Prostate Cancer Biopsies in 2025: A Comprehensive Guide

Introduction

A prostate biopsy is the only way to confirm a prostate cancer diagnosis by examining tissue under a microscope pmc.ncbi.nlm.nih.gov. Other tests (like PSA blood tests or MRI scans) can raise suspicion, but they cannot definitively diagnose cancer. Therefore, if prostate cancer is suspected, a biopsy is necessary to know for sure and to determine the cancer’s aggressiveness (the Gleason score). In 2025, there are two primary methods to obtain prostate biopsy samples: the traditional transrectal ultrasound (TRUS) guided biopsy and the newer transperineal biopsy approach. This guide will explain each method in simple terms, compare their pros and cons, and help patients, families, and caregivers understand what to expect.

Transrectal Ultrasound (TRUS) Biopsy

Procedure: In a TRUS biopsy, the doctor uses an ultrasound probe inserted gently into the rectum to visualize the prostate. The patient typically lies on his side (often the left side) with knees bent (the “fetal” position). First, the doctor will apply a local anesthetic to numb the area. Once numbed, a spring-loaded hollow needle is guided through the rectal wall into the prostate to take tiny tissue samples (called “cores”). You will hear or feel a quick click for each sample. Usually about 10–12 cores are taken from different parts of the prostate in a systematic pattern. The entire procedure is short (often about 10–15 minutes) and is usually done in an outpatient clinic or office setting.

What the patient experiences: During the biopsy, you may feel pressure in the rectum from the ultrasound probe. Thanks to the local anesthesia, pain is usually mild – patients often report the sensation as uncomfortable but tolerable. You might feel a brief pinch or jolt each time the needle takes a sample, but it’s very quick. In fact, studies have found that on average patients rate the discomfort only around 3 out of 10 on a pain scale healio.com. If you are especially nervous or sensitive, talk to your urologist – additional sedation or pain relief can be offered if needed, though this is not necessary for most men. After the procedure, you’ll be observed for a short time and then allowed to go home the same day. You may feel a bit sore or have a sensation of fullness in the rectum for a day or two.

After the biopsy – side effects and recovery: It is normal to see some blood after a prostate biopsy. You might notice a small amount of blood in your urine or in your stool for a day or two. It’s also very common to see blood in your semen (ejaculate) – this is called hematospermia. In fact, blood in the semen is the most frequently reported side effect after prostate biopsy (one study noted it in up to 90% of patients) mdpi.com. This can look alarming (brownish or reddish semen), but it is usually harmless and clears up on its own within a few weeks as your body heals. Only a minority of men find it bothersome, and the discoloration will gradually resolve. You may also have some minor rectal bleeding (spotting) from the needle path, but this too is typically light and stops quickly. Mild hematuria (blood in urine) can occur in the first days; about half of patients notice their urine tinged with a bit of blood initially, which also resolves as you heal. These bleeding-related side effects are usually self-limited. It’s a good idea to avoid heavy lifting or strenuous activity for 24–48 hours after the biopsy to minimize bleeding, but you can do light activities and return to normal routines by the next day if you feel up to it.

One of the main risks with a transrectal biopsy is infection. Because the needle passes through the rectum (which contains bacteria), there is a small chance that bacteria can enter the prostate or bloodstream. To reduce this risk, your doctor will likely have you take antibiotics around the time of the procedure. Despite precautions, a minority of patients (perhaps a few in a hundred) develop an infection such as a urinary tract infection or even sepsis (a serious bloodstream infection) after a TRUS biopsy. The vast majority (97–99%) of men do not experience severe infections, but it is something to be aware of. Signs of infection can include fever, chills, or burning with urination after the biopsy – if you notice these, you should contact your doctor immediately for treatment. Fortunately, serious infections requiring hospitalization are uncommon (approximately 1–3% of cases in recent reports). Overall, TRUS biopsy is considered safe and has been the standard approach for many years.

Pros of TRUS biopsy:

Widely available: Almost every urologist is experienced with this method, and it doesn’t require special equipment beyond a standard ultrasound probe.
Quick and convenient: It can be done in the office or outpatient clinic under local anesthesia. No general anesthesia is needed, so you remain awake and can go home soon after.
Well-established: Doctors have decades of experience with TRUS biopsies, and protocols are well-refined. It effectively samples the prostate and, if an MRI-targeted biopsy is being done, the MRI findings can be used with the transrectal approach just as well as with transperineal.

Cons of TRUS biopsy:

Infection risk: Because the needle goes through the rectum, there is a higher risk of infection. Antibiotics are required to mitigate this, but antibiotic-resistant bacteria are an increasing concern. Transrectal biopsies carry a small but notable risk of serious infection (sepsis) that is not completely avoidable.
Rectal route discomfort: Some men find the idea of a probe in the rectum unpleasant, though the discomfort is usually mild with proper numbing. There may be brief pain with each sample, but it’s short-lived.
Minor bleeding: You may have rectal bleeding in addition to blood in urine or semen. While usually minor, the sight of blood (especially in semen) can be worrisome if not expected.
Sampling limitations: In a very small number of cases (such as men with an unusual prostate position or prior rectal surgery), a transrectal approach might be challenging. Also, some areas at the front of the prostate can be a bit harder to sample via the rectum, though experienced doctors usually still get adequate tissue.

Transperineal Biopsy

Procedure: A transperineal biopsy involves accessing the prostate through the skin of the perineum, which is the area between the scrotum and the anus. In this procedure, you will typically lie on your back. Often your legs will be gently elevated or placed in stirrups (similar to a position used for certain surgeries or exams) so the doctor can reach the perineal area. The skin is cleaned thoroughly with an antiseptic solution (to kill bacteria on the skin), and local anesthetic is injected to numb the skin and deeper tissue along the path to the prostate. In some settings, transperineal biopsies may be done under sedation or light general anesthesia – this can depend on the practice and whether a template grid is used. (A template grid is a special guide with holes, placed against the perineum to systematically sample different regions of the prostate; this method is sometimes called a template-mapping biopsy and is often done with the patient asleep under general anesthesia due to the number of samples taken.) However, many transperineal biopsies in 2025 are now done under local anesthesia (numbing medicine only), just like TRUS biopsies, especially when fewer cores are needed or when using newer free-hand techniques. Recent studies have shown that transperineal biopsy can be performed in the office with local numbing with pain levels similar to the transrectal approach pubmed.ncbi.nlm.nih.gov.

During the transperineal biopsy, an ultrasound probe is still used to visualize the prostate (just as in a TRUS biopsy). Depending on the technique, the ultrasound probe might be placed in the rectum (to get clear images) or pressed against the perineum from the outside. In either case, the important difference is that the biopsy needles are inserted through the numb perineal skin rather than through the rectal wall. The doctor will push the biopsy needle through the skin and directly into the prostate, guided by the ultrasound images. Typically, multiple cores (e.g. 10–12 or more if needed) are taken, sampling various parts of the prostate in a systematic or targeted fashion. Each puncture is quick, and you may not feel much aside from some pressure thanks to the numbing. If sedation or anesthesia is used, you won’t feel or remember the procedure at all. The process usually takes a similar amount of time to a transrectal biopsy (perhaps 15–20 minutes). After the sampling, the doctor will apply a dressing to the needle puncture sites on the perineum. You’ll then be observed for a short while before going home. If you had general anesthesia, you’d need some time to fully wake up and you’d need someone to drive you home once cleared.

What the patient experiences: If the biopsy is done under sedation or general anesthesia, you will be asleep and feel nothing during the procedure. If it’s done under local anesthesia (numbing injections only), your experience will be somewhat similar to a TRUS biopsy. You will feel a pinch or slight burning sting when the local anesthetic is injected into the perineal skin – this is brief. Once numb, you shouldn’t feel sharp pain. You might still feel pressure or vibrationwhen the biopsy needle fires, and possibly some referred discomfort in the pelvic area, but it should be manageable. Some patients report that the most noticeable sensation is actually the ultrasound probe (if placed in the rectum) causing a sense of pressure, which is similar to the TRUS experience. The good news is that when comparing pain scores, transperineal biopsies under local anesthetic have been found to be no more painful than transrectal biopsies overall. One study showed transperineal and transrectal approaches had nearly identical patient-reported pain (average around 3–4 out of 10) when both were done with local numbing. Some patients did note the initial numbing injection for the transperineal approach was a bit more uncomfortable, but after that, the biopsy sampling itself felt similarpubmed.ncbi.nlm.nih.gov. During recovery in the first hour or two, you might feel a bit sore or have a dull ache in the pelvic area. If general anesthesia was used, you may feel groggy for a little while as you wake up.

After the biopsy – side effects and recovery: The after-effects of a transperineal biopsy are largely the same as for transrectal in terms of bleeding and urinary symptoms. You will likely have some blood in the urine for a day or two, and you will almost certainly have blood in the semen in the days or weeks following the biopsy (this comes from the prostate itself, not the skin). Because the rectum was not punctured, you should not have any rectal bleeding, and you avoid the risk of tracking fecal bacteria into the prostate. The perineal skin puncture may be tender or slightly bruised – sitting on a hard surface might be a little uncomfortable the first day, but this is usually minor. A small Band-Aid over the skin entry points is usually all that’s needed. The risk of infection is much lower with the transperineal route. Since the needles bypass the rectum entirely, we dramatically cut down the chance of encountering bacteria that cause prostate infections or sepsis. In fact, transperineal biopsies in studies have essentially a near-zero rate of serious infection; several large studies have reported 0% sepsis with transperineal biopsies when proper sterile technique is used pmc.ncbi.nlm.nih.gov. Because of this, many urologists do not require heavy antibiotics (or any antibiotics at all beyond maybe a single dose) for transperineal procedures. This is a big advantage, as it reduces antibiotic side effects and helps prevent antibiotic resistance. Nonetheless, as a precaution, you’ll still be advised to watch for any signs of infection (fever, chills, etc.) after the biopsy, and report them if they occur. Other possible side effects like urinary retention (difficulty urinating due to swelling or pain) are uncommon but can happen in a small percentage of patients; fortunately, studies show the risk of urinary retention is similar between transperineal and transrectal approaches (only around 3–4% of patients, usually temporary). If you have trouble urinating after the biopsy, let your doctor know – sometimes a temporary catheter may be needed until the swelling subsides, but this is rare. Overall, recovery from a transperineal biopsy is quick. If only local anesthesia was used, you can resume normal light activities later that day or the next day (with the same cautions about avoiding heavy exercise for a couple of days). If you had general anesthesia, you might need the rest of the day to fully recover from the anesthetic, but by the following day you should be feeling back to normal aside from maybe mild soreness.

Pros of transperineal biopsy:

Very low infection risk: This is the biggest advantage. By avoiding the rectal route, the chance of a severe infection is essentially near zero in many reports pubmed.ncbi.nlm.nih.gov. This means less reliance on prophylactic antibiotics and much lower odds of post-biopsy sepsis. Patients can be reassured that the risk of ending up in the hospital with an infection after a transperineal biopsy is extremely small (on the order of a fraction of a percent in experienced centers).
Comprehensive sampling: The transperineal approach allows excellent access to all regions of the prostate. It may be easier to sample the front part of the prostate (the anterior zones) via the perineum, which can sometimes be missed with a transrectal approach. Both systematic (mapping) cores and MRI-targeted cores can be taken transperineally with high accuracy. In fact, both methods have been found to detect cancer at very similar rates pubmed.ncbi.nlm.nih.gov, and transperineal biopsies do not miss significant cancers that transrectal would have found – if anything, they may catch some tumors that transrectal might miss in hard-to-reach areas.
No fecal contamination: The perineal route avoids passing through bowel contents, so there’s no risk of fecal material causing complications at the biopsy site. This also means you typically don’t need an enema or bowel prep beforehand (whereas some doctors recommend an enema before a TRUS biopsy to clear the rectum).
Advances allow local anesthesia: While transperineal biopsies in the past required general anesthesia, newer techniques and numbing methods now allow many of these biopsies to be done under local anesthesia in an office setting. This means you can potentially have the procedure awake, avoiding the risks and costs of general anesthesia, yet still benefit from the lower infection risk. (Not all centers have adopted in-office transperineal biopsy yet, but it is increasingly common.)
Comparable recovery: The overall recovery experience (bleeding, pain levels, downtime) is much like the transrectal biopsy. There’s no large incision – just needle sticks – so healing is quick. Many men feel back to normal within a day or two aside from minor symptoms.

Cons of transperineal biopsy:

Requires specialized setup or training: Transperineal biopsies have historically been done in an operating room with the patient under anesthesia. Not all urology clinics are equipped to perform transperineal biopsies under local anesthesia yet. Some doctors may not be as familiar with the technique if their training was primarily with transrectal biopsies. This means availability can be a con – depending on your location, the transperineal approach might not be offered by every provider (though this is rapidly changing).
Anesthesia considerations: If done under general or deep sedation, the procedure involves the additional planning and risks associated with anesthesia. You might need to fast beforehand, have an IV, and arrange for a ride home after anesthesia. This can make the procedure more logistically complex than a quick in-office TRUS biopsy. That said, as noted, many are now done with just local numbing, which mitigates this issue.
Perineal discomfort: While pain overall is similar to TRUS, the nature of the discomfort is a bit different. You have a few needle punctures in the skin that can be sore (like getting a shot, plus some deep ache from the prostate sampling). Some men might find sitting uncomfortable for a short time after the procedure. In contrast, TRUS might cause more rectal irritation. These discomforts are usually mild in both cases, but individual preference may vary.
Minor skin infection or bruising: Anytime a needle goes through the skin, there’s a small risk of a skin infection or bruise. With proper cleaning and precautions, serious infections are exceedingly rare (and far less likely than in TRUS), but you could get a local skin infection or abscess (very uncommon). You might also get some bruising in the perineal area. Again, these are infrequent and usually not severe.
Cost and insurance: In some healthcare systems, doing the biopsy under general anesthesia or in a surgical center could be more costly than an office procedure. However, this depends on insurance and local practices. The difference in cost is narrowing as more clinics adopt office-based transperineal biopsies. It’s worth discussing with your provider and insurer if cost is a concern.

Comparing TRUS and Transperineal Biopsies

Both transrectal and transperineal biopsies aim to accomplish the same goal: obtaining tissue from the prostate to diagnose cancer. They are both effective at finding prostate cancer, and in experienced hands one is not significantly more accurate than the other. The choice often comes down to the risk profile and practical considerations. The following table summarizes key differences and similarities between the two approaches:

Factor	Transrectal Ultrasound (TRUS) Biopsy	Transperineal Biopsy
Route of needle	Through the rectal wall into the prostate.	Through the perineal skin (between the anus and scrotum) into the prostate.
Patient positioning	Usually lying on the side.	Usually lying on the back (often with legs slightly elevated or in stirrups).
Anesthesia	Local anesthetic (numbing injections) is typically used. Generally no general anesthesia needed; you remain awake.	Often done with local anesthesia as of 2025, sometimes with sedation or general anesthesia especially if many samples are taken.
Procedure setting	Outpatient clinic or office procedure. No hospital stay.	Can be done in clinic with numbing; some cases done in an operating room if general anesthesia is used. Outpatient either way.
Infection risk	Higher risk of infection because the needle passes through the bacteria-rich rectum. Antibiotics are always given to reduce infection risk. Approximately 1–3% risk of serious infection (sepsis) even with precautions.	Very low risk of infection since the rectum is avoided. In many series, near 0% of patients get sepsis. Often no antibiotics (or only minimal) are needed
Accuracy of cancer detection	Excellent – this method has been used for decades and detects clinically significant cancers well. Can sample all regions of the prostate, though reaching the front (anterior) of the gland can be a bit more challenging in some cases. MRI-targeted biopsy can be performed via this route.	Excellent – studies show it is equivalent to TRUS in detecting cancer. Provides easy access to all parts of the prostate (including anterior zones). Also compatible with MRI-targeted techniques. Overall cancer detection rates are comparable to transrectal biopsies.
Discomfort during procedure	Pressure from the ultrasound probe in the rectum; brief pinch or poke with each sample. Pain is typically mild with proper numbing (average ~3/10). You are awake but the procedure is quick.	Pressure from the probe (either in rectum or on perineum) and a pinch feeling in the skin if awake. Pain also typically mild with local anesthetic (similar ~3–4/10). If done under sedation, you feel nothing during the procedure.
Bleeding after procedure	Common to have blood in urine and semen for days/weeks, and possibly a bit of rectal bleeding. These resolve on their own mdpi.com.	Common to have blood in urine and semen (just like TRUS). No rectal bleeding (since rectum isn’t entered). A small skin bruise or a drop of blood at the needle site can happen.
Urination issues after	Rarely, temporary urinary difficulty or retention due to swelling or discomfort (a few percent of patients).	Rare and similar rate to TRUS. Both approaches have low risk of causing urinary retention; if it happens, it’s usually temporary.
Antibiotic use	Yes – antibiotic prophylaxis is standard to prevent infection (commonly a fluoroquinolone or similar, sometimes augmented with more drugs if resistance is a concern).	Often not required, or a very short course, because infection risk is so low. This avoids antibiotic side effects and complications.
Availability	Widely available at virtually all urology practices. This has been the standard method for a long time.	Increasingly available, but not yet universal. Many centers in 2025 offer it, especially to reduce infection risk. Check with your provider if they perform transperineal biopsies under local anesthesia.
Procedure cost	Typically less costly, since it doesn’t require hospital facilities or an anesthesiologist. Covered by insurance as a standard diagnostic procedure.	May be higher if done in an operating room with anesthesia fees. However, in-office transperineal biopsies have similar cost to TRUS. Insurance usually covers either method; verify if there are any differences under your plan.
Patient preference	Some patients prefer this for convenience (no general anesthesia) and because it’s time-tested. However, many dislike the idea of a rectal procedure or the infection risk.	Many patients prefer this method when informed about the lower infection risk pmc.ncbi.nlm.nih.gov. In one study, over 90% chose transperineal when given the option. If anesthesia or extra steps are needed, a few patients opt to stick with transrectal for simplicity or cost reasons.

In summary, both methods are effective for diagnosing prostate cancer. Transrectal biopsy has the benefit of being quick and easily done under local anesthesia, but carries a higher (though still small) risk of infection. Transperineal biopsy, on the other hand, dramatically lowers infection risk and is now often done under local anesthesia as well, though it may not yet be available everywhere without a hospital setting. Many experts consider transperineal the safer approach due to near-zero infection rates, and its use has been increasing worldwide. It’s important to discuss with your urologist which approach makes the most sense for you, considering your personal risk factors and the resources available.

Real-World Patient Experiences

Hearing from other patients who have gone through the procedure can be reassuring. In general, patient feedback for both biopsy methods is that the experience is not as bad as they feared. Anxiety beforehand is common, but most men tolerate the biopsy with manageable discomfort and are glad to have the procedure behind them.

For TRUS biopsy, common remarks from patients include: “The anticipation was worse than the biopsy itself.” Patients often report a feeling of pressure and a series of quick stings as the samples are taken, but many say it was over quickly. With proper numbing, pain is minimal – some describe it as a 2 or 3 out of 10, or “more uncomfortable than painful.” Having an ultrasound probe in the rectum is admittedly awkward, but not typically painful, just a bit of pressure. Some men do experience brief sharper pain with a particular core sample, but it’s fleeting. Afterwards, patients frequently note they had blood in their urine or semen, which can be unsettling if not expected, but knowing that it’s normal helps alleviate worry. If a patient ejaculates and sees blood, it can cause alarm – one patient noted he “nearly panicked seeing reddish semen,” until the doctor explained it was a common effect and not dangerous. This underlines the importance of being aware of these side effects in advance. Most men have minor bleeding that clears up by itself. In terms of recovery, many patients take it easy for the rest of the day of the biopsy and are back to routine activities the next day. Some fatigue or mild soreness is common, but severe pain is not. A small number of patients may develop fever or infection after TRUS biopsy – those who experienced it describe feeling flu-like symptoms that required antibiotics in the hospital. However, these cases are the exception (occurring in only a small percentage of all patients).

For transperineal biopsy, patients who have had it often highlight the peace of mind knowing the infection risk is so low. One man said, “I chose the transperineal approach because I was worried about infection – I liked that they didn’t have to use strong antibiotics and the risk of getting sepsis was almost zero.” In terms of the procedure experience, those who underwent general anesthesia obviously didn’t feel anything during the biopsy. They report the inconvenience of the anesthesia (fasting beforehand, IV line, some grogginess after), but otherwise the biopsy itself wasn’t felt. For those who had it under local anesthesia while awake, the feedback is similar to TRUS biopsy experiences: mild to moderate discomfort, but quite tolerable. Patients commonly say the numbing injections in the perineum sting for a moment, and pressure from the ultrasound is present, but the actual sampling is quick and not severely painful. Some men note that it’s a bit strange to have your legs up and perineum exposed (versus lying on the side for TRUS), but once numbed, the focus is on getting through the sampling which is over in minutes. After a transperineal biopsy, patients report similar minor urinary bleeding and blood in semen. One difference they notice is the absence of rectal bleeding – not having to worry about any blood from the rectum or bowel movements is a small relief. A few patients mention soreness where the needles went in – for example, one patient said “it felt like I had a bruise between my legs for a day, but nothing too bad.” Sitting on a soft cushion for the ride home or that evening can help if the area is tender. The vast majority did not experience any difficulty urinating; they were able to pee normally, though it might sting a little if there’s blood in the urine at first. Importantly, virtually all patients who had transperineal biopsies avoided serious infection complications – they simply followed the post-care instructions and healed up without incident. This is a major point of reassurance for many: by two weeks post-biopsy, most men (regardless of method) feel completely back to normal, and the only thing that remains is waiting for the biopsy results.

Common concerns and how they are addressed:

Pain: Almost every man is concerned about pain. Both approaches, with modern techniques, are described by most patients as only mildly painful. Urologists now use effective local anesthesia to ensure you’re as comfortable as possible. If you’re very anxious about pain, discuss options like additional sedation or even doing the biopsy under anesthesia – doctors can accommodate these requests in many cases. Don’t “white-knuckle” through extreme pain unnecessarily; there are methods to manage it, but for most, the standard numbing is enough.
Bleeding: Seeing blood in urine, stool, or semen can be scary if unexpected. Patients who know about it beforehand tend to cope much better. Keep in mind that blood in the semen can persist for several weeks in a reducing amount – even if the first ejaculate after the biopsy is brownish-red, each subsequent one will get lighter as the remaining blood clears out. It does not harm you or your partner; it’s just old blood. If bleeding seems excessive (for example, passing lots of bright red blood or large clots), you should inform your doctor. But minor bleeding is to be expected and almost always stops on its own.
Infection anxiety: Many patients have read about infections after biopsy. It’s good to be vigilant, but not to the point of panic. Doctors take precautions (like giving antibiotics for TRUS biopsies). If you chose a transperineal biopsy, you’ve already vastly lowered that risk. Either way, serious infections are uncommon. Patients who do get an infection usually notice symptoms within a few days (fever, chills, feeling ill). The key is to seek prompt treatment – those who did recover after IV antibiotics. It’s an important risk to know, but remember that the majority of patients have no infection at all.
Urinary problems: It’s normal to have some burning when urinating the first couple times after a biopsy, especially if there’s blood. A few patients might have trouble urinating if the prostate swells. In practice, urinary retention (being unable to pee) is not very common, but it can happen. One patient shared that he couldn’t urinate that evening and ended up needing a catheter for two days – while unpleasant, it relieved the issue and was removed once the swelling went down. Knowing this is a possible (but infrequent) side effect is helpful. Most men will not experience it, especially if they had no issues prior, but if you suddenly can’t pass urine after the biopsy, call your doctor or go to an ER to get immediate help.
Waiting for results: The post-biopsy waiting period can be a source of anxiety for patients and families. Biopsy results usually take about 5–10 days (sometimes sooner) to come back from the pathology lab. It’s perfectly natural to feel anxious during this time. Many patients find it helpful to stay busy and avoid dwelling on the results. Make sure you have a follow-up appointment or phone call scheduled to discuss the findings. Remember that not all biopsies find cancer – if your biopsy is negative, your doctor will talk about next steps (which may include monitoring or a repeat biopsy in the future if suspicion remains high). If it is positive, you’ll discuss treatment options. Either way, the biopsy is a crucial step that guides what comes next, and patients generally feel better once they have a definite answer and plan.

Finally, patients often comment that reading guides like this one or watching videos of doctor explanations helped them feel more prepared. Being informed going into the procedure makes the experience less intimidating. It’s perfectly okay (and encouraged) to ask your healthcare team any questions you have – before, during, or after the biopsy. Nurses and doctors would rather you ask and feel comfortable than sit in silence with worries. As many patients will attest, knowledge and open communication are the best antidotes to fear.

Questions to Ask Your Doctor

When meeting with your urologist about a prostate biopsy, it’s a good idea to come prepared with questions. Here’s a list of important questions you may consider asking to ensure you have all the information you need before proceeding:

Which biopsy approach do you recommend for me, and why? (Should I have a transrectal or transperineal biopsy given my situation?)
Do you perform transperineal biopsies under local anesthesia in your practice? (If you are interested in the transperineal route, ask if it’s available and if it can be done without general anesthesia.)
What are the risks of infection with my biopsy, and how do we prevent them? (For TRUS: Will I receive antibiotics? For transperineal: Do I need antibiotics at all?)
What type of anesthesia or sedation will be used? (Will I be awake with local numbing, will I get light sedation, or will it be under general anesthesia? What does that entail for preparation and recovery?)
How should I prepare for the biopsy? (For example, do I need to stop any medications like blood thinners beforehand? Should I use an enema or do any special prep on the day of the procedure? Should I have someone come with me to drive me home?)
How long will the procedure take, and will I need to stay afterwards for observation? (Understand the time commitment and whether it’s an office procedure or requires a hospital outpatient setting.)
How many samples (cores) do you plan to take, and will the biopsy be targeted to any specific areas? (Ask if they will take the standard number of cores or more, and if an MRI finding is present, will they target that area specifically during the biopsy.)
What kind of side effects should I expect afterward, and for how long? (Ask about bleeding in urine/stool/semen, pain, and any activity restrictions. For instance: “Is it okay for me to exercise the next day? When can I resume sexual activity?”)
What symptoms after the biopsy should prompt me to call you? (Make sure you know the warning signs of complications – e.g. how high of a fever is concerning, what to do if you can’t urinate, or if bleeding seems heavy.)
How will I receive the results and how soon? (Will there be a follow-up appointment, a phone call, or an online portal message? Typically how many days does it take for results to come back from pathology?)
If the results are negative (no cancer), what are the next steps? (Do we monitor my PSA and MRI and possibly repeat biopsy later? Do we consider other tests?)
If the results show cancer, what happens next? (Will I be referred to discuss treatment options? Ask for a brief overview of what the process would be to plan treatment, so you know what to expect after the diagnosis.)
Are there any alternatives to an immediate biopsy? (In some cases, if suspicion is low, a doctor might suggest monitoring PSA or doing additional imaging first. However, if cancer is strongly suspected, a biopsy is standard – but it’s okay to ask about their rationale.)

Bringing a written list of questions to your appointment can be very helpful. Don’t hesitate to take notes or even have a family member with you to help remember the answers. Your doctor should be willing to address all of these points to ensure you are comfortable with the plan.

Conclusion

Facing a prostate biopsy can be daunting, but understanding the process and your options can make it much less intimidating. In 2025, patients have a choice between the traditional transrectal approach and the transperineal approach for prostate biopsies. Both methods are effective in diagnosing prostate cancer – they simply take different paths to the prostate. The transrectal (TRUS) biopsy has been the standard for many years and offers convenience, but it does carry a small risk of infection because the needle goes through the rectum. The transperineal biopsy is emerging as a new standard in many centers due to its extremely low infection risk, accessing the prostate through the skin instead of the rectum. Improvements in technique now allow transperineal biopsies to be done under local anesthesia, making it more accessible to patients without the need for an operating room in many cases.

Key takeaways: A biopsy is a crucial step in diagnosing prostate cancer – it provides information that no scan or blood test can fully give. Whichever method is used, the goal is to obtain tissue safely and accurately. Transrectal and transperineal biopsies have similar success rates in finding cancer pubmed.ncbi.nlm.nih.gov, so no matter which route is chosen, you are not compromising the quality of diagnosis. The main differences lie in the details of the procedure and certain risks (like infection). Talk to your urologist about these differences. Many doctors are now recommending the transperineal route for most patients due to its safety profile pubmed.ncbi.nlm.nih.gov, but individual circumstances (such as availability of equipment, your anatomy, or prior surgeries) might make one approach preferable over the other.

By being informed, you become an active participant in your care. Use this guide as a starting point for discussions with your healthcare team. There is no such thing as a “bad” question – if something is on your mind, bring it up. The decision on how to proceed with a biopsy should be made with you, not just for you. In the end, an informed patient can face the biopsy with confidence, knowing what to expect and how to handle it. Prostate biopsies in 2025 are safer and more patient-friendly than ever before, and by working with your doctor, you can ensure that you get the answers you need about your prostate health in the safest way possible.

Remember, this biopsy is being done for your benefit – to get a clear diagnosis and guide the next steps. Many patients feel a sense of relief after the biopsy, as the uncertainty is replaced with knowledge about what’s going on. We hope this comprehensive guide has answered your questions and eased your concerns. The final piece of advice is to keep communication open with your care team and make the decision that is right for you. With the support of your doctors and loved ones, you will get through this procedure and be on your way to the next steps of management with clarity and confidence.

References (Vancouver Style)

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Hu JC, Assel M, Allaf ME, et al. Transperineal vs transrectal prostate biopsy – The PREVENT randomized clinical trial. JAMA Oncol. 2024;10(11):1590-1593.
Berquin C, Perletti G, Develtere D, et al. Transperineal vs. transrectal prostate biopsies under local anesthesia: a prospective cohort study on patient tolerability and complication rates. Urol Oncol. 2023;41(9):388.e17-388.e23
Zattoni F, Rajwa P, Miszczyk M, et al. Transperineal versus transrectal MRI-targeted prostate biopsy: a systematic review and meta-analysis of prospective studies. Eur Urol Oncol. 2024;7(6):1303-1312
Taciuc IA, Angelescu E, Petcu C, et al. Current approach to complications and difficulties during transrectal ultrasound-guided prostate biopsies. J Clin Med. 2024;13(2):487
Lu M, Luo Y, Yang Z, et al. Transrectal versus transperineal prostate biopsy in detection of prostate cancer: a retrospective study of 452 patients. BMC Urol. 2023;23(1):11
Chen KW, Leong JY, Huang HH, et al. Comparing outcomes of transperineal vs transrectal prostate biopsies under local anesthesia. Prostate Int. 2022;10(3):141-146
Loeb S, Vellekoop A, Ahmed HU, et al. Systematic review of complications of prostate biopsy. Eur Urol.2013;64(6):876-892. (Note: Provides context on infection rates in TRUS biopsy.)
Patel HD, Johnson MH, Pierorazio PM, et al. Diagnosing prostate cancer: current status and limitations of biopsy techniques. Ther Adv Urol. 2015;7(4):177-188. (Note: Explains the role of biopsy in diagnosis.)