Urology Annals
About UA | Search | Ahead of print | Current Issue | Archives | Instructions | Online submissionLogin 
Urology Annals
  Editorial Board | Subscribe | Advertise | Contact
Users Online: 714   Home Print this page  Email this page Small font size Default font size Increase font size

Table of Contents
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 101-104  

Histopathological diagnoses and patterns in transrectal ultrasound-guided prostatic biopsy series from a large tertiary care center in Saudi Arabia

Department of Urology, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia

Date of Submission16-May-2020
Date of Acceptance19-Jun-2020
Date of Web Publication04-Nov-2020

Correspondence Address:
Dr. Ali A Alsulihem
Department of Urology, Prince Sultan Military Medical City, P O Box: 31465, Riyadh 11497
Kingdom of Saudi Arabia
Login to access the Email id

DOI: 10.4103/UA.UA_78_20

Rights and Permissions

Aim: The aim of the study was to report our transrectal ultrasound (TRUS)-guided prostatic biopsy histopathological diagnoses and clinical findings in our prostate cancer patients in a tertiary care center.
Methods: We have reviewed our TRUS biopsy series done in our department from January 2011 to December 2016. We reviewed our patient's prebiopsy prostate-specific antigen (PSA) findings and the histopathological diagnoses and determined the clinical and pathological features of prostate cancer patients in our series.
Results: A total of 398 patients underwent 12 core TRUS biopsies. Benign prostatatic hyperplasia was found in 48.5% of the patients and prostate cancer was found in 113 patients (28.4%). Among them, metastatic prostate cancer was found in 51.7% of them. High Gleason score (8–10) was found in 56.6% and a PSA of more than 20 was found in 63.3% of the patients.
Conclusion: We recommend a mass public awareness program to encourage our patients to seek early prostate cancer screening and to alert the medical community to encourage more awareness of prostate cancer screening.

Keywords: Gleason score, prostate biopsy, prostate cancer

How to cite this article:
Alsulihem AA, Al-Muaiqel M, Alsunbul A, Jawhar AB, Al-Dughaiman A, Bedaiwi KK, Al-Rashidi S, Al-Harbi F, El-Tholoth HS, Al-Hagbani M, Milibary B, Alghamdi AM. Histopathological diagnoses and patterns in transrectal ultrasound-guided prostatic biopsy series from a large tertiary care center in Saudi Arabia. Urol Ann 2021;13:101-4

How to cite this URL:
Alsulihem AA, Al-Muaiqel M, Alsunbul A, Jawhar AB, Al-Dughaiman A, Bedaiwi KK, Al-Rashidi S, Al-Harbi F, El-Tholoth HS, Al-Hagbani M, Milibary B, Alghamdi AM. Histopathological diagnoses and patterns in transrectal ultrasound-guided prostatic biopsy series from a large tertiary care center in Saudi Arabia. Urol Ann [serial online] 2021 [cited 2021 Sep 22];13:101-4. Available from: https://www.urologyannals.com/text.asp?2021/13/2/101/299952

   Introduction Top

Although prostate cancer is the second most common cancers in worldwide,[1] it is not as common in Saudi Arabia. In the United States, prostate cancer is the most common noncutaneous malignancy in men,[2] while in Saudi Arabia, it ranks sixth in men.[3] The age-standardized incidence rate was reported to be 4.5/100,000 in 2012, which is low when compared to the Western countries. AIRS for Ireland was 126.3/100,000 in the same period, 16 times higher than Saudi Arabia.[4],[5] In the United States, the incidence is about 100–126/100,000 population,[6] compared to the gulf countries which is between 3.1 and 6.5/100,000 population.[7],[8],[9] This low incidence rate was attributed to the lower aging population in our country.[10] However, the incidence of prostate cancer has increased by 48% from 1994 to 2006, which makes it the top raising genitourinary cancer in the country during that period.[10] Prostate cancer is often found advanced at presentation in Saudi Arabia. In the Eastern region, the median prostate-specific antigen (PSA) level at diagnosis was 52 ng/L, 65% had a PSA more than 20 ng/mL, and 52% of their series had bone metastasis at presentation.[11] In another series from Madinah city, the mean PSA was 363.4 ng/mL, and 81,6% of the cancer patients had PSA level >100 ng/mL.[12] Furthermore, in another screening trial from Riyadh city, the rate of discovering an advanced disease upon diagnosis was 26.9% of confirmed cancer cases,[13] in comparison to the United states where the finding of metastatic disease is estimated at around 4%.[14] This high incidence of the advanced stage upon detection could be due to a lack of national screening program and insufficient public awareness of prostate cancer.[4],[11],[12],[13]

Our aim in this study is to review a large series of transrectal ultrasound (TRUS)-guided prostate biopsy from our tertiary care center. Our primary outcome is to identify the prevalence of prostate cancer upon biopsied individuals and the stage at diagnosis. Secondary outcomes include the indication for biopsy, various histopathological patterns, the correlation of PSA level and diagnosis, and prostate cancer treatments undertaken among our patients.

   Methods Top

We retrospectively reviewed TRUS-guided biopsy that has been done at the Urology Department in Prince Sultan Military Medical City, Riyadh, Saudi Arabia. We collected the data for patients starting from 2011 until 2016. We have done a 12-core biopsy for all patients. All procedures have been done under local anesthesia. Prebiopsy negative urine culture has been obtained, and all patients have received prebiopsy antibiotics. We collected the patient age, various indications for biopsy, PSA level, and the digital rectal examination (DRE) findings. Histopathological diagnoses were also reviewed. Then, we have further examined the patients with prostate cancer and determined their prevalence whether localized or metastatic disease at presentation and the treatment they underwent. Data were analyzed using SPSS version 20 (SPSS Inc. Chicago, IL, USA).

   Results Top

From January 2011 to November 2016, a total of 398 biopsies have been done in our center for high PSA, abnormal DRE, or both. The mean age was 69.72 years (range: 38–102, standard deviation: 10.859).

DRE findings were normal in 108 (27.1%) and abnormal in 244 (61.3%) patients, while the remaining patients (46 patients, 11.6%) had no documentation of their DRE findings because of lack of documentation or patient refusal to undergo DRE.

PSA level was available for all patients. Ninety-two (23.1%) patients had a PSA <4 ng/mL, 148 (37.2%) of them had a PSA level between 4 and 10 ng/mL, 60 (15.1%) had a PSA level between 10 and 20 ng/mL, and 98 (24.6%) had a PSA level above 20 ng/mL.

The overall histopathological diagnosis of prostate cancer has been found in 113 (28.4%) and prostatic intraductal neoplasia in 7 patients. The most common diagnosis in our series was benign prostatic hyperplasia in 48.5% of the patients [Table 1].
Table 1: Overall histopathological diagnoses in total biopsy series

Click here to view

Among prostate cancer patients (n = 113), 68.1% of them has a PSA level above 20 ng/mL. About 13.3% had a PSA level between 10 and 20 ng/mL, 15% had a PSA level between 4 and 10 ng/mL, and 3.5% had a PSA level below 4 ng/mL [Table 2]. DRE was abnormal in 54.5%, 13% had a normal DRE, and 32.5% refused DRE. Gleason score for prostate cancer patients was ≤6 in 18 patients, Gleason score of 7 in 31 patients, and Gleason score of 8–10 was found on 64 patients [Table 3].
Table 2: Prostate-specific antigen level among prostate cancer patients

Click here to view
Table 3: Gleason score among diagnosed prostate cancer patients

Click here to view

Metastatic prostate cancer upon diagnosis was found in 52.2% of our prostate cancer patients. Localized prostate cancer was found in 54 patients. Among those, 31.5% had a Gleason score of 6, 40.7% had a Gleason score of 7, and 27.8% had a Gleason score of 8–10. About 46.3% had a PSA of 20 ng/mL, 16.7% with a PSA between 10–20 ng/mL, and 37.1% had a PSA <10 ng/mL. They were managed as following: 9 (16.7%) had radical prostatectomy, 38 (70.4%) had radiotherapy with hormonal therapy, 4 (7.4%) underwent active surveillance, while 3 (5.5%) had no documentation of the treatment they have received [Figure 1].
Figure 1: Algorithm of diagnosed prostate cancer patients and the treatment they have received

Click here to view

   Discussion Top

Prostate cancer in Saudi Arabia is not as common as in the western world.[5] This might be attributed to the less aging population in the country.[10] In a study comparing the results of TRUS biopsy between the Saudi and Canadian centers, the prostate cancer prevalence was 13.6% in King Saud University Hospital (KSUH) group and 49.1% in McGill University Health Center.[15] The prevalence of prostate cancer from Madinah was 17.7%.[12] Our series had a prevalence of 28.4%, which is higher than the reported from KSUH and Madinah groups but still lower than MUHC in Canada. This might be attributed to higher patients in our series (398 patients) which is the highest reported series from Saudi center or due to dated results (2011–2016) when compared to Madinah (2006–-2013) and KSUH (pre-2013). Our population is getting more urbanized, adopting a more western lifestyle, and having a more aging population due to improving health services. This might impact the prevalence of prostate cancer in the coming decades. In fact, the diagnosis of prostate cancer is increasing and becoming more prevalent as reported by Abomelha.[10] The incidence rate was reported as 3.3/100,000 population in 2000,[9] increased to 4.5 in 2008,[5] then to 5.5 in 2010.[3]

The prevalence of metastatic prostate cancer is high in our series (52.2%). In a series from the Eastern province, the rate of metastatic disease was 52%.[11] These are high figures when compared to the Western world where the incidence is about 4% upon diagnosis.[14] This enormous difference can be attributed to the lack of screening programs in our country and the lack of public awareness about the disease. The latest Saudi Oncology Society and Saudi Urological Association combined management guidelines for prostate cancer have not included any statements regarding screening.[16] Furthermore, a recent screening trial has advised against screening in Saudi Arabia due to low incidence (0.24%) but recommended increasing public awareness and shared decision-making with patients about PSA testing.[4] The lack of public awareness is evident in our series, as there were 11.6% of our patients refused the physical examination. Furthermore, in the screening trial by Arafa et al., they have noticed that 17.7% of patients with high PSA have lost follow-up, and the DRE was not carried out for most of their patients as it causes embarrassment.[4]

There is a higher prevalence of locally advanced disease in our series, as reflected by choice of radiation and hormonal therapy as the treatment modality in 70.4% of localized prostate cancer patients, along with a high prevalence of PSA level of 20 ng/mL and high prevalence of higher Gleason score (8–10), which were 63.3% and 56.6%, respectively. In the Eastern Province series, 65% of the patients had a PSA level above 20 ng/mL, which is comparable to our data. In Madinah series, PSA level <20 ng/mL was found only in 1.5% of their cancer patients and PSA level >100 ng/mL was found in 81.6%. All these figures are indicating the need for more rigorous attention to discover the disease in earlier stages.

Our study was not without limitations. Our data were retrospectively collected. Complete data were not available to all patients. Some have no documentation about their DRE, and some of our cancer patients have no documentation about the treatment they have received, possibly due to seeking treatment at another center. Our patients were from all over Saudi Arabia, but given the nature of our hospital, they were mostly from military or military families. Our center is a tertiary center and accepts oncology patients, which could have potentially increased or advanced and metastatic cases in our series.

   Conclusion Top

We recommend a mass public awareness program in our country, addressing the importance of prostate cancer early detection and the importance of PSA testing and DRE. We should increase the role of primary care physicians to do early PSA testing and the importance of shared decision making regarding prostate cancer screening with their patients. We cannot recommend a mass screening program due to the low prevalence of the disease in the country, but we should stress upon the fact that the aging population is increasing, and the prevalence of the disease is increasing, and the need for screening program might be necessary in the coming decades. We also encourage further research on prostate cancer in Saudi Arabia.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Center MM, Jemal A, Lortet-Tieulent J, Ward E, Ferlay J, Brawley O, et al. International variation in prostate cancer incidence and mortality rates. Eur Urol 2012;61:1079-92.  Back to cited text no. 1
Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017;67:7-30.  Back to cited text no. 2
Saudi Cancer Registry Annual Report; 2010. Access link: https://nhic.gov.sa/en/eServices/Documents/2010%20Report.pdf. [Last accessed on 2020 Jul 06].  Back to cited text no. 3
Arafa MA, Farhat KH, Al-Atawi MA, Rabah DM. Prostate cancer screening in a low prevalence population. Is it worth it? Saudi Med J 2017;38:733-7.  Back to cited text no. 4
Alghamidi IG, Hussain II, Alghamdi MS, El-Sheemy MA. The incidence rate of prostate cancer in Saudi Arabia: An observational descriptive epidemiological analysis of data from the Saudi Cancer Registry 2001-2008. Hematol Oncol Stem Cell Ther 2014;7:18-26.  Back to cited text no. 5
Parkin DM, Whelan SL, Ferlay J, Raymond L, Young J, editors. Cancer Incidence in Five Continents. Lyons: IARC Scientific Publications; 1997.  Back to cited text no. 6
Hanash KA, Al-Othaimeen A, Kattan S, Lindstedt E, Al-Zahrani H, Merdad T, et al. Prostatic carcinoma: A nutritional disease? Conflicting data from the Kingdom of Saudi Arabia. J Urol 2000;164:1570-2.  Back to cited text no. 7
Kehinde EO. Prostate cancer in the Middle East: Perspective Oman. In: Belldegrun A, Kirby RS, Oliver RT, editors. New Perspectives in prostate cancer. Oxford: ISIS Medical Media; 1998. p. 383-90.  Back to cited text no. 8
Memon A, Al-Muhanna AN. Annual cancer incidence in Kuwaitis 1992-1993. In: Parkin DM, Whelan SL, Ferlay J, Raymond L, Young J, editors. Cancer Incidence in Five Continents. VII Lyons: IARC Scientific Publications; 1997.  Back to cited text no. 9
Abomelha MS. Trends of genitourinary cancer among Saudis. Arab J Urol 2011;9:199-202.  Back to cited text no. 10
Osman E, Gomha MA, Harb A, Aldayel A, Aloraifi I, Almousa R, et al. An early-detection programme for prostate cancer in Saudi men: A call from a tertiary-care centre in the Eastern province. Arab J Urol 2014;12:187-91.  Back to cited text no. 11
Albasri A, El-Siddig A, Hussainy A, Mahrous M, Alhosaini AA, Alhujaily A. Histopathologic characterization of prostate diseases in Madinah, Saudi Arabia. Asian Pac J Cancer Prev 2014;15:4175-9.  Back to cited text no. 12
Rabah DM, Arafa MA. Prostate cancer screening in a Saudi population: An explanatory trial study. Prostate Cancer Prostatic Dis 2010;13:191-4.  Back to cited text no. 13
Gallina A, Chun FK, Suardi N, Eastham JA, Perrotte P, Graefen M, et al. Comparison of stage migration patterns between Europe and the USA: An analysis of 11 350 men treated with radical prostatectomy for prostate cancer. BJU Int 2008;101:1513-8.  Back to cited text no. 14
Al-Abdin OZ, Rabah DM, Badr G, Kotb A, Aprikian A. Differences in prostate cancer detection between Canadian and Saudi populations. Braz J Med Biol Res 2013;46:539-45.  Back to cited text no. 15
Abusamra A, Murshid E, Kushi H, Alkhateeb S, Al-Mansour M, Saadeddin A, et al. Saudi oncology society and Saudi urology association combined clinical management guidelines for prostate cancer. Urol Ann 2016;8:123-30.  Back to cited text no. 16
[PUBMED]  [Full text]  


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded103    
    Comments [Add]    

Recommend this journal