Indications and timing for prostate biopsy, diagnosis of early stage prostate cancer and its definitive treatment: a clinical conundrum in the PSA era.

The use of PSA for prostate cancer screening has led to a large increase in the number of men undergoing transrectal ultrasonography (TRUS) - guided biopsy of the prostate to determine the presence of prostate cancer. Recently, the indications for prostate biopsy based on PSA level have been questioned and new prostate cancer risk calculators that consider other factors related to prostate cancer have been proposed. Also, there have been significant changes over the years regarding the protocols used to sample the prostate. Most protocols recommend more extensive sampling of the prostate with more laterally directed biopsies of the peripheral zone for both initial and subsequent biopsies. There is still much controversy over the appropriate number and location of biopsy cores, and timing to optimize the diagnosis of prostate cancer on initial and repeat biopsy. Finally, discovery of a new molecular marker independent of the PSA level will be very important in the diagnosis and prognosis of prostate cancer.