Figure 4: TRUS-G biopsy of two lesions requiring special needle orientation and experience for aiming TB. This 62-year-old man with a PSA of 8.25 ng/mL referred to our centre because persisting elevated PSA after 2 biopsy sessions. Last biopsy showed 2 positive cores at the right apex (2 mm each, ). Prebiopsy MRI (a) shows a 13 mm highly suspicious (5/5) image at the extreme apex (AFMS). MRI report (b), as well as the zonal location of this lesion (extreme apex, large urethral contact, size) helped its detection at TRUS (c). This lesion (red-dotted; image (b)-left) could not be detected at TRUS imaging. Core sampling (labeled C2-VI) was performed by brushing the urethral sphincter (yellow-dotted) to avoid its perforation. A hypoechoic image ((d); left image white arrowhead) was visible at TRUS, but not described at prebiopsy MRI. It was sampled (label C1-VI) with high probe angulation (prostate contour is blue-dotted), and simulation of the needle trajectory, in order to avoid urethral or ejaculatory duct damage ((d); right image showing the needle trace). Each lesion was sampled by 2 TB. AFMS targets were both positive with 14 and 13 mm of adenocarcinoma Gleason ; midline lesion (C2vi) TB were both negative.