LAUSR

In a recent review, Borghesi et al [1] 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’’ [2]. The World Health Organization implores us to reduce unnecessary 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 irresponsible. Furthermore, in July 2016, the US Food and Drug Administration issued a safety announcement that due to ‘‘disabling and potentially permanent side effects’’ fluoroquinolones should not be used unless there are no other treatment options [3]. The current standard practice of antibiotic prophylaxis for transrectal biopsy is therefore no longer sustainable. Transperineal biopsy, however, represents a clean alternative, with minimal infection risk and no need for quinolones, let alone other broader spectrum antibiotics. Borghesi et al [1] quote our early experience of transperineal biopsy in 245 consecutive cases with a hospital readmission rate for infection of zero [4]. Our 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 Committeeapproved prospective database. Our rate of infective