State of the Art

Fred Lee, MD Soren

#{149} T. Torp-Pedersen, MD Douglas
#{149} B. Siders, MD Peter
#{149} J. Littrup, MD #{149}
Richard D. McLeary, MD

Transrectal Ultrasound in the Diagnosis

and Staging of Prostatic Carcinoma’

S INCE its clinical application in In 1988, with 2 years experience performed, and readily accepted by
1971 by Watanabe (1), transrectal with 7-MHz scanners, the appear- patients.
ultrasound (TRUS) has now devel- ance of prostate cancer is generally By applying McNeal’s concept of
oped into a sophisticated technology. accepted as hypoechoic (9-11). Can- zonal anatomy, we now understand
Its widespread acceptance is reflected cers may appear isoechoic if they are areas of anatomic weakness through
in increased numbers of scientific smaller than the size allowed by re- which cancer may escape the con-
publications on prostate imaging in solving capabilities of the scanner, or fines of the prostate. Strategic US-
the current literature. if the tumor involves the entire pros- guided transrectal biopsy accurately
Early in the history of TRUS, bi- tate, thus replacing any residual nor- samples these areas. The role of biop-
stable 3-MHz transverse images pro- ma! tissue. In our recent screening sy has been extended from its use in
vided information about prostate size program, 9% (two of 22) of the can- the diagnosis of prostate cancer to in-
and shape (2). In the late 1970s and cers were initially overlooked with dude evaluation of tumor extension
early 1980s, gray-scale longitudinal TRUS and diagnosed by means of for staging.
and transverse scanners were intro- digital rectal examination (ORE) (12). The results reported in the litera-
duced (3). Visualization of the inter- We have thus witnessed marked ture have been confusing due to non-
nal architecture of the prostate was technical improvements and changes uniformity in equipment and the cri-
then possible, and two zones were in image interpretation. The fact that teria applied for cancer echogenicity.
identified: the internal and the exter- the appearance of prostate cancer was Still in 1988, data are published in
nal gland. At that time, the majority thought to be hyperechoic and then which conclusions are based on the
of investigators believed cancers hypoechoic did little to lend credibil- use of uniplanar 4.0-MHz equipment
were hyperechoic (4-6). ity to TRUS. However, implementa- and lack of a criterion for cancer
In 1985, studies were performed tion of TRUS in the diagnosis of echogenicity (19). A recent literature
with 5.0 MHz scanning in both trans- prostate cancer is now widespread. review has documented this confu-
verse and longitudinal planes. The An evolution in biopsy technique sion (20).
hyperechoic nature of prostate cancer has paralleled the improvements in Our current concepts of the clinical
was then challenged (7). US imaging. Transperineal biopsies significance of the zonal anatomy of
In 1986, 7.0-MHz scanning was in- guided by transverse imaging in 1981 the prostate and the importance of
troduced. The improvement in reso- (13), and longitudinal imaging in strategic US-guided biopsy for diag-
lution allowed visualization of the 1983 (14), are still performed. More nosis and staging of prostate cancer
infrastructure of the prostate corre- recently, 7.0-MHz longitudinal scan- are described herein.
sponding to McNeal’s 1981 concept ners with transrectal biopsy capabili-
of zonal anatomy (8). ties have caused a trend toward biop-
PROSTATE ANATOMY
sy by the transrectal route (11,15,16).
Ease of biopsy is important for le- Current textbooks still describe
Index terms: Prostate, biopsy, 844.126 Pros-
#{149}

tate, neoplasms, 844.32 Prostate,

#{149} US studies,
sions less than 1.5 cm in average di- Lowsley’s 1912 concept of anatomy
844.1298 State-of-Art
#{149} reviews Ultrasound
#{149} mension. Cancers of this size are of the prostate. Anatomic dissections
(US) guidance, 844.12985 most likely confined within the pros- initially published by McNeal in
tate gland and are possibly curable. 1968 (21) and by Blacklock and Bou-
Radiology 1989; 170:609-615 In the performance of transperineal shill in 1977 (22) confirm a zonal
biopsy of a lesion, the prostate must concept of prostate anatomy. A simi-
be punctured from a distance of up to lar concept was suggested by Sa-
15 cm (between perineum and pros- lander and Tisell in 1975 and 1981
‘From the Departments of Radiology (F.L., tate), making it difficult to obtain sat- (23).
S.T.T.P., P.J.L., R.D.M.) and Pathology (D.B.S.), isfactory tissue from small lesions We use McNeal’s concept of the
St Joseph Mercy Hospital, 5301 E Huron River (17). Transrectal biopsy is performed prostate as composed of three glan-
Dr, P0 Box 995, Ann Arbor, MI 48106. Re-
ceived August 18, 1988; revision requested Sep-
at a much closer distance, usually be-
tember 27; revision received and accepted No- ginning just outside the gland (up to
vember 7. Supported by research funds from 3.0 mm between rectal wall and pros-
Huron Valley Radiology Professional Corp and tate), thus allowing accurate biopsy Abbreviations: CZ = central zone, DRE =

the Department of Clinical Research and Clini- digital rectal examination, PZ = peripheral
of smaller lesions as well as of multi-
cal Research Committee of St Joseph Mercy zone, TRUS = transrectal ultrasound, TURP =

Hospital. Address reprint requests to F.L. ple areas in the gland (18). Transrec- transurethral resection of the prostate, TZ =

© RSNA, 1989 tal biopsy is highly accurate, easily transition zone.

609
 TRANSON ZONE

a.

b. C. d.
Figure 1. Transition zone (TZ). (a) Graphic depiction of the TZ (blue) viewed from the top. (b) Graphic depiction of the TZ (blue) viewed
from the side. (c) Transverse histologic whole mount of TZ tissue. (d) Axial scan of TZ. The proximal urethra (*) separates the bilateral TZ.
The TZ is separated from the peripheral zone (PZ) by the surgical capsule (arrows). The verumontanum (*) gives an Eiffel Tower configura-
tion on TRUS. The urethra subtends an angle of 350 at the level of the verumontanum.

CENTRAL ZONE

a.

b. c. d.
Figure 2. Central zone (CZ): (a) Graphic depiction of the CZ (orange), viewed from the top. (b) Graphic depiction of the CZ (orange),
viewed from the side. (c) Histologic whole mount of CZ tissue. (d) Sagittal scan of CZ. The confluens of the seminal vesicle (SV) and the vas
deferens (VD) form a beak configuration (arrowheads), which continues as the ejaculatory duct (arrows). The loose connective tissue of the
extraprostatic space (x) invaginates with the SV beak, forming the invaginated extraprostatic space, which follows the ejaculatory duct to the
verumontanum (*). B = urinary bladder, * urethra, PZ = peripheral zone, R = rectum, DE = Denonvilliers fascia, AFS = anterior fibro-
muscular stroma, PS = preprostatic sphincter.

dular zones-transition, central, and The proximal urethra is surround- dular tissue. It is composed of smooth
peripheral zones-and one nonglan- ed by periurethral glandular tissue muscle and extends from the bladder
dular region-anterior fibromuscular whose ducts open directly into the neck to verumontanum.
stroma. The urethra, its associated ureteral lumen. Prostatic calculi may Varying amounts of striated mus-
sphincteric complexes, and the ejacu- form within these glands and appear cle are present around the distal ure-
latory ducts pass through these as echogenic foci on TRUS scans (24). thra and blend with the external
zones. These calculi are thought to be sec- sphincter at the apex of the prostate.
In its passage through the prostate, ondary to reflux of urine into the
the urethra is divided into proximal ducts (exogenous), differing from the
Transition Zone
(from bladder neck to verumon- corpora amylacea that arise from the
tanum) and distal (from verumon- prostatic glands (endogenous). The The transition zone (TZ) (Fig 1),
tanum to external sphincter). The internal or preprostatic sphincter is prior to development of benign pros-
proximal and distal urethra form an situated around this complex of prox- tatic hyperplasia, constitutes approxi-
angle of 35#{176}at the verumontanum. imal urethra and periurethral glan- mately 5% of prostatic glandular tis-

610 Radiology
#{149} March 1989
 TRAPEZOID AREA

a. b. C.

4 Figure 3. Peripheral zone (PZ). (a) Graphic

depiction of the PZ (yellow) viewed from
the top. (b) Graphic depiction of the PZ
viewed from the side. (C) Graphic depiction
of the PZ and apex (trapezoid area), sagittal
view. (d) Histologic whole mount, sagittal
section of prostatic apex. (e) Sagittal scan of
the prostatic apex. The trapezoid area is de-
limited by the following borders: anteriorly
by the membranous urethra (*), posteriorly
by the rectum (R), proximally by the PZ, and
distally by the rectourethralis muscle (ar-
rowheads). CZ = central zone, arrows =

ejaculatory duct, AFS = anterior fibromuscu-

lar stroma, * = verumontanum.

d.

Figure 4. Graphic depiction of zonal anatomy of the prostate gland. Blue = TZ, orange =

CZ, yellow = PZ, green = AFS.

Figure 5. Axial scan showing a transition

zone (TZ) cancer (arrows). A second cancer
is also present in the adjacent peripheral
zone (PZ). R = rectum, * = urethra.

hyperechoic pattern and define the

caudal limits of the transition and
central zones (24). The TZ is separat-
ed from the adjacent peripheral and
central zones by the surgical capsule.
a. b.
Figure 6. Cancer with seminal vesicle involvement. (a) Histologic whole mount of base of Central Zone
prostate. (b) Corresponding sagittal scan. The “beak” (arrows) of the seminal vesicle (SV) is
displaced anteriorly by tumor (T). Due to an absent prostate capsule at the base of the gland, The central zone (CZ) (Fig 2) is a
cancer extends into the extracapsular space (*). CZ = central zone, PZ = peripheral zone, * pyramidal-shaped structure at the
= urethra. base of the prostate constituting ap-
proximately 25% of prostatic glandu-
lar tissue. The CZ narrows to an apex
sue. It is located on both sides of the the verumontanum. Deposits of pros- at the verumontanum. This acinar tis-
proximal urethra. TZ ductal systems tatic calculi within glands of the sue is larger and more variable in
run parallel to the urethra and end in proximal urethra and verumontanum size than acini of the peripheral
the proximal urethra at the level of produce an “Eiffel Tower”-shaped zone. Ducts from the CZ radiate from

Volume 170 Number

#{149} 3 Radiology 611
#{149}
the base of the gland to the verumon- (TURP) mainly samples tissue from
tanum. the TZ. When cancer is diagnosed in-
The points of entrance into the CZ cidentally at TURP, it is designated
of the ducts of the vas deferens and stage A by the Whitmore Staging
seminal vesicles vary. Their conflu- System (27). Cancers of the TZ com-
ence forms the ejaculatory ducts, monly arise circumferentially in its
which pass through the CZ and emp- most anterior region, in proximity to
ty into the urethra at the verumon- the anterior fibromuscular stroma
tanum. (28).
The entrance of the seminal vesi- Benign prostatic hyperplasia origi-
des and vas deferens into the CZ nates in the TZ (8). The US appear-
produces a site of anatomic weakness ance of the TZ largely depends on
due to absence of an encompassing the degree and type of hyperplasia.
capsule (25). A hypoechoic beaklike There are three primary types of be-
configuration on TRUS scans is a. nign prostatic hyperplasia (29): (a)
formed by the entrance of seminal homogeneous stromal (or fibromus-
vesicles and vas deferens into the CZ. cular) hyperplasia, which is hypo-
This beak continues as a hypoechoic echoic in appearance and can be com-
band formed by smooth muscle sur- pared in ultrasonic terms with myo-
rounding the ejaculatory ducts and ma of the uterus; (b) glandular
extends to the verumontanum. The hyperplasia, which may be hypo-
seminal vesicles and ejaculatory echoic or hyperechoic, depending on
ducts are separated from glandular gland size and variability of cystic
elements of the CZ by only loose changes; and (c) an admixture of stro-
connective tissue, an inward exten- mal and glandular hyperplasia,
sion of the extraprostatic space, which is most common of the three
which we will call the “invaginated types. Because of the frequent pres-
extraprostatic space.” Thus a poten- ence of these hypoechoic foci, the
tial anatomic pathway exists from the cancer yield on biopsy within the TZ
center of the prostate to outside of is lower than that from areas of simi-
b.
the gland. lar echogenicity within the CZ or PZ
Figure 7. PZ trapezoid area. Axial (a) and
The echogenicity of the CZ is nor- (30). Our prospective study of biopsy
sagittal (b) scans show a hypoechoic tumor
mally greater than that of the periph- (T) in the PZ. The trapezoid area is defined of hypoechoic lesions in the TZ
eral zone, since glands of the CZ are by the membranous urethra (*) anteriorly, greater than or equal to 1.0 cm in av-
larger and more reflective. There are the rectum (R) posteriorly, the rectourethra- erage dimension yields a positive
more corpora amylacea present in lis muscle (arrowheads) distally, and the PZ predictive value of approximately
proximally. Arrows = prostate.
acini of the CZ than in the peripheral 13%, one out of eight biopsies being
zone. Corpora amylacea are thought positive for cancer. For lesions of
to develop as a gel from secretions of comparable size in the PZ, our posi-
acini and later become calcified, hy- tive predictive value was 41%, or ap-
droxyapatite deposits (26). Only a distally, the membranous urethra an- proximately one out of two biopsies
thin band of connective tissue sepa- teriorly, and the rectal wall posterior- being positive for cancer (15).
rates the central and peripheral ly. The PZ is homogeneous in texture Localized asymmetry with a hypo-
zones. This interface between these and is defined as isoechoic. echoic lesion is the most suspicious
zones may be seen as a thin hyper- finding within the TZ (Fig 5).
echoic line. The surgical capsule sep- The exact role of TRUS in the as-
Anterior Fibromuscular Stroma
arates the CZ, as well as the peripher- sessment of cancer in the TZ has not
al zone, from the TZ. The anterior fibromuscular stroma yet been proved. However, our expe-
is a nonglandular region which rience indicates a role for TRUS in
forms the anterior surface of the the restaging of stage A cancers. The
Peripheral Zone prostate. presence of a hypoechoic lesion adja-
This zonal concept of prostate cent to a TURP defect in a patient
The peripheral zone (PZ) (Fig 3)
anatomy is important to understand with stage A cancer necessitates biop-
constitutes 70% of prostatic glandular
because cancers within each zone sy.
tissue. Glands are relatively uniform
may have different clinical implica- Prospective studies are under way
in size and are somewhat smaller
tions. The three-dimensional rela- to evaluate the role of US in pre- and
than glands of the CZ. The PZ com-
tionship of these zones is shown in postoperative evaluation of the TZ.
prises the posterior, lateral, and api-
cal aspects of the prostate and ex- Figure 4.
tends anteriorly for a variable dis-
Central Zone
tance. Ducts of the PZ enter the PROSTATE ZONAL
urethra at, and distal to, the veru- ANATOMY: CLINICAL The CZ is relatively resistant to
montanum. disease processes. It is the site of ori-
IMPLICATIONS
The apex of the gland is a site of gin for 5%-10% of prostate cancers.
anatomic weakness where the pros- The site where the seminal vesicles
Transition Zone
tatic capsule is thin or absent (25). A and vas deferens enter the CZ is de-
“trapezoid” area is formed caudal to The TZ is the site of origin for void of prostate capsule (25). Cancer
the apex by the peripheral zone prox- 10%-20% of prostate cancer. Trans- may escape the confines of the pros-
imally, the rectourethralis muscle urethral resection of the prostate tate through this area of anatomic

612 Radiology
#{149} March 1989
weakness (Fig 6). This po- the surgical capsule,
BIPLANE _________
which separates it from
tential pathway for cancer
spread, the invaginated
#{149}
Sector-Sector \I // the TZ. The TZ appears to
extraprostatic space, ex- be relatively resistant to
tends the length of the cancer invasion from the
ejaculatory ducts to the PZ unless a cancer is large
verumontanum. There is (28).
no tissue barrier between Cancer frequently in-
the invaginated extrapros- BIPLANE _____ volves the apex of the
tatic space and the adja- #{149}
Sector-Linear Jj prostate, where prostate
cent CZ, allowing cancer capsule is thin or absent,
easy access to this path- thus allowing ready ac-
way. Thus, tumor spread cess to the trapezoid area
can readily extend from (25,31) (Fig 7).
the base to the apex of the
prostate gland. When ejac- MULTIPLANE ________
ulatory ducts become en- #{149}
Rotating Sector
IMAGING
veloped by cancer, a “ha- #{149}
Symmetncal TECHNIQUES
lo” sign may be seen on The capability to obtain
axial images. Partial ob- images in transverse as
struction can occur with well as sagittal or parasag-
dilatation of the ipsilater- ittal planes must be avail-
al seminal vesicle. MULTIPLANE able for optimal evalua-
Currently, our US crite- tion of the prostate.
na for seminal vesicle #{149}
Moveable
Though many transducer
and/or ejaculatory duct designs are currently
involvement are (a) a “ha- available (Fig 8), the most
lo” about the ejaculatory
effective design is an
duct produced by sur- “end-viewing” transducer
rounding tumor, (b) oblit- in which scan planes are
eration or displacement of
MULTIPLANE
directly centered along
the beak of seminal vesi- the long axis of the trans-
cle by cancer, (c) cancer ducer. Since the probe
directly extending into a acts as a direct extension
seminal vesicle (31), and/ of the hand, simple ma-
or (d) an extraprostatic neuvering or rotation al-
mass at the entrance of lows instantaneous multi-
Figure 8. Multiplanar/biplanar probes: Biplane sector-sector probe:
the seminal vesicle obli- directional imaging. Rap-
The two sectors are at right angles to each other. The planes over-
terating the seminal vesi- lap in a distal part of the image. Therefore most lesions will have id evaluation of the three
cle/prostate angle. to be relocated when the scan plane is changed. Biopsy is limited dimensions of any suspi-
Microscopic extension to the transperineal route. Biplane sector-linear probe: The linear cious hypoechoic lesion is
of cancer into either the probe is used for longitudinal scanning, and the sector, which
thus possible. Scan planes
seminal vesicles, or along may be a curved array, is used for transverse imaging. There is no
overlap between planes. All lesions must be relocated when the in transverse projections
the invaginated extrapros- are oblique to the true
scan plane is changed. Biopsy is limited to the transperineal route.
tatic space, cannot be Multiplane rotating sector probe with symmetrical rotating axis: All transverse planes, wheth-
demonstrated with TRUS. planes between longitudinal and transverse can be obtained. The er an axial or end-viewing
If a lesion is adjacent to rotation axis is in the center of the image. Any structure on the transducer is used (Fig 9).
the ejaculatory ducts, sem- center axis of the image will stay in the image as the scan plane is In our practice, this end-
inal vesicles, or the medi- changed. Biopsy is limited to the transperineal route. Multiplane
nonmovable sector probe: The scan plane is changed by rotating the viewing probe has proved
al base of the prostate, a highly effective for both
housing of the transducer. All planes between longitudinal and
staging biopsy of the ap-
“transverse” are obtained. The transverse planes sweep from co- diagnosis and biopsy of
propriate areas of poten- ronal to horizontal by tilting the transducer. Any structure on the the prostate.
tial spread must be per- center axis of the image will stay in the image as the scan plane is
formed. changed with rotation. Transrectal biopsy can be performed. Mu!-
tiplane rotating sector probe with asymmetrical rotating axis: Because BIOPSY
the rotation axis is off center, the 40#{176} transverse image changes to
a longitudinal image demonstrating the tissues in front of the The presence of a hypo-
Peripheral Zone
transducer. Any structure on the rotation axis will remain in the echoic lesion only sug-
Seventy percent of image as the scan plane is changed. Both transrectal and transper- gests cancer, which must
prostate cancers originate meal biopsies are possible. be proved by biopsy. With
in the PZ (25). These can- the end-viewing probe,
cers, which may be multi- transrectal biopsies can be
focal (31), are usually located close to from the CZ is easily traversed by performed anywhere in the prostate,
or in direct contact with the prostate cancer. Thus, a PZ cancer can directly in any projection (Fig 10).
capsule. Cancer spreads down these extend into the CZ and spread to The main role for TRUS-guided bi-
paths of least resistance (32): (a) into ejaculatory ducts and/or seminal yes- opsies is to obtain tissue for histolog-
the subcapsular space, and/or (b) ides via the invaginated extraprosta- ic diagnoses. Several cores are neces-
along the prostatic acini and ducts. tic space. sary to enable accurate prediction of
The interface separating the PZ Medially, the PZ is bordered by histologic grade and evaluation of

Volume 170 Number

#{149} 3 Radiology 613
#{149}
 True Horizontal Scanning

10.

“Transverse” = Oblique Coronal Scanning

Figure 9. Horizontal versus transverse imaging. When a trans- 11.

verse image is truly horizontal, the probe actually touches the Figures 10,11. (10) Graphic depiction of
prostate. To create a distance between probe and prostate, the transrectal biopsy technique. (11) End-view-
scanner is tilted away. The transverse plane then becomes an ing probes for transrectal biopsy, with an
oblique coronal plane. automatic Biopty system.

possible extraprostatic extension. THE ROLE OF TRUS than DRE. Since TRUS can also offer
Since we can now visualize the inter- information regarding tumor size
nal anatomy of the prostate, we can An imaging procedure for evaluat- and extent, we recommend that
predict and prove extraprostatic ex- ing anatomic details in the prostate TRUS-guided biopsy be performed
tension by using strategic TRUS- provides valuable information in the first on all palpable lesions. Studies
guided biopsy of known sites of ana- study of prostate cancer. have shown that up to 50% of nega-
tomic weakness: (a) the seminal vesi- In a screening setting, the presence tive biopsies guided by palpation
cle beak, (b) the invaginated of a hypoechoic lesion proved to be have been subsequently proved posi-
extraprostatic space, which follows twice as sensitive as a palpable ab- tive for cancer with TRUS-guided bi-
the ejaculatory ducts to the verumon- normality in predicting the presence opsy (18,33). Should a TRUS-guided
tanum, and (c) the trapezoid area. of cancer (12). In this study, for every biopsy of a palpable lesion not dis-
The automatic Biopty system (Bard two cancers detected with TRUS, one close cancer, a palpation-guided bi-
Urological Division, Covington, Ga) is cancer was detected with DRE. opsy must be performed.
superior to any other method we have In our clinical setting, where a hy- The role of TRUS in staging is to
tried for obtaining histologic speci- poechoic lesion was the criterion for obtain tissue from areas where micro-
mens via the transrectal route (Fig 11). biopsy, 41% proved to be cancer (15). scopic extracapsular extension is like-
In more than 1,000 biopsies, we have Sixty-eight percent of these cancers ly to be present. Biopsy may provide
never obtained insufficient tissue. In were palpable. Therefore, for every histologic confirmation.
the past, using the transperineal route four cancers detected with TRUS, When TURP discloses unsuspected
for biopsy we experienced insuffi- three cancers were detected with cancer and a staging TURP is indicat-
cient tissue cores and crush artifacts DRE. ed, TRUS may be an alternative.
with the 19-gauge Sure-Cut (Sure-Cut In another clinical setting, where a TRUS-guided biopsy of suspected re-
biopsy needle, 230 mm; Meadox Sur- palpable lesion was the criterion for sidual tumor is less expensive and
gimed, Oakland, NJ) and 14-gauge biopsy, 14 cancers were diagnosed less traumatic than repeat TURP.
Tru-Cut needles (Tru-Cut biopsy nee- (19). Transperineal biopsies were
dle, 11.4 cm; Travenol Laboratories, guided by palpation and by TRUS. THE ROLE OF TRUS IN
Deerfield, Ill) (17,18). DRE-guided biopsy results were posi- SCREENING
Strategic TRUS-guided biopsy al- tive for cancer in 13 cases, and TRUS
lows for more accurate staging when in 12. Therefore, though the numbers The role of US in detecting non-
a diagnosis of prostate cancer has were small and the US equipment palpable cancer is controversial.
been established (16). We are cur- was substandard, detection rates for Nonpalpable cancers cannot be
rently conducting an ongoing pro- TRUS and DRE were nearly equal. found without screening. It is accept-
spective study using strategic TRUS- Thus, in any diagnostic situation ed that palpable cancers are clinically
guided biopsy. TRUS is equal to or more sensitive relevant. The clinical significance of

614 Radiology
#{149}
March 1989
nonpalpable cancers found by TRUS die of prostate cancer in 1988 (37). 15. Lee F, Torp-Pedersen S. Littrup PJ. Hypo-
echoic lesions of the prostate: clinical rele-
has yet to be determined. Autopsy Because prostate cancer is the second vance of tumor size, digital rectal examina-
and prostatectomy data will provide leading cause of death from cancer in tion, and prostate-specific antigen. Radiology
1989; 170:29-32.
information about this issue. American men, along with colorectal 16. Stamey TA. Ultrasound-guided Biopty cores:
There is a good correlation be- cancer, we must utilize diagnostic a revolution for the urologist. Presented in
Transrectal Ultrasound of the Prostate: A
tween the volume of cancer and the modalities that enable early detec- Practical Course for Urologists. Stanford Uni-
malignancy potential. In an analysis tion. We support the use of TRUS in versity School of Medicine Postgraduate
Medical Education course, Palo Alto, Califor-
of 100 autopsy specimens, McNeal the early detection of prostate cancer. nia, January 1988.
showed that prostate cancers reach- 17. Lee F, Littrup PJ, McLeary RD. et al. Needle
aspiration and core biopsy of prostate cancer:
ing a size of 1.0 cm3 were clinically comparative evaluation with biplanar trans-
significant (due to capsular invasion SUMMARY rectal US guidance. Radiology 1987; 163:515-
520.
and/or extraprostatic tumor exten- Indications for TRUS are: (a) for di- 18. Torp-Pedersen ST. Lee F, Littrup PJ, et al.
sion) (34). He also showed that the agnosis of nonpalpable cancer, or de-
Transrectal biopsy of the prostate guided by
transrectal ultrasound: experience with longi-
majority of tumors exceeding 3.0 cm3 tection of cancer with greater accura- tudinal and multiplane scanning. Radiology
were no longer confined within the cy than is possible at present; (b) for
1988 (in press).
19. Resnick MI. Transrectal ultrasound guided
prostate. Using this correlation be- guidance of transrectal biopsies of versus digitally directed prostatic biopsy: a
tween tumor volume and malignancy hypoechoic lesions for histologic
comparative study. J Urol 1988; 139:754-756.
20. Cole HM, ed. Diagnostic and therapeutic
potential, we may select those pros- confirmation of cancer; (c) for guid- technology assessment (DATTA): transrectal
tate cancers we wish to diagnose. ance of staging biopsies to ensure di-
ultrasonography in prostate cancer. JAMA
1988; 259:2757-2759.
If in a screening setting we limit agnoses of extraprostatic extension; 21. McNeal JE. Regional morphology and pa-
diagnoses to cancers >0.5 cm3, we thology of the prostate. Am J Clin Pathol
and (d) for staging previously diag- 1968; 49:347-357.
will diagnose 35% of the cancers. nosed prostate cancer. U 22. Blacklock NJ, Boushill K. The zonal anatomy
Prevalence in McNeal’s study was of the prostate in man and in the rhesus mon-
key. (Macaca mulatta). Urol Res 1977; 5:163-
23% (100 of 436). The prevalence 167.
then for those cancers we wish to di- Acknowledgments: The authors wish to ex- 23. Salander H, Johansson 5, Tisell LE. The his-
press their gratitude to Robin Hite, medical il- tology of the dorsal, lateral, and medial pros-
agnose (>0.5 cm3) is 8% (35% of 23%). lustrator; Anne Mitchell, literary consultant; tatic lobes in man. Invest Urol 1981; 18:479-
This prevalence is probably a maxi- 483.
and Michael Wilson, ultrasound technician.
24. Orland SM, Hanno PM, Wein AJ. Prostatitis,
mum value, since it is derived from prostatosis, and prostatodynia. Urology 1985;
an autopsy series and not from 5:439-459.
References 25. McNeal JE. Normal anatomy of the prostate
healthy men without symptoms. gland: axial and s.agittal planes. Presented in
1. Watanabe H, Kaiho H, Tanaka M, Terasawa Y. Transrectal Ultrasound of the Prostate: A
Screening for prostate cancer is
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548.

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