In TRUS biopsy, the trocar traverses the rectal mucosa, passing from ‘dirty’ to ‘clean’, contravening the basic surgical principle of avoiding contamination of a sterile environment. As a result, faecal flora may gain access not only to the highly vascular prostate gland, but thereon to the bloodstream, causing life-threatening septicaemia. From the outset of the use of TRUS biopsy, this risk of sepsis was recognised . Prophylactic antibiotics were therefore recommended and are routinely given for TRUS biopsy today, although regimens used vary widely .
However, despite prophylactic antibiotics, evidence suggests that the rate of TRUS-biopsy sepsis is rising. Nam et al.  reported a population study of 75 190 Canadian men undergoing TRUS biopsy from 1996 to 2005. During this period, the rate of re-admission for infection rose dramatically from 0.6% to 3.6%.
In an international prospective study of 521 TRUS biopsy patients in 2010 and 2011, 3.1% required hospitalisation . Over the same 2 years in Christchurch, New Zealand, 1421 men underwent TRUS biopsy; 2.8% were re-admitted for infection, 10% of whom required admission to an intensive care unit (ICU). In a 2012 report, as many as 5% of 316 UK men undergoing TRUS biopsy using standard antibiotic prophylaxis were re-admitted with infection. They noted independent risk factors of recent travel or antibiotic use and all positive cultures grew fluoroquinolone-resistant E. coli .
ESBL and quinolone-resistant bacteria are now commonly found in rectal flora, and their prevalence continues to rise . In a large Spanish study, 28 307 E. coli blood isolates were examined from 2001 to 2009. The rate of ciprofloxacin-resistance increased from 17.6% to 32.7%. Over the same period, the community use of levofloxacin increased 307.2%. They concluded that community use of quinolones was a major factor in the rapid increase in resistance .
In the face of increasing resistance, carbapenems are increasingly being used not only to treat TRUS-biopsy sepsis, but also as routine prophylaxis. These antibiotics are nearing the last line of defence against such bacteria. Furthermore, there are now reports of CRE found across the world, in patients in a paediatric hospital in UK  and an ICU in Australia .
Routine use of fluoroquinolones for prophylaxis in TRUS biopsy is therefore becoming less effective , and may be accelerating the development of antibiotic resistance. Based on current trends, its ongoing use in TRUS-biopsy prophylaxis would appear to be unsustainable. Recognising the serious nature of this problem, alternative approaches have been sought. The use of pre-biopsy rectal screening swabs and instillation of disinfectant enemas have met with limited success as these techniques retain the fundamental problem of transrectal trocar passage [28, 29].
TP biopsy has typically been reserved for patients undergoing repeat biopsy, either for AS of low-risk cancer, or for a rising PSA level despite a negative TRUS biopsy .
TP biopsy has several drawbacks that have prevented more widespread use. It usually requires a general anaesthetic, although nerve block techniques and local anaesthesia have been reported [7, 18, 21, 30]. TP biopsy also takes longer to take than a TRUS biopsy, and typically involves taking more cores. It is therefore more costly and a significant drain on resources, including reporting of the pathology. Furthermore, for template grid biopsy, specialised equipment is required, including a brachytherapy grid, stepper, stabiliser and bi-plane transducer.
A systematic review and meta-analysis of all randomised and case-control trials comparing TRUS to TP biopsy was reported by Shen et al.  in 2012. They found equivalence in cancer detection rate when comparing sextant, extended core and saturation biopsies for each technique. Studies have even reported superiority of TP over TRUS biopsy for detection of anterior tumours [12, 32, 33].
The reported rate of urinary retention in TP biopsy is similar to TRUS biopsy . The largest series of TP biopsy reported a rate of 6.7% of 3000 patients, with only 56% taking an α-blocker . However, the Guy's Hospital series of 634 men reported a retention rate of 1.7% .
TP biopsy is not associated with a greater risk of erectile dysfunction  and its effect on dissection in RP appears to be anecdotal only .
Perhaps the most significant advantage of TP biopsy is its avoidance of transrectal trocar passage. Evidence of this advantage was first described in a small but elegant study in 1982. Thompson et al.  found lower rates of bacteraemia and plasma endotoxin levels when using the TP approach, and that any bacteraemia was predominantly with skin commensals only.
The present finding of zero sepsis echoes that of published TP biopsy series, showing negligible rates of sepsis, which are 40 to 70 times lower than those currently reported for TRUS biopsy. The importance of this lies not only in the dramatic risk reduction of significant and potentially life-threatening morbidity to patients. From the public health and antimicrobial stewardship perspective, TP biopsy also enables the safe avoidance of the use of carbapenems which, in turn, may slow the development of further resistance. Indeed, even fluoroquinolones are unlikely to be required for TP biopsy. This subject is currently under investigation by the VTBC.
One limitation of the present study was data collection by chart review. Although the vast majority of the database was populated prospectively, it is possible that episodes of re-admission for infective complications were missed. However, this is felt to be unlikely as all patients undergoing the procedure were reviewed either in the clinic of the institution where the biopsy was performed, or in the office of the urologist who performed the procedure.
Another weakness of the present study was the lack of standardisation of TP biopsy techniques across our institutions. Varying templates, core numbers and prophylactic antibiotics were used. However, despite these variations the sepsis rate of zero was consistent. Standardisation of technique and alignment of our database with the minimal dataset proposed by the Ginsburg Study Group  is underway.
In conclusion, in today's environment of rising rates of TRUS-biopsy sepsis and antibiotic resistance, we think that the risk–benefit ratio has now shifted sufficiently to warrant offering TP biopsy as an option to all men in whom a prostate biopsy is indicated.
This paradigm shift is likely to have a significant impact on health resources. Whilst the procedure of TP biopsy alone is clearly more costly than TRUS biopsy, the savings from its lack of infective complications must also be considered. This will include savings on hospital re-admission, carbapenem use, stays in ICU, prolonged antibiotic therapy in the community, and loss of productivity. This subject is also under investigation by our collaborative group.