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Sir,

I read this article [1] with great interest; I commend the authors’ work on the correlation between the site of biopsy and cancer detection. I share their view that the biopsy protocol targeting peripheral zones around prostate enhances the cancer detection rate. The authors quantified the cancer detection rate in repeat prostate biopsies according to the biopsy sites. The detection rate was higher in mid and apical sites than basal site biopsies. It is not clear from the article if they altered the biopsy sites for repeat prostate biopsies. The number of biopsies did not vary between initial and repeat biopsies. Assuming no change in the biopsy protocol, the cancers detected in repeat biopsies were those possibly missed in the initial biopsy. Hence the likely reason is one of sampling error (the intended site was not actually biopsied) [2,3]. It is not uncommon to miss the apical and mid zones despite intending to target them, for technical reasons which are largely operator-dependent. Hence targeting the biopsies at these zones at the initial biopsy would improve the cancer detection rate.

From the results of Prostate Cancer Prevention Trial (PCPT) [4], the cancer detection rate varied between 54% (803/1476) and 68% (1147/1667), whereas the cancer detection was 16.6–35.9% in this study.

Hence proper targeted biopsies would improve the cancer detection rate in line with American series, although they might never reach their high values due to case selection. As increasingly many TRUS biopsies are taken by junior urological trainees, adequate sampling needs to be ensured. Hence adequate focused training is a key factor, rather than altered protocol or saturation biopsies, for improving the cancer detection rate for prostate biopsies.