Biopsy of the vesico-urethral anastomosis after radical prostatectomy: When and how

Objectives: Transrectal ultrasound (TRUS) of the prostatic fossa in association with US-guided needle biopsy may be performed after radical prostatectomy to detect a local recurrence in patients who have a detectable prostate-specific antigen (PSA) level or a local abnormality found on digital rectal examination. Nevertheless, the conclusive role of the biopsy of the vesico-urethral anastomosis and its prognostic significance is still unclear. The aim of this review is to provide an accurate description of the normal and pathologic ultrasound features of the vesico-urethral anastomosis after radical surgery and to analyse its place as a prognostic factor after salvage radiotherapy. Methods: Literature on prostate biopsy was reviewed and a selection of articles made. Key words used for the Medline search included: prostate cancer, biopsy, transrectal ultrasound, prostatectomy and diagnosis. Results: In the detection of local recurrence after radical prostatectomy, TRUS is definitely more sensitive than Digital Rectal Examination (DRE). To improve the accuracy of TRUS of vesico-urethral anastomosis, it could be useful to provide a baseline TRUS image of the prostatic fossa for each patient after radical prostatectomy. No standardised technique of anastomotic sampling has been provided. Cancer recurrence detection seems to be poorly correlated to the number of cores taken, but rather to PSA levels or pathological stage at radical prostatectomy. On the contrary, all studies indicate the importance of biopsies targeted at TRUS detectable lesion in association with random biopsies of the perianastomotic tissue. Conclusions: Although its relative inability to detect minimal tumour mass with low PSA is evident, TRUS biopsy is presently the most sensitive method available in the detection of local recurrence. The time delay in performing salvage radiotherapy until a positive biopsy has been demonstrated may be detrimental. The need to perform a biopsy of the vesico-urethral anastomosis before treatment in the event of PSA failure is still under investigation.