TPs avoid the germy rectum and virtually never cause infections or potentially deadly and disabling sepsis, although nothing is 100%. The biopsy needle is placed through the perineum, the space between the rectum and the testicles. This is not only patently more hygienic avoiding all fecal material, but also allows access to posterior areas of the prostate that cannot be reached with the TR protocol. Here’s an excellent short video to better explain.

Over 800 people—fellow patients and some leading physicians—have signed his petition to phase out transrectal biopsies. Wolinsky called on Medicare and Congress to intervene after a scandal in Norway caused the European Association of Urology to take on the issue in 2021 when a Norwegian died from sepsis following a prostate biopsy. The policy head of EAU told Wolinsky that transrectal biopsies were tantamount to “malpractice” in Europe.  Wolinsky moderated a debate on TP vs. TR at AnCan in 2022  AnCan also ran two webinars on the topic in 2022:

So what did the American Urological Association do?

You might expect some resistance to a major change in practice that’ would cost urologists time to be trained and up to   $40,000 in equipment to set up this new approach. That’s what happened. Wolinsky, representing AnCan, as a consumer reviewer, told the AUA Early Detection Guidelines in 2023 that they should recommend transperineal biopsies as the preferred method. He said men were dying while they were debating which end of the egg is better to break first.

AUA still put TP on par with TR in its guidelines. A small step for men, as Neil Armstrong said on the first moon landing. The AUA is conservative and says it requires high levels of evidence from research before changing its guidelines—even though EAU counterparts consider TP their preferred method. Daniel Lin, MD, vice chair of the AUA committee, said in 2023 that randomized clinical trials would be the key to resolving the issue and several were coming in the next year.

Here’s an analysis on the different approaches taken by AUA and EAU to TP vs. TR: “Urology Groups Endorse Two Prostate Biopsy Approaches”. The randomized trials have started to come out and essentially only muddied the waters. “U.S. debate on transperineal vs. transrectal drags on despite randomized trials”

• Dr. Badar Mian’s single-center RCT at the University of Albany showed TR and TP essentially had the same results in terms of infections. It was widely criticized for not having enough patients to reveal rates for sepsis.
• Dr. Jim Hu’s multi-center study based at Weill-Cornell “almost” showed a statistical benefit to TP in a paper presented last January. But no cigar. The study was expanded and it is clear that TP wins in this research. Hu told the recent AUA meeting about it, but won’t talk about the results until the study is published.

But TP, meanwhile, is in increasing demand. A poll of 145 AS-educated readers of TheActiveSurveillor.com found that 36% had undergone a TP biopsy – far above the national average of 15% now and 10% two years ago. 54% of respondents expect to undergo transperineal procedures in their next biopsies.

None of this is say biopsies should be eliminated, just that they should be done as necessary and as infrequently as possible. A decade ago, urologists recommended annual biopsies. As their confidence in AS has increased, the frequency varies by practice: from every other year to three to five years as in Dr. Klotz’s practice in Toronto. Wolinsky’s own care as a peer in this Active Surveillance cohort has de-intensified with annual visits to his doctor, Dr. Brian T. Helfand | NorthShore  He has not had an MRI or biopsy in eight years–though his doctor still considers Wolinsky on AS. At age 76, he is considering hopping off the AS train.

Just in case you think Howard is a one-track (or even three-track) pony, here are a few other issues he has undertaken on behalf of men living with very low, low and intermediate prostate cancer.