"TREXIT 2020": Why the Time to Abandon Transrectal Prostate Biopsy Starts Now - Beyond the Abstract

More than three years have now passed since our call in this article for TREXIT 2020 - an end to the transrectal (TR) approach to prostate biopsy. So, where are we now?

There have been major changes in some parts of the world. Less so in others. The EAU Guidelines now make clear the preference for transperineal (TP) biopsy due to its significantly lower risk of infection compared to the TR approach.1 Importantly, this is regardless of antibiotic prophylaxis – a factor in the debate often forgotten by TR loyalists. Not only does TP biopsy confer less risk of sepsis to our individual patients, but it also aligns with modern antibiotic stewardship, whose aim is to minimise the unnecessary use of antibiotics and slow the development of resistance and the ongoing rise of “superbugs”.

The recommendations made by both the Prostate Cancer and Urological Infections panels of the EAU Guidelines were based partly on a systematic review and meta-analysis of over 1,300 patients in 7 randomised studies published in the Journal of Urology.2 Pragmatically, the panels also offered clear guidelines on TR biopsy for situations where TP biopsy is not yet available but made it clear that TP biopsy is the preferred choice.

On the other hand, the recently published AUA/SUO Guideline on Early Detection of Prostate Cancer, also published in the Journal of Urology, makes no such distinction between biopsy approaches, stating that “either a TR or TP biopsy route” may be used.3

The Urological Society of Australia and New Zealand (USANZ), which endorses the EAU Guidelines, made a submission to the Government to alter Medicare such that TP biopsy received greater reimbursement than TR biopsy. The majority of all prostate biopsies performed in Australia and New Zealand are now TP, showing that, rightly or wrongly, reimbursement has a major impact on how we practice medicine.4

The above example of variation in guidelines also leads us to an interesting broader question. In today’s world of global access to all the same published scientific data, and especially now with our ability to harness the power of AI to instantly collate this data, how is it that guidelines published by different organisations can offer different recommendations? Is one set of guidelines simply wrong and another right? Or could unconscious personal heuristics and/or cultural biases be playing a role here?

Whatever the answers, we hope that published guidelines will always aim to optimise the health and safety of our patients first and foremost and take care not to be swayed by the prevailing dogma or what may be simply more convenient for clinicians.

Written by: Jeremy Grummet, MBBS, MS, FRACS, Urologic Surgeon and Prostate Cancer Specialist, Deputy Director of Urology, Alfred Health, Melbourne Clinical Associate Professor, Monash University, Melbourne, Australia


  1. EAU Guidelines. Edn. presented at the EAU Annual Congress Milan 2023. ISBN 978-94-92671-19-6.
  2. Pradere B, Veeratterapillay R, Dimitropoulos K, et al. Nonantibiotic Strategies for the Prevention of Infectious Complications following Prostate Biopsy: A Systematic Review and Meta-Analysis. J Urol, 2021. 205: 653.
  3. Wei JT, Barocas D, Carlsson S, et al. Early detection of prostate cancer: AUA/SUO guideline part I: prostate cancer screening. J Urol. 2023;210(1):45-53.
  4. O' Callaghan ME, Roberts M, Grummet J, et al. Trends and variation in prostate cancer diagnosis via transperineal biopsy in Australia and New Zealand. Urol Oncol 2023 Jul;41(7):324. e13-324.e20.
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