TZ. PZ and right TZ have
no indication of cancer.
We regularly perform TZ biopsies, although primary
TZ cancers are rare because we often find TZ
infiltration in middle to high Gleason score PZ
cancers.
Complications and Treatment
TRUS-guided biopsies are considered safe and can
be performed in the outpatient setting.
Minor complications such as perineal pain, tran-
sient mild hematuria, hematospermia, and rectal bleed-
ing are relatively frequent and self-limiting.
Severe complications such as urinary retention and
infection, severe rectal bleeding or hematuria, prostate
infection, or abscess with fever/sepsis are very rare
(less than 1%) if patients comply with the given
instructions. Massive rectal hemorrhage may occur for
up to 4 days after the biopsy. Although direct digital
compression is useful for immediate postprocedure
bleeding control, endoscopy with Foley balloon tam-
ponade, coaptive coagulation, and epinephrine injec-
tion are very successful in attaining hemostasis.30
Urinary retention requires Foley catheterization.
Infection is managed with IV antibiotic administration
and hospitalization.
A written information form with the possible com-
plications is given to the patients after the procedure.
They are advised to stay at home at least for 1 day, to
increase fluid intake, and to abstain from alcohol and
sexual activity for 2 weeks.
81
FIG 9. (A) 3D image of prostate gland with medium BPH. Three (3) axial biopsy levels at base, middle, and apex. (B) Axial image, base. Lateral
and medial biopsies. PZ ⫽ red, TZ ⫽ purple, fibromuscular stroma ⫽ yellow. (C) Axial image, middle. Lateral and medial biopsies. (D) Axial
image, apex. Lateral and medial biopsies.
In the case of a severe complication, patients are
instructed to seek professional medical help on an
emergency basis.
Repeat Biopsies
In the case of a negative initial biopsy, a repeat
biopsy should be performed:
● In patients with persistently elevated PSA ⬎4
ng/mL.
● In patients with a high-grade PIN (prostate intra-
epithelial neoplasia) found in the first biopsies.
PIN is a histopathologic entity at the precancer-
ous cellular borderline. There are low-grade and
high-grade PIN, with the high grade being an
indication for patient follow-up with a repeat
biopsy.31
● In patients with increased prostate volume more
than 60 mL.
82
● In patients with risk factors such as family
history of prostate cancer, black race, free/total
PSA ratio less than 25%, and PSA velocity more
than 0.75 to 1 ng/mL/year.
The interval between initial and repeat biopsy is
between 6 and 12 months.32–34 Repeat biopsy tech-
nique should direct needles to a more apico-dorsal
location and transition zone biopsies should always be
performed. Although a second prostate biopsy is
justified when indications apply and prostate cancer is
found in 10% of biopsies, third repeat biopsy should
be spared for selected patients since they tend to detect
rare cancers (5%) with low grade and stage.
Summary
TRUS- and ultrasound-guided biopsies of the prostate
gland have become a valuable tool in the detection and
Curr Probl Diagn Radiol, March/April 2005
management of prostate cancer and other benign
prostatic pathology.
Detailed knowledge of prostatic anatomy, TRUS
examination technique, the various imaging findings,
as well as the biopsy technique contribute to improved
treatment planning and therapeutic outcome.
REFERENCES
1. Rifkin MD, Sudakoff GS, Alexander AA. Prostate: tech-
niques, results and potential applications of Color Doppler US
scanning. Radiology 1993;186:509-13.
2. Coakley VF, Hricak H. Radiologic anatomy of the prostate
gland: a clinical approach. Radiol Clin North Am 2000;38:
15-30.
3. Littrup JP, Bailey ES. Prostate cancer: the role of transrectal
ultrasound and its impact on cancer detection and manage-
ment. Radiol Clin North Am 2000;38:87-113.
4. Halpern JE, Frauscher F, Forsberg F, et al. High-frequency
Doppler US of the prostate: effect of patient position. Radi-
ology 2002;222:634-9.
5. Grossfeld DG, Coakley VF. Benign prostatic hyperplasia:
clinical overview and value of diagnostic imaging. Radiol Clin
North Am 2000;38:31-47.
6. Kessler B, Albertsen P. The natural history of prostate cancer.
Urol Clin North Am 2003;30:219-26.
7. Eastham AJ, Sardino TP. Early diagnosis and treatment of
prostate cancer. Dis-A-Month 2001;47:417-60.
8. Clements R. Ultrasound of prostate cancer. Eur Radiol 2001;
11:2119-25.
9. Yu KK, Hricak H. Imaging prostate cancer. Radiol Clin North
Am 2000;38:59-85.
10. Varghese LS, Grossfeld DG. The prostatic gland: malignan-
cies other than adenocarcinomas. Radiol Clin North Am
2000;38:179-202.
11. Bostwick GD, Qian J, Schlesinger C. Contemporary pathol-
ogy of prostate cancer. Urol Clin North Am 2003;30:181-207.
12. Greene DR, Wheeler TM, Egawa S, et al. A comparison of the
morphological features of cancer arising in the transition zone
and in the peripheral zone of the prostate. J Urol 1991;146:
1069-76.
13. Noguchi M, Stamey TA, McNeal JE, et al. An analysis of 148
consecutive transition zone cancers: clinical and histological
characteristics. J. Urol 2000;163:1751-5.
14. Halpern JE, McCue AP, Aksnes KA, et al. Contrast-enhanced
US of the prostate with Sonazoid: comparison with whole-
mount prostatectomy specimens in 12 patients. Radiology
2002;222:361-6.
15. Halpern JE, Verkh L, Forsberg F, et al. Initial experience with
contrast-enhanced sonography of the prostate. Am J Roentgenol
2000;174:1575-80.
16. Halpern JE, Rosenberg M, Gomella GL. Prostate cancer: con-
trast-enhanced US for detection. Radiology 2001;219:219-25.
Curr Probl Diagn Radiol, March/April 2005
17. Rifkin MD, Alexander AA, Pisarchick J, et al. Palpable
masses in the prostate: superior accuracy of US-guided biopsy
compared with accuracy of digitally guided biopsy. Radiology
1991;179:41-2.
18. Partin WA, Stutzman ER. Elevated prostate-specific antigen,
abnormal prostate evaluation on digital rectal examination and
transrectal ultrasound and prostate biopsy. Urol Clin North
Am 1998;25:581-9.
19. Okihara K, Fritsche AH, Ayala A, et al. Can complexed
prostate specific antigen and prostatic volume enhance pros-
tate cancer detection in men with total PSA between 2.5 and
4.0 ng/ml. J Urol 2001;165:1930-6.
20. Jeon SS, Woo SH, Hyun JH, et al. Bisacodyl rectal preparation
can decrease infectious complications of transrectal ultrasound
guided prostate biopsy. Urology 2003;62:461-6.
21. Bastide C. Tolerance of pain during transrectal ultrasound-
guided biopsy of the prostate: risk factors. Pr Cancer Prostatic
Dis 2003;6:239-41.
22. Bulbul MA. Periprostatic infiltration with local anesthesia
during TRUS guided prostate biopsy is safe, simple and
effective: a pilot study. Clin Imaging 2002;26:129-32.
23. Basillote JB. Influence of prostate volume in the detection of
prostate cancer. Urology 2003;61:167-71.
24. Kuligowska E, Barish MA, Fenlon HM, et al. Predictors of
prostate carcinoma: accuracy of grayscale and Doppler US
and serum markers. Radiology 2001;220:757-64.
25. Halpern JE, Frauscher F, Strup ES, et al. Prostate: high-
frequency Doppler US imaging for cancer detection. Radiol-
ogy 2002;225:71-7.
26. Presti CJ. Prostate cancer: assessment of risk using digital
rectal examination, tumor grade, prostate-specific antigen and
systematic biopsy. Radiol Clin North Am 2000;38:49-58.
27. Purohit SR, Shinohara K, Meng VM, et al. Imaging clini-
cally localized prostate cancer. Urol Clin North Am 2003;
30:279-93.
28. Terris KM. Prostate biopsy strategies: past present and future.
Urol Clin North Am 2002;29:205-12.
29. Djavan B, Remzi M, Marberger M. When to biopsy and when
to stop biopsying. Urol Clin North Am 2003;30:253-62.
30. Kinney PT, Kozarek AR, Ylvisaker TJ, et al. Endoscopic
evaluation and treatment of rectal hemorrhage after prostate
biopsy. Gastrointest Endosc 2001;53:117-9.
31. Iczokowski AK, Bostwick GD. Prostate biopsy interpretation.
Current concepts 1999. Urol Clin North Am 1999;26:435-52.
32. Leventis KA, Shahrokh FS, Kevin MS. Local recurrence after
radical prostatectomy: correlation of US features with pros-
tatic fossa biopsy findings. Radiology 2001;219:432-9.
33. Swindle WP, Kattan WM, Scardino TP. Markers and meaning
of primary treatment failure. Urol Clin North Am 2003;30:
377-401.
34. Nudell MD, Wefer EA, Hricak H, et al. Imaging for recurrent
prostate cancer. Radiol Clin North Am 2000;38:213-29.
83