Objective• To determine the rate of hospital re-admission for sepsis after transperineal (TP) biopsy using both local data and worldwide literature, as there is growing interest in TP biopsy as an alternative to transrectal ultrasonography (TRUS)-guided biopsy for patients undergoing repeat prostate biopsy. Patients and Methods• Pooled prospective databases on TP biopsy from multiple centres in Melbourne were queried for rates of re-admission for infection.• A literature review of PubMed and Embase was also conducted using the search terms: 'prostate biopsy, fever, infection, sepsis, septicaemia and complications' . Results• In all, 245 TP biopsies were performed (111 at Alfred Health, 92 at Epworth Healthcare, 38 at Peter MacCallum Cancer Centre, and four at other institutions).• The rate of hospital re-admission for infection was zero.• The literature review showed that the rate of sepsis after TRUS biopsy appears to be rising with increasing rates of multi-resistant bacteria found in rectal flora, and is as high as 5%.• However, the rate of sepsis from published series of TP biopsy approached zero. Conclusions• Both local and international data suggest a negligible rate of sepsis with TP biopsy.• This compares to a concerning rise in the rate of sepsis after TRUS biopsy due to the increasing prevalence of multi-resistant bacteria in rectal flora.• Although TRUS biopsy is convenient, cheap and quick to perform, we think that TP biopsy should now be offered as an option, not only to patients undergoing repeat prostate biopsy, but to all patients in whom a prostate biopsy is indicated.

It is safe to use single-dose cephazolin only as antibiotic prophylaxis prior to TPB, negating the need for quinolones. This study supports Australia's current Therapeutic Guidelines recommendation for TPB prophylaxis and the existing evidence that sepsis post-TPB is a rare complication. Whether any antibiotic prophylaxis is needed at all for TPB is the subject of a future study.

Prostate biopsy is typically performed via either the transrectal or transperineal approach. MRI-targeted biopsy, whether using any of the three options of cognitive fusion, MRI-ultrasound fusion software, or in-bore MRI-guided biopsy, can also be performed via either transrectal or transperineal approaches. As an extension of traditional random prostate biopsy, the transrectal approach is far more commonly used for MRI-targeted biopsy due to its convenience. However, in the context of today’s increasing multi-drug resistance of rectal flora, the transperineal approach is being used more often due to its lack of septic complications. In addition, only a first-generation cephalosporin, not a fluoroquinolone, is required as antibiotic prophylaxis. Evidence shows excellent detection rates of significant prostate cancer using magnetic resonance imaging (MRI)-targeted and/or systematic transperineal biopsy (TPB). However, there are no head-to-head studies comparing the different MRI-targeted methods within TPB. To provide truly patient-centred care, the biopsy technique using the safest method with the highest detection rate of significant cancer should be used. Depending on healthcare context and hospital resource utilization, MRI-targeted TPB is an excellent option and should be performed wherever available and feasible. Whilst building capacity for TPB in one’s practice, the routine use of rectal culture swabs prior to any transrectal biopsies is strongly encouraged. Independent of biopsy route, the addition of systematic cores needs to be discussed with the patient weighing maximal detection of significant cancer against increased detection of insignificant lesions.

ConclusionsTPB is an alternative approach to TRUS biopsy of the prostate, offering a high rate of detection of clinically significant prostate cancer. It provides excellent sampling of the anterior region of the prostate, which is often undersampled using the TRUS approach, and should be considered as an option for all men in whom a prostate biopsy is indicated.