Prostate cancer is one of the most common male cancers in the UK, Europe and the USA, and is currently the second most common cause of male cancer mortality in the USA [1]. Prostate cancer screening by prostate specific antigen (PSA) has become very popular in the USA and many European countries, with calls for some form of prostate cancer screening to be available for men in the UK. Strategies to detect prostate cancer at an early stage have concentrated on PSA and transrectal ultrasound. Initial response by radiologists and urologists to the introduction of transrectal ultrasound in the early 1980s was lukewarm, owing to the use of a chair mounted probe using a low frequency (3.5 MHz) transducer without a biopsy facility. However, a greater understanding of prostate anatomy and cancer location within the prostate, and the introduction of hand-held transducers and spring-operated biopsy devices, together with extensive international contemporary clinical experience, have now ensured that ultrasound guided transrectal needle biopsy of the prostate has become the standard method of prostatic cancer diagnosis. There has been a progressive improvement in the equipment used for ultrasound in the last decade, with the use of higher frequencies, broad bandwidth technology, colour and power Doppler, and most recently harmonic imaging. These refinements aid the demonstration of subtle focal alterations of echogenicity within the prostate. There is still, however, relatively little imaging information available about the biological potential of prostate cancer in an individual patient. Ultrasound contrast agents are now becoming available and these could theoretically aid the visualization of subtle alterations in prostatic echotexture by highlighting changes in the microvasculature. This may help us to distinguish high grade from low grade tumours. Full assessment of prostate cancer by biopsy remains problematic because prostate cancer is often both multifocal and histologically heterogeneous. Recent reports suggest that an eight core systematic biopsy, taking the six parasagittal cores of the conventional sextant biopsy plus two lateral cores, may have the same cancer yield as a detailed lesion directed approach with high specification contemporary ultrasound equipment [2]. Thus, there is a conflict of opinion in the literature between simply increasing the number of cores from systematic biopsy and the alternative approach of using ever more sophisticated ultrasound technology to more precisely identify cancers in areas that might otherwise have been regarded as isoechoic. What, therefore, is the optimum approach to use for contemporary ultrasound guided prostate biopsy?