How to use new transrectal ultrasound in prostate cancer detection and biopsy for beginners and experts:

A narrative review

Article information

Precis Future Med. 2025;9(1):25-34

Publication date (electronic) : 2025 March 31

doi : https://doi.org/10.23838/pfm.2025.00016

Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Corresponding author: Byung Kwan Park Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-6457 E-mail: rapark@skku.edu

Received 2025 January 9; Revised 2025 February 28; Accepted 2025 March 11.

Abstract

Many radiologists and urologists believe that many prostate cancers are invisible under transrectal ultrasound (TRUS) imaging. Frequently, they use TRUS only as a guiding tool or fuse TRUS images with magnetic resonance images for prostate biopsy in men with high prostate specific antigen. However, TRUS software and hardware have been developed and have potential to depict many prostate cancers. Currently, there are only a few papers dealing with how to use TRUS for detection and biopsy of prostate cancers. The aim of this review is to describe the new TRUS techniques, imaging features, and biopsy techniques.

Keywords: Magnetic resonance imaging; Prostate biopsy; Prostatic neoplasms; Transrectal ultrasound

INTRODUCTION

Transrectal ultrasound (TRUS) is a useful imaging modality to guide a biopsy in men with elevated prostate specific antigen (PSA) [1-3]. Many radiologists and urologists believe that TRUS is not a screening test but only a guiding tool to do a systematic biopsy for cancer detection. They have general consensus that many cancers are not seen on TRUS and do not concern well how to set up TRUS sequence, to control image quality, and to TRUS features of significant prostate cancer. Accordingly, they do not have good idea about what TRUS features suggest peripheral or transition cancer. However, as hardware and software of TRUS scanners have been developed constantly, it can enable so many prostate cancers to be depicted on TRUS images [4-6]. To reach an accurate histologic diagnosis, they need to be familiar with how to prepare good imaging quality, what to suggest cancer and how to differentiate insignificant and significant cancers. Then, they can target a lesion precisely with TRUS without relying on magnetic resonance imaging (MRI)-TRUS fusion techniques. Besides, they can obtain biopsy cores in men whose anus are stenotic from recurrent inflammation or absent following Miles’ operation.

The current Prostate Imaging and Reporting and Data System (PI-RADS) does not rely on TRUS findings but MRI findings to determine the likelihood of significant prostate cancer [7-9]. Therefore, they prefer to use MRI-TRUS image fusion to target a lesion but frequently encounter mis-targeting due to in-born error such as mis-registration of MRI and TRUS images. To our knowledge, there are only a few investigations dealing with the TRUS sequence, imaging findings, and target biopsy of prostate cancer [10-12]. The aim of this review is to show how to prepare TRUS for good scan setting, to describe TRUS features of peripheral and transition cancer, how to differentiate insignificant and significant cancers, and how to apply TRUS features for biopsy.

NECESSITY OF PRE-BIOPSY MRI

Currently, the number of MRI scans is being increased in men with elevated PSA. This imaging modality can be scanned in multi-parametric (mp) sequences, in which anatomical and functional magnetic resonance (MR) imaging helps to detect prostate cancer [13-15]. T2-weighted and diffusion-weighted imaging are the key MR sequences in determining PI-RADS category. Basically, peripheral lesion is categorized with diffusion-weighted imaging and transition lesion is categorized with T2-weighted imaging. mpMRI can precisely predict or stratify the risk of significant cancer in most cases [7-9]. Besides, contrast-enhanced MR imaging offers added value to T2-weighted and/or diffusion-weighted imaging [16]. Accordingly, mpMRI prior to biopsy is strongly recommended to plan how to do a target biopsy in PI-RADS 3–5 lesions. It can reduce unnecessary biopsy, complication, and cost [13-15]. Also, the number of TRUS-guided biopsy cores will be decreasing due to precise targeting a lesion which is depicted on MR images [17]. Post-biopsy bleeding or infection will be reduced because the number of systematic cores can become smaller. For these reasons, mpMRI is now a trend prior to biopsy in men with high PSA. However, there are many things to concern about how to scan and read mpMR images. The current PI-RADS system accepts various kinds of MRI scanners (1.5T vs. 3.0T), coils (surface coil vs. endorectal coil) and MR sequences obtaining T2-weighted, diffusion-weighted, and dynamic contrast-enhanced images. Therefore, image qualities of mpMRI are widely ranged in many institutions and hospitals. Besides, radiologists’ experience and education are not clearly stated in the PI-RADS system. No one knows how many MRI scans they should read per year, how many times they should be educated in the refresher courses or related conferences or how long they should be trained prior to formally reporting prostate mpMR images.

HOW TO PREPARE TRUS

Transducer preparation

A TRUS transducer should be well prepared with ultrasonic gel and condoms to avoid air-induced artifacts. Enough gel is put on the transducer tip and next, transducer is wrapped tight with a condom. This preparation alone is good enough for TRUS imaging. To proceed to biopsy setting, a biopsy guide is placed appropriately on the transducer. Then, sufficient gel is put on the transducer tip and the transducer is wrapped tight with another condom again. Air-trapping should be avoided during these whole preparations. The external orifice of anus is searched and touched by the tip of transducer to gently introduce it into the rectum air. Then, the prostate gland, seminal vesicle, and vas deference are to be centered and magnified to occupy at least half of the whole screen by controlling the scan depth and focal zone. Also, it should be kept in mind that these organs are included as much as possible in the TRUS monitor. Especially, hyperechoic band is frequently created at the anterior rectal wall due to strong reflection of ultrasound (US) and is optimized by timegain control or automatic control such as i-scan. Radiologists and urologists need to check out gray-scale frequently. The entire prostate, seminal vesicle, and vas deference are carefully scanned on gray-scale US and next, abnormal hypervascular area should be searched with color or power Doppler US. The bilateral margins of the prostate are likely to be neglected in the transverse scan and thus, the transducer should be moved laterally not to miss a cancer.

TRUS sequence

Harmonic imaging is a default setting for currently available TRUS scanners, but it is recommended to be replaced with fundamental imaging (Table 1) [18-22]. Even though the latter looks noisier and coarser, it offers better tissue contrast between prostate cancer and normal tissue compared to the latter (Fig. 1). Dynamic range of current TRUS scanners is set more than 60 as a default, but it should be lowered to 40–50 to increase tissue contrast (Fig. 2) [18,19,23]. Fundamental imaging and dynamic range are two key factors in keeping tissue contrast good (Table 1). Even though this TRUS sequence or technique decreases image resolution as a tradeoff, it helps radiologists or urologists to identify a prostate cancer which becomes contrasted from normal tissue clearly [18,19]. Tissue contrast can provide good information on analyzing tumor size, demarcation, and margin. If it becomes high, a tumor becomes well demarcated, and tumor size can be measured precisely. But also, it helps to determine if tumor margin is smooth or irregular.

Table 1.

Two types of TRUS sequences

Fig. 1.

Harmonic imaging vs. fundamental imaging. Harmonic imaging (A) provides low contrast and high resolution images whereas fundamental imaging (B) does high contrast and low resolution images. Therefore, a benign hyperplastic nodule (white arrowheads) and a calcification (black arrowheads) on fundamental image are more clearly depicted compared to those on harmonic image.

Fig. 2.

Low dynamic range vs. high dynamic ranges. Transverse transrectal ultrasound (TRUS) image (A) with low dynamic range (40) depicts more clearly a significant cancer (white arrows) than that (B) with high dynamic range (70) because of high contrast. However, the quality of TRUS image becomes coarse and degraded because of low resolution.

INSIGNIFICANT VS. SIGNIFICANT CANCERS

Tumor echogenicity

Peripheral cancer is frequently seen as a hypoechoic mass on TRUS (Table 2) [10-12]. Reportedly, tumor echogenicity is related to the Gleason score (GS). As cancer echogenicity becomes hypoechoic, the GS becomes greater. Insignificant cancer (GS 6 or less) looks slightly hypoechoic compared to normal peripheral tissue and thus is difficult to detect on TRUS. However, significant cancer (GS 7 or greater) tends to be more hypoechoic than insignificant cancer (Fig. 3). If a lesion is clearly hypoechoic on TRUS, it can be identified and targeted easily. This tumor proves to be histologically a significant cancer [10-12]. However, many benign lesions such as inflammation, infection, infarction, and abscess are seen also as hypoechoic lesions. Therefore, radiologists or urologists need to correlate patients’ clinical signs or symptoms, past medical history, and laboratory findings. But also, MRI findings should be correlated with TRUS findings prior to lesion detection and biopsy.

Table 2.

Insignificant and significant cancer: TRUS findings

Fig. 3.

Significant peripheral cancer in a 60-year-old man with high prostate specific antigen (9.80 ng/mL). (A) Diffusion-weighted axial image shows a Prostate Imaging and Reporting and Data System (PI-RADS) 5 lesion (white arrow) in the peripheral zone of right mid-gland. It is measured 2 cm and hyper-intense. Extra-capsular extension is equivocal. (B) Transverse transrectal ultrasound image shows that the tumor (white arrow) is in the peripheral zone of right base. It is ill-demarcated and heterogeneously hypoechoic. (C) When a transducer is moved to the right lateral transverse plane, extra-capsular extension (black arrowheads) is clearly depicted. The tumor margin is irregular or spiculated. Extensive extra-capsular extension was confirmed at the histologic examination of radical prostatectomy.

Transition cancer in contrast to peripheral cancer is not hypoechoic but hyperechoic compared to adjacent transition tissue (Table 2) [10-12,17,24]. Still, radiologists and urologists are not familiar with this TRUS finding because they stick to traditional concept that prostate cancer is hypoechoic regardless of tumor location. As transition cancer becomes hyperechoic, the GS becomes higher (Fig. 4). Lesion conspicuity becomes clearer and thus tumor targeting becomes more precise. Many benign prostate nodules also can be seen as hyperechoic lesions. If a hyperechoic lesion is lenticular within the benign prostate hyperplastic nodule, it is likely to be a significant cancer which can be categorized as a PI-RADS 4 or 5. When a lesion is difficult to differentiate prostate cancer and benign prostate hyperplasia, radiologists or urologists should review mpMR images for lesion correlation.

Fig. 4.

Significant transition cancer in a 74-year-old man with high prostate specific antigen (4.70 ng/mL). (A) T2-weighted axial image shows a moderately-hypointense lenticular mass (white arrows) in the transition zone of right mid-gland. It is measured 1.6 cm and shows a low likelihood of extra-capsular extension. (B) Transverse transrectal ultrasound image shows that the tumor (white arrow) is in the transition zone of right apex. It is a 2 cm hyperechoic mass which is surrounded by hypoechoic rim (white arrowheads). The tumor margin is irregular or spiculated so that extra-capsular extension (black arrowheads) is clearly depicted.

Tumor size

The size of peripheral or transition tumor is another important finding to differentiate insignificant and significant cancers (Table 2, Figs. 3, 4). If a tumor increases in size, the GS becomes higher. PI-RADSv2.1 suggests that 1.5 cm is a size threshold to distinguish PI-RADS 4 and 5 [7-9]. The proportion of significant cancers is much higher in PI-RADS 5 compared to PI-RADS 4. However, Park et al. [25,26] reported that the size criteria should be changed from 1.5 to 1.0 cm because significant cancer detection rate in a tumor of 1.0 cm or greater becomes higher and is not different from that that in a tumor of 1.5 cm or greater. Further investigations are necessary to determine what size is optimal to differentiate PI-RADS 4 and 5. Many men with serious co-existing diseases frequently does not need systematic biopsy requiring many biopsy cores when they have PI-RADS 5. For this reason, re-adjusting size criteria are of great importance in men who can have high post-biopsy morbidity or mortality.

Tumor texture

Tumor texture is also useful TRUS finding to differentiate insignificant and significant cancers (Table 2) [18,19,27]. As a tumor becomes heterogeneous, the GS becomes higher (Figs. 3, 4). Otherwise, as a tumor becomes homogeneous, it is likely to be insignificant cancer. Frequently, higher GS cancer tends to have necrosis, degeneration, hemorrhage, or calcification. These pathologic features can make the tumor texture look heterogeneous on TRUS image. Evaluating tumor texture seems to be easier on TRUS compared to mpMRI because of higher image resolution because transducer’s frequences can be widely controlled in the commercially available TRUS scanners. If a tumor becomes heterogeneous, the GS becomes various according to where target cores are obtained within the tumor. Therefore, target cores should be sampled in the tumor periphery as well as tumor center [28].

Tumor margin

Tumor margin is another important finding to differentiate insignificant and significant cancers (Table 2) [18,19]. As it becomes irregular, infiltrative, or spiculated, the GS becomes higher (Figs. 3, 4). Insignificant cancer tends to have smooth tumor margin where the GS is 6 or less. If a tumor margin becomes partly irregular, infiltrative, or spiculated, it should be targeted to discover higher GS cancer. When a tumor shows becomes locally aggressive, the tumor margin is infiltrative or spiculated in most cases. Fundamental imaging offers better information on tumor margin which is clearly identified under strong tissue contrast. Therefore, radiologists and urologists need to replace harmonic imaging with fundamental imaging to precisely analyze tumor margin on TRUS.

Tumor vascularity

If GS becomes higher, a tumor tends to be hypervascular because of increased vascularity [29]. Color or power Doppler TRUS shows significant cancer to have strong frequency shift, suggestive of tumor hypervascularity [30,31]. This finding is frequently seen in the peripheral significant cancer. However, it is not seen in many transition significant cancer. Probably, it is due to the distance between transducer and tumor. Generally, transition cancer is far from the transducer compared to peripheral cancer. Therefore, analyzing tumor vascularity is difficult when a tumor is close to the anterior capsule. When a tumor is detected with gray-scale TRUS, a transducer should not be pushed to the posterior capsule because of banana-shape deformity of the prostate. However, it should be pushed if a lesion is close to the anterior capsule to shorten the distance between transducer and tumor. If an anterior tumor becomes close to the transducer, analyzing vascularity and tumor targeting are more accurate.

HOW TO BIOPSY WITH TRUS

Correlation of MRI and TRUS

TRUS-guided biopsy is usually performed when a PI-RADS 4 or 5 lesion is detected on mpMR images because significant cancer is likely or highly likely to exist. Many radiologists or urologists do not know well how it is precisely identified or targeted on TRUS images. There is a significant difference between MRI and TRUS images in terms of tumor location, size, and shape because of different scan axis between TRUS and MRI (Fig. 5). Usually, MRI is scanned perpendicular to the pros tate urethra, whereas TRUS is scanned oblique to it [18,19]. As a tumor is closer to anterior capsule on MR images, it looks closer to the apex on TRUS images (Fig. 5) [18,19]. As a tumor is closer to the posterior capsule on MR images, it looks closer to the base on TRUS images (Fig. 5) [18,19]. This location difference also results in different tumor size and shape on TRUS. Even though a tumor is round and 1.0 cm or greater, it is not surprising that it looks oval or less than 1.0 cm on TRUS images. Therefore, if radiologists or urologists are not familiar with these differences, they have difficulty in detecting a tumor on TRUS images. When TRUS is scanned to search for a tumor, a transducer should not be pushed to the posterior capsule because a tumor is embedded or deformed. Also, the prostate tends to look like a banana. This shape deformation is more severe in peripheral tumor than transition tumor. These imaging findings or techniques are also useful when an ultra-resolution TRUS scanner is performed. Systematic biopsy barely can be skipped because it offers added value to significant cancer detection [32]. However, if men with severe co-existing diseases have locally aggressive tumor and lymphatic or hematogenous metastasis, target biopsy alone is good enough to detect a significant cancer. Only a few target cores are sufficient to confirm a significant cancer in men who have extra-capsular extension, seminal vesicle invasion or metastasis if he does not wean anti-coagulant therapy [17].

Fig. 5.

Correlation of tumor location between magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS). (A) T2-weighed sagittal image indicates the MRI scan axis (white lines) perpendicular to the prostate urethra. Three round lesions are in the mid-gland and marked with blue (anterior), yellow (middle), and red (posterior). (B) T2-weighed sagittal image indicates the TRUS scan axis (white lines) oblique to the prostate urethra. Each lesion is located at the apex (blue), mid-gland (yellow), and base (red). (C) Transverse TRUS image shows the blue lesion in the anterior apex. As a lesion becomes closer to the anterior capsule on magnetic resonance (MR) image, it is more inferiorly located on TRUS image. (D) Transverse TRUS image shows the yellow lesion in the center of mid-gland. As a lesion is located with the same distance to anterior and posterior capsules on MR image, the tumor location is not changed on TRUS image. (E) Transverse TRUS image shows the red lesion in the posterior base. As a lesion becomes closer to the posterior capsule on MR image, it is more superiorly located on TRUS image.

Target and systematic biopsies

Before radiologists and urologists begin TRUS-guided biopsy, they need to perform local anesthesia to reduce pain [33-35]. Lidocaine should be injected around the bilateral neurovascular bundles at the level of base. They should wait for 10 minutes until lidocaine works and then begin target and systematic biopsies.

If a tumor is targeted and biopsied with 1–2 cores alone (oligo-targeting), the GS can be underestimated [28]. Even though a biopsy needle is bound for the tumor center, it is slightly off centered in many cases [18]. Therefore, if 5–6 cores should be sampled from the tumor, multi-targeting may increase the likelihood of detecting higher GS [28]. A 12-core systematic biopsy is recommended to do a biopsy of PI-RADS 2–3 lesions. Adding systematic biopsy to target biopsy contribute to detect higher GS cancer in PI-RADS 1–3 compared to PI-RADS 4–5. Performing multi-target and/or systematic biopsy increases the likelihood of significant cancer detection [32,36]. However, it is doubtful if systematic biopsy with many biopsy cores should be performed always in men with PIRADS 5 showing clearly extra-capsular extension, seminal vesicle invasion or metastasis. When a lesion is close to the posterior capsule, a transducer should not be pushed to the tumor because it is frequently invisible. However, when a lesion is close to the anterior capsule, a transducer should be pushed slightly to the posterior capsule. This procedure makes the tumor-to-transducer distance shortened for precise tumor targeting. When systematic biopsy is performed, pushing transducer is useful to obtain longer cores and to reduce post-biopsy bleeding, as well.

Currently, the term ‘target biopsy’ is not well known because many radiologists and urologists are unfamiliar with the new TRUS techniques and imaging features as describe above. They still insist that it is cognitive biopsy. However, cognitive biopsy should be defined only when cores are obtained when a tumor is expected to exist on TRUS. If a tumor is identified on TRUS, we should not use cognitive but target biopsy [37].

Prostate biopsy in stenotic anus

If radiologists or urologists are familiar with new TRUS techniques and imaging features, they can try to do a prostate biopsy in men with stenotic anus as follows. TRUS-guided biopsy is successfully performed in many cases without relying on general anesthesia. Those who have anal stenosis are likely to have recurrent fistula, fissure, and/or hemorrhoid. The anus becomes so stenotic that it cannot be easily dilatated greater than the diameter of TRUS transducer. They complain of severe pain when a transducer is forced to introduce into the stenotic anal canal. Enough lidocaine gel is carefully put on external and internal orifices with a gloved finger and wait for 10 to 15 minutes before a transduce is introduced [38-40]. Then, a transducer can gently pass through the anal canal in many cases without so pain or resistance. Radiologists or urologists try to move the transduce tip to the posterior prostate capsule as close as possible in order to shorten the distance between transducer tip and prostate tumor. Shortening the tumor-to-transducer distance is useful for precise tumor targeting. If these procedures do not work, general anesthesia is recommended for prostate biopsy.

Prostate biopsy in absent anus

Those who have a history of Miles’ operation due to ano-rectal cancer do not have anus. Therefore, radiologists or urologists cannot perform TRUS but transperineal US-guided biopsy. Most peri-rectal fat as well as the rectal cancer is surgically removed and thus prostate becomes closer to the perineum (Fig. 6) [37,41,42]. Accordingly, a PI-RADS 4 or 5 lesion can be depicted when transducer tip is pushed to the perineum [37,41,42]. As a tumor becomes larger or closer to the apex, cancer detection rate increases. Park et al. [41] reported that PI-RADS 5 lesions were all depicted and targeted on transperineal biopsy.

Fig. 6.

Transperineal biopsy in a 71-year-old man with high prostate specific antigen (11.90 ng/mL). (A) T2-weighted axial image shows a Prostate Imaging and Reporting and Data System (PI-RADS) 5 lesion (black arrow) in the right mid-gland. His rectum and peri-rectal fat are absent (black arrowhead) due to rectal cancer which was treated with Miles’ operation 10 years ago. As a result, the distance (white arrow) between prostate and coccyx becomes shortened. (B) Transverse transrectal ultrasound image shows clearly a hypoechoic mass (white arrow) in the peripheral zone of right base. A black arrowhead indicates the surgical scar in which rectal and peri-rectal fat were surgically resected.

Important technical tips of transperineal biopsy are sufficient local anesthesia, pushing transducer constantly, and keeping US images good for lesion targeting [41]. Perineum is very sensitive to the pain and thus local anesthesia is repeated many times to kill pain completely. Pushing transducer is important to shorten the tumor-to-transducer distance for good tumor depiction and targeting. Unlike TRUS, keeping a transducer constant to the perineum is difficult because it is not introduced into hollow viscus. Besides, lidocaine or US gel makes it slippery and difficult to fix at the skin entry site of a biopsy needle.

HOW TO REDUCE BIOPSY COMPLICATIONS

Prior to biopsy, patients need to fast for at least 6 hours and to empty their recto-sigmoid colon to remove fecal material as much as possible [43]. Acute prostatitis is one of the frequent complications and can result in life-threatening complications such as abscess formation and sepsis [44-46]. Antibiotic medication is recommended from one day before biopsy to post-biopsy 3 to 5 days [47-49]. During the biopsy procedures, a biopsy needle should be draped with sanitizer just before each core is sampled. This sterile procedure reduced the incidence of acute prostatitis in my institute. Radiologists and urologists are recommended to perform TRUS immediately after biopsy is completed [50]. They can detect biopsy tracts to determine if they target a tumor precisely and bleed actively. The tracts are seen as hyperechoic or hypoechoic lines [36,50]. When the hyperechoic lines are crossing the tumor, this finding indicates that tumor targeting is precise. When blood flow is seen in the hypoechoic lines, transducer compression is useful under the guidance of color Doppler TRUS [50]. If the bleeding is stopped, blood flow is not seen any longer on color Doppler TRUS. The hypoechoic line frequently becomes hyperechoic because of thrombosis.

CONCLUSION

Current TRUS cannot be merely a guiding tool for prostate biopsy but used for cancer detection. This imaging modality has potential to depict many significant cancers which are detected or missed on MR images. Therefore, radiologists or urologists need to be familiar with new TRUS imaging features and techniques to target a significant cancer.

Notes

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS

Conception or design: BKP.

Acquisition, analysis, or interpretation of data: BKP.

Drafting the work or revising: BKP.

Final approval of the manuscript: BKP.

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TRUS parameters	TRUS sequences
TRUS parameters	Harmonic imaging	Fundamental imaging
Image quality	Good	Poor
Image resolution	Good	Poor
Tissue contrast	Poor	Good
Dynamic range	High	Low
Image artifacts	Rare	Frequent

Tumor morphology	Peripheral cancer		Transition cancer
Tumor morphology	Insignificant findings	Significant findings	Insignificant findings	Significant findings
Tumor size	Small	Large	Small	Large
Tumor demarcation	Good	Poor	Good	Poor
Tumor margin	Smooth	Irregular	Smooth	Irregular
Echo degree	Less hypoechoic	More hypoechioc	Less hyperechoic	More hyperechoic
Echo texture	Homogeneous	Heterogeneous	Homogeneous	Heterogeneous
Tissue perfusion	Low	High	NA	NA
Hypoechoic rim	NA	NA	Clear	Unclear