Safer Biopsies Transform Active Surveillance for Prostate Cancer Patients

New techniques slash infection risks, 

making repeat biopsies more tolerable for men monitoring low-risk disease

BLUF (Bottom Line Up Front): For men on active surveillance—who may face multiple biopsies over years of monitoring—safer biopsy techniques are game-changing. The transperineal approach reduces infection risks from up to 9% to less than 1% by avoiding rectal bacteria entirely. Combined with MRI-fusion targeting, these methods detect cancer progression more accurately while minimizing complications. This makes active surveillance more sustainable and less anxiety-provoking, particularly important as surveillance protocols now recommend biopsies every 1-3 years indefinitely.

The Active Surveillance Challenge

When Tom Martinez learned his Gleason 6 prostate cancer qualified for active surveillance rather than immediate treatment, he felt relieved—until his urologist explained the monitoring protocol. "You'll need follow-up biopsies every year or two," his doctor said. "We have to make sure nothing changes."

Tom's relief turned to dread. His diagnostic biopsy had left him feverish and hospitalized for three days with a serious infection. The thought of repeating that experience annually for potentially decades made immediate surgery seem almost appealing, despite its side effects.

Tom's dilemma reflects a growing concern in prostate cancer care. With up to 40% of newly diagnosed men now choosing active surveillance for low-risk disease, and protocols requiring periodic re-biopsy indefinitely, biopsy safety has moved from a one-time concern to an ongoing quality-of-life issue. Men face accumulated infection risks over multiple procedures spanning years or decades.

Now, a comprehensive review published in Prostate Cancer and Prostatic Diseases by Dr. Pavlov Valentin Nikolaevich and an international research team offers compelling evidence that modern biopsy techniques have fundamentally improved this risk-benefit equation, potentially making active surveillance more sustainable for many more men.

Why Traditional Biopsies Carry Infection Risks

For decades, the standard transrectal ultrasound-guided biopsy (TRUS-Bx) has required passing needles through the rectal wall to reach the prostate. Each needle pass exposes prostate tissue to rectal bacteria, creating infection opportunities that increase with each additional tissue core sampled.

The review, analyzing 78 studies published between 2014 and 2025, documents infection rates after transrectal biopsies ranging from 0.5% to 9.4% for sepsis (life-threatening bloodstream infections) and 0.3% to 4.9% for febrile urinary tract infections requiring hospitalization. While individual procedure risk seems modest, these percentages compound dramatically for men facing five, ten, or more biopsies during long-term surveillance.

Consider the mathematics: A man on active surveillance undergoing biopsies every two years for twenty years—ten procedures total—faces cumulative infection risks that could exceed 30% with older protocols. Even "low" individual procedure rates of 2-3% create substantial lifetime exposure.

Two factors have worsened this problem over time. Modern biopsy protocols typically take 12 or more tissue cores instead of the 6 cores common in earlier years, multiplying bacterial exposure opportunities. More critically, antibiotic-resistant bacteria have proliferated in the gut, particularly fluoroquinolone-resistant strains that evade the antibiotics traditionally used to prevent biopsy infections.

The Transperineal Revolution: Bypassing the Problem Entirely

The solution reshaping biopsy safety is elegantly straightforward: avoid the rectum completely. Transperineal biopsy (TP-Bx) accesses the prostate through the perineum—the skin between the scrotum and anus—using a template grid or freehand technique guided by ultrasound.

By eliminating rectal bacteria exposure, transperineal approaches reduce infection rates to less than 1% across multiple studies reviewed. For men on active surveillance, this difference transforms the long-term risk profile. Using the same twenty-year surveillance scenario, cumulative infection risk with transperineal biopsies could be under 10%—a fundamental improvement in the safety calculus.

Dr. Akinyemi Olalekan Samuel, one of the study's co-authors, emphasizes that this infection reduction is particularly valuable for surveillance populations: "Men on active surveillance are typically younger, healthier patients who expect to live decades. Exposing them to repeated infection risks from transrectal biopsies no longer makes sense when safer alternatives exist."

Several centers now report performing transperineal biopsies without any antibiotic prophylaxis at all, relying on sterile skin preparation alone. A notable British study included in the review documented infection rates remaining below 1% even without antibiotics—unthinkable with transrectal approaches.

For surveillance patients, transperineal biopsies offer another advantage: more comprehensive prostate sampling. The template-based approach systematically covers the entire gland, potentially improving detection of cancer progression compared to targeted-only sampling. This thoroughness matters when the goal is confirming disease stability rather than just detecting cancer presence.

MRI-Fusion: Smarter Targeting for Surveillance

Beyond infection prevention, technological advances have revolutionized what biopsies can accomplish. MRI-ultrasound fusion technology, which electronically overlays suspicious areas identified on pre-biopsy MRI scans with real-time ultrasound during the procedure, addresses a critical surveillance challenge: distinguishing true disease progression from sampling variability.

Men on active surveillance often face anxiety when follow-up biopsies show slightly "worse" findings—perhaps Gleason 3+4 instead of 3+3. But did the cancer actually progress, or did the initial biopsy simply miss that area? MRI-fusion helps answer this question by enabling precise re-sampling of previously biopsied locations and targeting new suspicious areas identified on interval MRI scans.

The review documents cancer detection rates up to 71.8% with fusion-guided biopsies—dramatically higher than traditional systematic sampling alone—while maintaining complication rates below 5%. For surveillance patients, this improved accuracy means greater confidence in monitoring results and potentially fewer total biopsy cores needed, as sampling can be concentrated on MRI-visible lesions plus systematic coverage of invisible areas.

Dr. Michael Katz, a urologic oncologist not involved in the study, notes: "MRI-fusion has transformed active surveillance from a protocol based on systematic re-biopsy hoping to catch progression, to a more intelligent monitoring strategy where we're specifically looking for growth or change in known lesions. It's the difference between fishing with a net versus spearfishing."

Several institutions now combine transperineal access with MRI-fusion guidance, offering surveillance patients both superior infection profiles and enhanced detection accuracy. This combination represents current best practice for men requiring repeat biopsies.

Improved Options When Transrectal Biopsies Remain Necessary

Geographic and economic realities mean many men—including those on active surveillance—still undergo transrectal biopsies. For these patients, infection prevention strategies have become substantially more sophisticated.

Targeted antibiotic prophylaxis uses rectal swab cultures obtained several days before biopsy to identify antibiotic-resistant bacteria in individual patients. When resistant organisms are detected, antibiotics can be tailored accordingly. Multiple studies in the review demonstrated significant infection reductions with this personalized approach, though it adds cost and coordination requirements.

Combination antibiotic regimens—using fluoroquinolones with fosfomycin (which concentrates in urine) or adding ceftriaxone (a powerful injectable antibiotic)—attack bacteria through multiple mechanisms, overcoming some resistance patterns. These combinations have shown infection rate reductions of 50% or more compared to single-agent prophylaxis in several studies.

Rectal preparation with povidone-iodine cleansing before needle insertion reduces bacterial contamination at the puncture site. While not eliminating infection risk, this simple adjunct contributes to overall safety when combined with appropriate antibiotics.

For surveillance patients facing multiple lifetime procedures, even incremental safety improvements compound beneficially over time. A reduction from 3% to 1.5% infection risk per procedure—achievable with optimized transrectal protocols—substantially improves the long-term safety profile, though not matching transperineal approaches.

The Patient Experience: What Actually Matters

Beyond statistics, the review examined what matters to men undergoing biopsy: pain, anxiety, recovery, and impact on daily life.

Transperineal biopsies typically require better anesthesia than transrectal procedures—usually a perineal nerve block or light sedation rather than just local anesthetic gel. While this means additional preparation and monitoring, most men report the procedure itself is quite tolerable, and they greatly appreciate the dramatically lower infection risk afterward.

For surveillance patients particularly, the psychological benefit of not dreading infection proves substantial. Men report less anticipatory anxiety before scheduled biopsies and can return to normal activities—including travel and work commitments—more confidently when infection concerns are minimal.

Recovery differences are notable. After transrectal biopsy, men watch for fever, chills, or urinary symptoms for up to two weeks—the window when infections typically appear. This vigilance period disrupts activities and creates ongoing worry. After transperineal biopsy, these concerns largely disappear, replaced mainly by minor perineal bruising that resolves within days.

Emerging protocols using topical anesthetic cream applied to the perineum, combined with careful technique, have achieved good pain control even without heavy sedation in some studies. This "anesthesia-light" approach may expand transperineal access by reducing the need for anesthesia specialists—particularly valuable for surveillance patients requiring repeated procedures.

Special Considerations for Active Surveillance Patients

The review's findings have specific implications for men on active surveillance protocols:

Cumulative risk reduction: Over decades of monitoring, using transperineal rather than transrectal approaches could reduce lifetime infection risk by 50-80%, transforming the safety calculus of long-term surveillance.

Improved compliance: Men less fearful of biopsy complications are more likely to complete recommended surveillance protocols rather than dropping out or choosing treatment out of anxiety.

Better progression detection: MRI-fusion guidance combined with comprehensive transperineal sampling may detect clinically significant progression earlier and more reliably than traditional approaches.

Quality of life preservation: Minimizing complications from monitoring procedures preserves the quality-of-life advantage that makes active surveillance attractive initially.

Several large surveillance programs, including those at Memorial Sloan Kettering Cancer Center and University College London, have transitioned predominantly or entirely to transperineal approaches with MRI-fusion guidance, citing both safety and detection accuracy advantages.

Barriers to Universal Access

Despite compelling evidence, adoption of safer biopsy techniques remains uneven, affecting surveillance patients' options:

Training gaps: Many urologists trained predominantly in transrectal techniques must invest time learning transperineal methods. Some practices lack the specialized support systems that make transperineal procedures most efficient.

Reimbursement issues: In some healthcare systems, payment structures favor traditional transrectal approaches, creating financial disincentives for adopting transperineal methods despite better outcomes.

Resource constraints: MRI access, fusion technology platforms, and consistent antibiotic supplies remain limited in many regions. For these settings, optimizing transrectal biopsy safety through improved prophylaxis remains critically important.

Anesthesia requirements: Transperineal procedures requiring sedation or nerve blocks may face scheduling and resource constraints compared to transrectal biopsies performed with only local gel anesthetic.

The review authors emphasize that these barriers, while real, should not prevent continued progress toward safer techniques. They advocate for clinical pathways that make transperineal approaches the default, with transrectal biopsies reserved for specific circumstances.

What Surveillance Patients Should Ask

If you're on active surveillance facing repeat biopsies, you have important questions for your urologist:

1. Does your practice offer transperineal biopsy? If not, why not? Are referrals to centers with this capability possible?

2. Is MRI-fusion guidance available for targeting any areas that changed since the last scan? This improves both detection accuracy and confidence in stable disease.

3. If transrectal biopsy is necessary, what infection prevention protocol is used? Single antibiotic? Combination therapy? Rectal culture screening? Cleansing preparation?

4. What are your actual infection rates? Practices should track and know their complication rates for both initial and repeat biopsies.

5. How do you balance systematic sampling with targeted sampling? Both matter for surveillance monitoring.

6. What anesthesia or pain control is standard? This significantly affects comfort during and after the procedure.

Don't hesitate to seek second opinions or request referral to academic centers with comprehensive surveillance programs if you're uncomfortable with the answers. Some men have successfully advocated for transperineal referrals when their local urologist only performed transrectal procedures.

For IPCSG members particularly, those facing repeat biopsies should strongly consider centers offering both MRI-fusion guidance and transperineal access. The combination maximizes detection of meaningful changes while minimizing accumulated infection risks over time.

Looking Forward

The transition from transrectal to transperineal as the dominant biopsy approach is accelerating, driven partly by recognition that surveillance populations need optimally safe procedures for long-term monitoring sustainability.

The review identifies remaining evidence gaps: large-scale randomized trials directly comparing techniques in surveillance populations, cost-effectiveness analyses accounting for prevented infections and improved cancer detection, and optimal re-biopsy intervals using modern techniques.

Several ongoing studies are addressing these questions. The PROTECT trial in the United Kingdom is evaluating long-term outcomes of men on active surveillance using different monitoring strategies. The PRECISION trial demonstrated MRI-targeted biopsies detect more clinically significant cancers while avoiding detection of insignificant disease—findings with direct surveillance implications.

For men like Tom Martinez, who started this journey fearing annual biopsies after his initial infection, modern techniques offer transformed prospects. Two years into surveillance, Tom underwent his first follow-up biopsy using transperineal MRI-fusion guidance at a regional academic center. He experienced minimal discomfort, no complications, and confirmation of stable low-risk disease. His third-year biopsy is scheduled without the dread that nearly drove him to abandon surveillance initially.

The Bottom Line

Active surveillance has emerged as preferred management for low-risk prostate cancer, sparing many men the side effects of immediate treatment. But surveillance sustainability depends fundamentally on biopsy safety—men won't continue protocols that repeatedly expose them to serious infection risks.

Modern evidence clearly demonstrates that transperineal approaches, enhanced by MRI-fusion targeting and thoughtful infection prevention strategies, make long-term surveillance more feasible and less anxiety-provoking. For men facing not one biopsy but potentially dozens over decades of monitoring, these advances represent not incremental improvements but fundamental transformations in care.

Your surveillance biopsies should provide confident cancer monitoring without creating medical problems of their own. With today's techniques, that goal is increasingly achievable. The challenge now is ensuring all men have access to these safer approaches, regardless of geography or healthcare system.

Patient advocacy matters here. Men asking for safer biopsy options and insisting on current best practices can accelerate beneficial change. Your urologist should be able to explain why their approach represents optimal care for your surveillance needs—or refer you to centers where that care is available.

Active surveillance works when men trust the monitoring process. Safer biopsies build that trust.

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Sources

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Note: This article synthesizes current medical evidence to inform IPCSG members about biopsy safety developments. Individual medical decisions should be made in consultation with your healthcare team, considering your specific clinical situation, risk factors, and available resources.

Infection risks and biopsy-associated complications in prostate cancer diagnosis: a review of recent literatures | Prostate Cancer and Prostatic Diseases