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Letter to the Editor

Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al.

Complications After Systematic, Random, and

Image-guided Prostate Biopsy. Eur Urol 2017;71:353–65

In a recent review, Borghesi et al


concluded that sepsis is

the most troublesome complication following transrectal

prostate biopsy and that its incidence continues to increase

due to the ongoing rise of fluoroquinolone resistance. We

believe the time is nigh to abandon the transrectal approach.

In performing transrectal biopsy, we forsake basic

surgical principles of sterility for the convenience of this

approach, using antibiotics as a substitute for hygiene.

Quinolones are recommended as standard prophylaxis, but

are losing their effect. The US Center for Disease Control

states that ‘‘use of antibiotics is the single most important

factor leading to resistance around the world’’


. The

World Health Organization implores us to reduce unneces-

sary antibiotic usage for fear of creating a postantibiotic era.

Proposed preventative solutions to prostate biopsy sepsis

involving multidrug or broader spectrum prophylaxis are

therefore in direct contravention of these warnings and are


Furthermore, in July 2016, the US Food and Drug

Administration issued a safety announcement that due to

‘‘disabling and potentially permanent side effects’’ fluor-

oquinolones should not be used unless there are no other

treatment options




The current standard practice of antibiotic prophylaxis

for transrectal biopsy is therefore no longer sustainable.

Transperineal biopsy, however, represents a clean alterna-

tive, with minimal infection risk and no need for

quinolones, let alone other broader spectrum antibiotics.

Borghesi et al


quote our early experience of

transperineal biopsy in 245 consecutive cases with a

hospital readmission rate for infection of zero


[4] .


series has since grown to 1194 consecutive cases performed

at five centers across Melbourne, Australia, by six urologists

in a private group practice. All patients were followed

up by the same urologists who performed their biopsy

and all data were recorded on an Institutional Ethics

Committee-approved prospective database. Our rate of

infective readmission remains at zero. This compares to a

population-based study we performed in our state of

Victoria over a 5-yr period to 2012, showing a rate of 1.7% of

infective readmission


. Using transperineal biopsy

exclusively, we have eliminated postbiopsy sepsis from

our practice. Importantly, the latter 710 (59.5%) patients in

our series were only given a single dose of intravenous

cephazolin as prophylaxis. This is in accordance with the

new recommendations on antibiotic prophylaxis for trans-

perineal biopsy in Australia’s Therapeutic Guidelines series.

Borghesi et al


state that the transperineal biopsy is

infrequently used due to logistics. Transperineal biopsy is

typically performed under general anesthesia and would

have a major impact on workflow if uptake were to become

routine. However, techniques for performing transperineal

biopsy as an office procedure have been recently developed.

Furthermore, it has been shown that multiparametric

magnetic resonance imaging could reduce unnecessary

prostate biopsies by up to half

[6] ,

thereby substantially

mitigating this resource issue.

From a medico-legal standpoint it is difficult to justify

the risk of sepsis to patients as an acceptable complication

when a cleaner biopsy alternative is available. In this era of

patient-centered care and increasingly ineffective antibiotic

prophylaxis, we believe that logistical reasons are no longer

an excuse for transrectal biopsy.

Conflicts of interest:

Grummet was sponsored to attend the Urological

Association of Asia Congress in 2016 by Biobot, makers of the Mona Lisa

robotic transperineal device.


This work has been supported by grants from Ipsen

and Tolmar





Borghesi M, Ahmed H, Nam R, et al. Complications after systematic, random, and image-guided prostate biopsy. Eur Urol 2017;71: 353–65


[2] Centers for Disease Control and Prevention. Antibiotic resistance

threat search results. &terms=antibiotic+resistance+threat


[3] US Food and Drug Administration. FDA Drug Safety Communica-

tion: FDA updates warnings for oral and injectable fluoroquinolone

antibiotics due to disabling side effects. DrugSafety/ucm511530.htm . E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) e 1 4 3 – e 1 4 4

ava ilable at

journal homepage:

DOI of original article:




2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.