Gray-scale Transrectal Ultrasonography Research Articles

555 - Contrast enhanced ultrasound for the localization of prostate cancer – correlation with radical prostatectomy specimens

Introduction & Objectives: Trans Rectal UltraSound (TRUS) is an affordable, portable and safe imaging platform well known to the urologist for prostate imaging. However, prostate cancer (PCa) cannot be visualized with Greyscale TRUS. In Contrast-Enhanced UltraSound (CEUS), an intravenous Ultrasound Contrast Agent (UCA) consisting of gas filled microbubbles is used to visualize PCa-associated vascular anomalies. Contrast-ultrasound dispersion imaging (CUDI) analyses the UCA dispersion patterns as the UCA spreads through the prostate, with the intention to objectify and simplify the interpretation of CEUS. The aim was to determine the value of 2D CEUS imaging and the additional value of CUDI derived parametric maps for the localization of significant PCa.

Hypoechoic versus hypervascular lesion in the diagnosis of prostatic carcinoma

ObjectiveThe goal of this study was to get a better understanding the role of Power Doppler (PDUS) and conventional Gray Scale transrectal ultrasound (TRUS) in targeting prostatic biopsy in men with high prostate-specific antigen (PSA). Patients and methodsA prospective comparative study of 100 men, categorized according to PSA level into two groups: Group (A) with a PSA level (4.0–10.0) ng/ml (Gray zone) and Group (B) with PSA >10.0 ng/ml, above Gray zone. Gray Scale scanning was done, followed by Color Doppler and Power Doppler to test the blood flow all over the prostate and suspicious foci. Twelve systematic TRUS-guided core needle biopsies were performed, and additional biopsies of abnormal lesions on Gray Scale TRUS and PD-TRUS. The demographic data, clinical data, imaging results, laboratory investigations, histopathological report and its correlation with pathological results and any complications during or post the procedure estimated. ResultsThe age of the Group (A) ranged between 50 and 75 years with a mean ± S.D. of 65.7 ± 6.8 years, while in the Group (B), it ranged between 54 and 84 years with a mean ± S.D. of 69.5 ± 6.3 years. TRUS biopsy revealed prostate cancer in 11 (35.5%) out of 31 cases of the Group (A) and 35 (50.7%) out of 69 cases of the Group (B) (p < 0.003). Thirty out of 39 (76.9%) from Group (B) were hypervascular in PDUS (p < 0.04).PDUS sensitivity, specificity, positive predictive value (PPV) and negative predictive values were 74.5%, 85.7%, 84.4% and 76.4%. ConclusionPower Doppler ultrasonography (PDUS) increase the cancer detection rate diagnosis, PDUS combination with Gray Scale TRUS-guided biopsy increases the reliability of the diagnosis of cancer prostate.

DO COLOR DUPLEX AND POWER DOPPLER SONOGRAPHY INCREASE THE DETECTION RATE OF PROSTATE CANCER?

Background: Although gray-scale Trans Rectal Ultrasonography (TRUS) was a major achievement in diagnosis of prostate cancer, it has several limitations. Expert users are not able to discriminate among images with more than 32 gray levels out of 256 displayed on a gray-scale image. Objective: The aim of the study was using color and power doppler in targeting prostatic biopsy and detecting prostate cancer. Patients and methods: This prospective study included 100 consecutive patients attended Al-Azhar University Hospitals and National Institute of Urologyand Nephrology with lower urinary tract symptoms (LUTS), and have either Prostatic Specific Antigen (PSA)> 4 ng/ml or abnormal prostate on digital rectal examination (DRE). Patients with coagulopathy, history of prostate cancer diagnosis or evidence of a prostatic intraepithelial neoplasm of any grade were excluded. All patients were subjected to (DRE), International Prostatic Symptoms Score (IPSS), complete laboratory investigation including PSA, pelvi-abdominal ultrasound, gray-scale, color and power doppler TRUS, and TRUS-guided systematic biopsies with other focal lesion-targeted biopsies. Results: Histopathological examination of cores taken from hypo-echoic lesions revealed adenocarcinoma in 24 cases: 6 out of them were of group (A), and 18 were of group (B). So, cancer was detected in 50 % (6/12) of hypo-echoic lesions in group (A), and in 64.3% (18/28) of group (B) which was statistically significant. Correlation between the cores taken from hyper-vascular areas and the results of histopathology revealed that cancer was detected in 38 (74.5%) out of 51 hyper-vascular areas (8 out of them were of group A, and 30 were of group B). So, the incidence of cancer detection in hyper-vascular areas in group B (83.3%) was higher than group A (53.3%) which was statistically significant. Conclusion: The combination of color and power doppler ultrasound and gray-scale TRUS increased the sensitivity of detecting prostate cancer while not decreasing the specificity.

Lokale Bildgebung der Prostata

Recently several new technologies for prostate imaging have been developed. The aim of these technologies was to improve the diagnosis of prostate cancer. Especially the transrectal ultrasound (TRUS) has been refined to the so-called enhanced ultrasound, as regular grey scale TRUS has limited ability to identify cancer lesions in the prostate. In several studies elastography has shown good capability to identify cancer lesions in the prostate as well as to absolutely increase the detection rate of randomized biopsies by up to 10 %.. Contrast-enhanced ultrasound shows varying results in the published literature with increased detection rates on the one hand and unchanged detection rates relative to randomized biopsy on the other hand. The online available ANNA/C-TRUS system shows detection rates with six targeted biopsies that are comparable to the published detection rates of randomized saturation biopsies. Direct systematic comparison to randomized biopsies is missing. The Histoscanning system currently provides the poorest data as no biopsy studies are available. Multicenter trials are mandatory for all new imaging technologies in order to implement them as standard into clinical practice.

Applications of transrectal ultrasound in prostate cancer

Transrectal ultrasound (TRUS) was first developed in the 1970s. TRUS-guided biopsy, under local anaesthetic and prophylactic antibiotics, is now the most widely accepted method to diagnose prostate cancer. However, the sensitivity and specificity of greyscale TRUS in the detection of prostate cancer is low. Prostate cancer most commonly appears as a hypoechoic focal lesion in the peripheral zone on TRUS but the appearances are variable with considerable overlap with benign lesions. Because of the low accuracy of greyscale TRUS, TRUS-guided biopsies have become established in the acquisition of systematic biopsies from standard locations. The number of systematic biopsies has increased over the years, with 10-12 cores currently accepted as the minimum standard. This article describes the technique of TRUS and biopsy and its complications. Novel modalities including contrast-enhanced modes and elastography as well as fusion techniques for increasing the sensitivity of TRUS-guided prostate-targeted biopsies are discussed along with their role in the diagnosis and management of prostate cancer.

Interstitial Brachytherapy Using Virtual Planning and Doppler Transrectal Ultrasonography Guidance for Internal Iliac Lymph Node Metastasis

To expand the indications for high-dose-rate interstitial brachytherapy (HDR-ISBT) for deep-seated pelvic tumors, we investigated the usefulness of Doppler transrectal ultrasonography (TRUS) guidance and virtual planning. The patient was a 36-year-old female. She had right internal iliac lymph node oligometastasis of vaginal cancer 12 months after radical radiotherapy. The tumor could not be found by gray-scale TRUS and physical examination. Virtual planning was performed using computed tomography with template and vaginal cylinder insertion. We uploaded the images to our treatment planning software and reconstructed the contours of the clinical target volume (CTV) and right internal iliac vessel. Virtual needle applicators were plotted using the template holes for virtual planning. At the time of implantation, Doppler TRUS was used to prevent vessel injury by needle applicators. Applicators were implanted in accordance with virtual planning and Doppler TRUS could detect the right iliac vessel. The percentage of CTV covered by the prescribed dose was 99.8%. The minimum dose received by the maximally irradiated 0.1-cc volume for the right internal iliac vessel was 95% prescribed dose. Complete response was achieved, however, radiological findings showed marginal recurrence at 15 months after HDR-ISBT. Post-radiation neuropathy occurred as a late complication four months after treatment; however, the pain was well controlled by medication. We consider that virtual planning and Doppler TRUS are effective methods in cases where it is difficult to detect the tumor by physical examination and gray-scale TRUS, thereby expanding the indications for ISBT.

Transrectal Elastosonography for Diagnosis of Prostate Cancer

Histopathology remains the mainstay of confirming the diagnosis of prostate cancer (PCa). Grey scale (B-mode) transrectal ultrasound (TRUS), which is based on increased brightness in relation to the strength of the echo, is widely used for prostate biopsies [1]. The grey scale TRUS is useful in guiding needles into the desired region as per the biopsy protocol however, it does not differentiate between normal and cancerous tissue in up to 50% of the cases [2-4].

Impact of high‐consistency area evaluated under hand‐operated transrectal compression using a sonographic probe on prostate cancer detection: Clinicopathological analysis

Aim of this investigation was to determine whether the evaluation of a new dynamic finding on conventional greyscale transrectal ultrasonography (TRUS), which we named as high-consistency area (HCA), is useful in detection of prostate cancer (PCa). Fifty-one consecutive patients were prospectively enrolled in this study. When TRUS-guided prostate biopsy was performed, HCA that was difficult to transform, due to transrectal compression using sonographic probe, was evaluated. HCA-targeting biopsy, digital rectal examination (DRE)-targeting biopsy and systematic 12-core biopsy were performed. All biopsy cores were diagnosed histopathologically. As the results, twenty-three PCas were detected in 51 patients. The sensitivity and specificity of HCA-targeting biopsy for correct diagnosis were 60.9% and 78.6%, respectively. The sensitivity and specificity for DRE-targeting biopsy were 47.8% and 78.6%, respectively. In conclusion, HCA-targeting biopsy of this study was superior to DRE-targeting biopsy with regard to detection of PCa. Before prostate biopsy, patients should be evaluated for DRE and HCA, and DRE and HCA-targeting biopsy should be performed.

Comparison of power Doppler ultrasound with gray scale transrectal ultrasound in predicting cancer positive prostate biopsy cores.

The aim of this study is to compare the effect of transrectal power Doppler ultrasound (PDUS) and gray scale transrectal ultrasound (TRUS) for the diagnosis of prostate cancer. Seventy-six patients evaluated with transrectal PDUS and TRUS underwent eight systematic TRUS guided core-needle biopsies, with additional cores from abnormal areas. Histologic diagnoses were classified as benign prostatic hyperplasia, chronic prostatitis, intraepithelial neoplasia and adenocarcinoma. TRUS and PDUS findings of the cases were recorded. PDUS sensitivity, specificity, positive predictive value (PPV) and negative predictive values were 81%, 81%, 54% and 94%, respectively. PDUS had a greater sensitivity and specificity than TRUS (43% and 60%, respectively) and identified cancer cases more accurately (Table 2). Hypervascular foci in PDUS signify suitable zones for biopsy. When combined with systematic TRUS guided biopsy, PDUS increases the cancer detection rate with additional biopsies from suspicious hypervascular foci. Transrectal PDUS guided biopsy should be combined with gray scale TRUS guided biopsy to increase accuracy in the diagnosis of prostate cancer.

Evaluation of contrast-enhanced transrectal ultrasound in differential diagnosis of prostate cancer and benign prostatic hyperplasia

Objective To evaluate the application of contrast-enhanced transrectal ultrasound ( CETRUS) to identify prostate cancer(PCa) from benign prostatic hyperplasia(BPH). Methods A total of 86 patients with focal prostatic disease detected by trans rectal ultrasound(TRUS) were enrolled in this study.Each patient underwent grey-scale TRUS, CE-TRUS, and targeted-biopsy of prostateunder ultrasound guidance successively on the same day. The criteria of perfusion pattern would be statistically analyzed among groups divided by pathological findings. Every patient's images of CE-TRUS were observed and features of perfusion pattern were recorded by two doctors who were blind to any clinical data of patient.Then these features recorded by two doctors were compared, if the features were coherent, they would be recorded as final results,and otherwise two doctors would consult till the features were coherent. Results Compared with BPH group, the enhancement features of PCa group were rapid enhancement, increased enhancement, heterogeneous enhancement, well-defined boundary of lesion after enhancement, asymmetric appearance of intraprostatic vessels, rapid decrease, perfusion defect areas within lesions and the roughly discontinuous juncture between enhancement and no enhancement area within lesions. Conclusions There was significant difference in enhancement pattern between BPH and PCa groups, observing enhancement pattern could help to identify prostate cancer from benign prostate hyperplasia. Key words: Ultrasonography; Microbubbles; Prostatic neoplasms; Prostatic hyperplasia

Contrast-enhanced Gray-scale Transrectal Ultrasound-guided Prostate Biopsy in Men with Elevated Serum Prostate-specific Antigen Levels

Our goal was to evaluate the role of contrast-enhanced gray-scale transrectal ultrasound (CETRUS)-guided prostate biopsy in patients with elevated serum prostate-specific antigen (PSA) levels. A total of 115 men (mean age, 70 years; range, 47-85) with serum PSA levels of greater than 4.0 ng/ml were assessed using gray-scale transrectal ultrasound (TRUS), power Doppler ultrasound (PDU), and CETRUS. Subsequently, these patients underwent systematic sextant transrectal biopsy and additional biopsies for positive sites on gray-scale TRUS, PDU, and CETRUS. The cancer detection rates of the three techniques were compared. Cancer was detected in 63 of the 115 patients (55%). CETRUS was positive in 50 patients, 35 of whom (70%) had prostate cancer; CETRUS had a higher sensitivity, specificity, and accuracy of 65% (41/63), 83% (43/52), and 73% (84/115), respectively. CETRUS could have saved a significant number of patients from undergoing unnecessary biopsies, compared to TRUS and PDU. However, no significant correlation was found between the Gleason score and CETRUS grade. The use of CETRUS in detecting prostate cancer might reduce the number of unnecessary needle biopsies of the prostate in patients with abnormally high serum PSA levels and increase the detection rate of clinically significant prostate cancer.

Transrectal ultrasound in detecting prostate cancer compared with serum total prostate‐specific antigen levels

We carried out a retrospective study to review the efficiency of grey-scale transrectal ultrasonography (TRUS) in detecting prostate cancer compared with the data in recent published work, including alternative imaging methods of the prostate gland. Our study group consisted of 830 patients who underwent TRUS-guided biopsy of the prostate between May 2000 and June 2004. The relation between abnormal TRUS findings and serum total prostate-specific antigen (tPSA) levels was evaluated in patients with prostate cancer who were divided into three different groups according to serum tPSA levels. Group I included patients with tPSA levels of 4-9.9 ng/mL, group II included tPSA levels of 10-19.9 ng/mL and group III included patients with tPSA levels of 20 ng/mL or more. In general, TRUS detected 185 (64%) of 291 cancers with a specificity of 89%, a PPV of 76% and an accuracy of 80%. TRUS findings enabled the correct identification of 22 (56%) of the 39 cancers in group I, 28 (30%) of the 93 cancers in group II and 135 (85%) of the 159 cancers in group III. In conclusion, TRUS alone has a limited potential to identify prostate cancer, especially in patients with tPSA levels lower than 20 ng/mL. Therefore, increased numbers of systematically placed biopsy cores must be taken or alternative imaging methods are required to direct TRUS-guided biopsy for improving prostate cancer detection.

Differentiation of Malignant From Benign Distal Ureteral Obstructions

The purpose of this study was to evaluate the feasibility of transrectal ultrasonography (TRUS) and color Doppler ultrasonography (CDUS) in differentiating malignant from benign distal ureteral obstructions. Our study group consisted of 16 malignant distal ureteral obstructions and 12 benign distal ureteral obstructions. The 16 malignant distal ureteral obstructions were transitional cell carcinomas involving the distal ureter. The 12 benign distal ureteral obstructions consisted of benign strictures (n = 4), ureteral edema after stone passage (n = 3), tuberculosis (n = 2), a fibroepithelial polyp (n = 1), amyloidosis (n = 1), and a hematoma (n = 1). Findings from gray scale transabdominal ultrasonography, gray scale TRUS, CDUS, and duplex Doppler imaging were retrospectively evaluated. Gray scale transabdominal ultrasonography and TRUS showed no specific difference between malignant and benign distal ureteral obstructions. On CDUS, malignant distal ureteral obstructions showed dotlike blood flow in 5, moderately increased blood flow in 9, and markedly increased blood flow in 2; and benign distal ureteral obstructions showed absence of blood flow in 5 and dotlike blood flow in 7. Flow spectra could be obtained in 12 malignant distal ureteral obstructions, and they showed arterial waveforms. Duplex Doppler imaging was not tried in 4 malignant distal ureteral obstructions. In 7 benign distal ureteral obstructions with dotlike blood flow, flow spectra could not be obtained. Moderately or markedly increased blood flow within a ureteral mass on CDUS and an arterial waveform within a ureteral mass on duplex Doppler imaging may be helpful in differentiating malignant from benign distal ureteral obstructions.

Initial evaluation of prostate cancer with real‐time elastography based on step‐section pathologic analysis after radical prostatectomy: A preliminary study

To determine whether real-time elastography can be used to detect prostate cancer as a relatively non-invasive modality based on the tissue strain value. Seventeen patients underwent real-time elastography in conjunction with digital rectal examination (DRE), conventional gray-scale transrectal ultrasonography (TRUS), color Doppler ultrasonography (CDUS), and magnetic resonance imaging (MRI) prior to radical prostatectomy. The elastogram was compared to findings of conventional modalities and pathological findings of prostatectomy specimens. To obtain the elastogram, compression of the prostate was performed along with a visual indicator on a video screen. Twenty of 27 pathologically confirmed tumors were detected with real-time elastography. The cancer detection rate with real-time elastography was superior to the rates of other modalities and nearly equal to both on the anterior side (75.0%) and the posterior side (73.7%) of the prostate. A higher tumor detection rate for real-time elastography was observed for tumors with a higher Gleason score and larger tumor volume. In our preliminary study, real-time elastography in conjunction with gray-scale TRUS is a non-invasive modality to detect prostate cancer.

The potential value of power Doppler ultrasound imaging compared with grey-scale ultrasound findings in the diagnosis of local recurrence after radical prostatectomy

To determine the value of power Doppler ultrasound (PDUS) imaging during transrectal ultrasonography (TRUS) in detecting local recurrence after radical retropubic prostatectomy (RRP). Eighteen patients were evaluated in whom local recurrence of prostate cancer was suspected on the basis of elevated serum prostate-specific antigen (PSA) levels (above 0.4 ng/ml) after RRP with no evidence of metastatic disease. Grey-scale TRUS and PDUS-guided biopsies of the vesicourethral anastomosis (VUA) and perianastomotic soft tissues were obtained after TRUS examinations of the prostatic fossa. The ability to detect locally recurrent prostate cancer using grey-scale TRUS alone was compared with TRUS combined with PDUS. Fifteen of the 18 patients (83%) had positive biopsies for local recurrent tumour at histological examination. TRUS alone detected grey-scale abnormalities in 15 of 18 patients (83%), of whom 14 (77%) had positive TRUS-guided biopsies. PDUS during TRUS showed hypervascularity in 14 of 18 patients (77%). Biopsies of these hypervascular regions were positive in all patients (100%). The sensitivity and specificity of TRUS alone in detecting recurrent tumour were 93 and 67%, respectively, with a positive predictive value (PPV) of 93% and a negative predictive value (NPV) of 67%. TRUS combined with PDUS had a sensitivity and specificity of 93 and 100%, respectively, with a PPV and a NPV of 100 and 75%, respectively.

Prospective Observational Study to Assess Value of Prostate Cancer Diagnostic Methods

The purpose of this article is to evaluate the efficiency and effectiveness of analytical and imaging methods for diagnosing prostate cancer in northwest Spain. The authors investigated prospectively two groups of patients with a pathological digital rectal examination (DRE) or prostate-specific antigen (PSA). Sensitivity, specificity, positive predictive value, negative predictive value, receiver operating characteristics curves, and other analyses were performed to determine the relative contributions of PSA, DRE, gray-scale transrectal ultrasonography (TRUS), color Doppler ultrasound (CDUS), symptoms, and patient age to cancer prediction. The presence of prostatic disease symptoms did not distinguish between subjects with and without cancer. The most sensitive (98%) was total PSA (&gt; 4 ng/mL), and the most specific (78%) was DRE and TRUS (65%). The contribution of PSA, DRE, and TRUS to the diagnosis of prostate cancer was significant. In patients with a PSA between 4 and 10 ng/mL, PSA specificity increased, using a free/total PSA ratio of 15%. The PSA continues to be the most sensitive method for prostate cancer diagnosis. DRE tends to be more negative at early stages of cancer detection. Comparing the conventional TRUS echography with the CDUS, the latter is a better detector in the diagnosis of cancer.

Using gray-scale and two different techniques of color Doppler sonography to detect prostate cancer

Objectives To correlate the findings of prostate color Doppler sonography (CDS) with those of site-specific transrectal ultrasound-guided core biopsy; to evaluate the significance of two different color presets in detecting prostate cancer compared with gray-scale transrectal ultrasonography; and to compare the accuracy of conventional gray-scale transrectal ultrasound (CGS)-guided biopsy with CDS-guided biopsy. Methods Seventy patients were enrolled in this prospective study. CDS was performed before biopsy. Two color presets were used: CDS-1 (high sensitivity) and CDS-2 (high specificity). The color flow was graded on a scale from 0 to 2+. At the completion of the color grading, color maps were constructed. In each case, CDS-guided biopsy was performed followed by CGS-guided biopsy (six sextant biopsies and focal lesional biopsies). Results The cancer detection rate was 33%, 31%, and 27% for CGS-guided biopsy, CDS-1, and CDS-2, respectively. CDS-1 was more sensitive than CDS-2 (81% versus 60%) but both presets had similar specificities (79% versus 82%). CGS-guided biopsy yielded a sensitivity of 90%, a specificity of 38%, and a positive and negative predictive value of 34% and 83%, respectively. A biopsy strategy combining hypoechoicity with increased color flow increased the specificity to 97%, positive predictive value to 68%, and negative predictive value to 84%, but its sensitivity was low (18%). Conclusions Our experience suggests that low-velocity, high-sensitivity color is superior to all other CDS settings. The presence of focal peripheral zone hypervascularity at CDS is associated with a high likelihood of prostate cancer. However, only a combination of CDS guidance with six sextant biopsies may achieve maximal sensitivity and specificity.

New Technical Improvements for TRUS in the Diagnosis of Prostate Cancer

Objectives: Together with the aging population the incidence of prostate cancer (Pca) is still increasing. For the detection of Pca the PSA blood test, digital rectal examination (DRE), and transrectal ultrasound (TRUS) are frequently used methods. TRUS has an important role in diagnosing Pca. However, the low specificity and sensitivity of conventional grayscale TRUS have made it into a volume measuring and biopsy-guiding tool. Methods: A Medline literature search on transrectal ultrasound was performed and relevant articles were reviewed. Results: New ultrasound techniques were introduced to overcome the limitations of conventional grayscale TRUS. In this paper, an overview of developments in TRUS with 3D, Doppler, contrast, intermittent, harmonic, and pulse inversion techniques along with possibilities for future development are discussed. Conclusions: The underlying principles and methods are discussed briefly and clinical results published in recent literature are presented.

Power Doppler ultrasonography-directed prostate biopsy in men with elevated serum PSA levels: an evaluation of the clinical utility and limitations

Objectives. To determine the utility and limitations of power Doppler ultrasonography (PDU)-directed prostate biopsy in patients with elevated serum prostate-specific antigen (PSA) levels. Methods. A total of 108 men (mean age 67.7 years, range 50 to 86) with serum PSA levels of greater than 4.0 ng/mL were assessed using digital rectal examination (DRE), gray-scale transrectal ultrasonography (TRUS), and PDU. Prostate vasculature identified on PDU was judged using a grading system. Subsequently, these patients underwent systematic six-core transperineal biopsy and additional biopsies for positive sites on DRE, gray-scale TRUS, and PDU. Results. A hypervascular site and prostate cancer on PDU was identified in 43 (40%) and 40 (37%) cases, respectively. PDU-directed and systematic six-core biopsies could independently detect 36 and 30 cancer cases, respectively. The sensitivity of PDU for cancer detection was 90%, specificity 90%, positive predictive value 84%, negative predictive value 94%, and accuracy 90%. High test performance was also observed in 53 cases with serum PSA levels of 4.1 to 10 ng/mL (sensitivity 77%, specificity 88%, positive predictive value 67%, negative predictive value 92%, and accuracy 85%). These values were superior or comparable to those of DRE and gray-scale TRUS. Inflammatory reactions and prostatic calculi were probable major causes of false-positive and false-negative results on PDU, respectively. Conclusions. PDU can identify appropriate sites for biopsy and improve the cancer detection rate. However, PDU-directed biopsy does not appear to identify prostate cancer with sufficient accuracy to omit the systematic biopsy, and combined use of these methods should be preferable.

TRUS and Biopsy: Practical Aspects

Transrectal ultrasonography (TRUS) has become a standard imaging technique for prostatic diseases and ultrasound guided biopsies are the golden standard for the early detection of prostate cancer. Newly developed TRUS modalities, such as computer assisted automated detection, neural networks, colour Doppler ultrasound (CDU), power Doppler ultrasound (PDU), contrast ultrasound and three-dimensional imaging cannot replace systemic biopsies in the diagnosis of prostate cancer. However, such modalities will be able to improve biopsy yield and increase sensitivity and specificity of traditional grayscale TRUS. Their use in non-surgical treatment of localised prostate cancer may also improve outcome and reduce side-effects, such as erectile dysfunction. Nevertheless, because the improvements made so far are limited and the fact that these modalities are expensive, they do not yet have a place in routine practice.