Dear Editors,
We would like to thank Drs Hüsnü Tokgöz and Özlem Tokgöz for their thoughtful correspondence regarding our prospective cohort study on complications after transrectal ultrasound-guided prostate biopsy in a Brazilian public reference centre.(1) In their letter, they accurately summarise our main findings, including a marked association between recent quinolone use and post-biopsy infectious complications.
Currently, the ongoing global struggle against bacterial resistance is a growing challenge to patient safety. Consequently, stewardship-driven approaches – such as monitoring local bacterial resistance patterns, adopting targeted prophylaxis (with different prophylactic regimens recommended by national and international agencies), and minimising unnecessary antibiotic exposure – are increasingly central to peri-procedural decision-making.(2) In the specific context of prostate biopsy, a transperineal approach is recommended to minimise infectious complications.
It has been argued that recently published randomized studies may be underpowered to detect a rare yet feared complication such as urosepsis. Nevertheless, meta-analyses indicate a lower rate of this outcome and support the safety of the transperineal approach. (Table 1) Our research group has an ongoing meta-analysis protocol on this subject registered in PROSPERO (CRD42024556787), and we anticipate that the forthcoming synthesis will favour the transperineal approach regarding urosepsis (Figure 1).
Table 1. Meta-analysis of prospective and randomized clinical trials on urosepsis following prostate biopsy.
| Meta-analysis | Comparison | Urosepsis rate (%) | |||
|---|---|---|---|---|---|
| Transrectal | Transperineal | ||||
| Periprocedural prophylactic antibiotics | |||||
| With | Without | ||||
| Castellani et al, 2022(3) | TP with versus w/o ATB prophylaxis | - | 0.13 | 0.09 | RR: 1.09, (0.21-5.61), p=0.92 |
| Wolff et al, 2024(4) | TP with versus w/o ATB prophylaxis | - | 0.13 | 0.16 | OR=1.3 (0.46-3.4), p=0.62 |
| Madhavan et al, 2024(5) | TR versus TP | 0.23 | 0.80 | OR=0.49, (0.09–2.71), p=0.42 | |
| Zattoni et al, 2024(6) | TR versus TP | 0.13 | 0 | OR=0.6, (0.1–4.5) | |
| Stangl et al, 2025(7) | TR versus TP | 0.77 | 0.25 | OR=0.49, (0.09–2.68) p=0.41 | |
| Our group (unpublished) PROSPERO CRD42024556787 |
TR versus TP | 2.6 | 0.18 | p<0.01 (excluding RCT with no urosepsis cases reported) | |
Figure 1. Forest-plot of urosepsis in randomized clinical trials comparing trasnrectal versus transperineal prostate biopsy.
Source: Heldwein FL, Korczaguin GG, Santos S, Maschietto VMM. Transrectal versus transperineal prostate biopsy: a systematic review and meta-analysis of randomized controlled trials on complications and efficacy. PROSPERO. 2024 [cited 2025 Dec 07]. Available from: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024556787(8)
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REFERENCES
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