['To assess the effect of additional extreme apical sampling on prostate cancer (PCa) detection and aggressiveness in patients with standard risk versus high risk of a positive biopsy.', 'Three thousand fifty three men were reviewed from our institution review board approved prostate biopsy database. Two thousand five hundred and twenty one underwent biopsy with 12 cores while 532 underwent 14 core sampling (2 extra cores from the extreme anterior apex). Patients were stratified into one of two risk groups: (1) standard risk of PCa (elevated prostate specific antigen (PSA)\u2009<\u200910\u2009ng/ml, normal digital rectal exam (DRE), and no lesions on transrectal ultrasound (TRUS)), and (2) higher risk of PCa (PSA\u2009>\u200910\u2009ng/ml and/or abnormal DRE and/or lesion on TRUS). Prostate cancer detection and disease characteristics were compared between the biopsy schemes stratified by risk of a positive biopsy.', 'PCa detection with 14 core sampling was more likely in all patients (OR 1.339, 95% CL 1.070-1.676) and in men with standard risk (OR 1.334, 95% CL 1.007-1.769). A greater median number of positive cores (3 vs. 2) and a higher maximum cancer % per core (40% vs. 25%) were seen in the 14 core cohort when stratified to standard risk. Gleason ≥7 was more likely detected with 14 cores in the standard risk group (55.6% vs. 45.2%). Differences in PCa detection and Gleason ≥7 between biopsy techniques were not noted in the higher risk group.'] Do low risk patients benefit from extreme anterior apical sampling on initial biopsy for prostate cancer diagnosis?