Extended biopsy schemes have increased the ability to detect prostate cancer and significantly contribute to risk stratification models for men with localized prostate cancer. In addition, they provide more reliable results with respect to predicting the grade of cancer and facilitate treatment planning. Knowing that the apex is entirely composed of peripheral zone tissue and is the most likely site of undiagnosed malignancy, we recommended adding the 2 apical anterior cores to the standard 12 cores biopsy scheme. A 14 cores extended biopsy scheme should routinely be used in the initial evaluation of patients for prostate cancer.Cancers missed on initial biopsy are almost without exception laterally /or apically based, so focus should be on the lateral areas most likely to be positive in patients undergoing repeat biopsy. With the morbidity reportedly no higher than with published rates for sextant biopsy, there is little disincentive to increase the number of cores to 20 if cancer is suspected after negative biopsy. Counter intuitively, despite its tolerability, saturation biopsy does not seem to provide additional value during the initial biopsy, so should be reserved for repeat biopsy.