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Minesh Patel and Joseph Norris discuss how antibiotic prophylaxis heterogeneity, operator transition from TRUS to TP, potential learning curve effects, and possible selection bias may confound infection-rate comparisons. They also place findings in context of trials including PROBE-PC, PREVENT, and TRANSLATE, noting trade-offs in infection complications and diagnostic yield, and conclude with the need for multicentre studies using standardised protocols.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/a-response-to-nasrallah-et-al-infection-rates-of-trans-perineal-versus-trans-rectal-prostate-biopsy-a-middle-eastern-tertiary-center-experiencetime-for-a-change-letter-to-the-editor/454979/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/a-response-to-nasrallah-et-al-infection-rates-of-trans-perineal-versus-trans-rectal-prostate-biopsy-a-middle-eastern-tertiary-center-experiencetime-for-a-change-letter-to-the-editor/454979.png","ImageObject",300,407,{"name":92,"@type":93},"Marglet","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-08","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":14},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"How do the authors address concerns about heterogeneity in antibiotic prophylaxis?","Question",{"text":112,"@type":113},"They note that antibiotic prophylaxis varied across fluoroquinolones, aminoglycosides, and cephalosporins, creating confounding. Without stratified subgroup analysis or adjustment for antibiotic regimen, infection-rate differences cannot be attributed solely to biopsy approach.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"Why might operator transition from TRUS to TP affect infection outcomes?",{"text":117,"@type":113},"Several operators switched from TRUS to TP during the study period. The TP approach requires adaptation in access routes, needle trajectories, and anaesthetic methods, potentially introducing a learning curve that could elevate infection rates early in the TP cohort.",{"name":119,"@type":110,"acceptedAnswer":120},"What evidence from prior trials is used to compare TRUS vs TP outcomes?",{"text":121,"@type":113},"The letter cites PROBE-PC and PREVENT, which found no clear discernible differences in infection-related complications, and discusses TRANSLATE, which reported greater detection of higher-risk disease (Gleason grade group 2 or higher) with TP in biopsy-naïve patients, though infection-related differences were not statistically significant.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},454979,1790741832,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":14,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":129,"read_time":24,"preview_page_count":4},2336477982702,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","ARAB JOURNAL OF UROLOGY 2026, VOL. 24, NO. 1, 66–67  \n[https://doi.org/10.1080/20905998.2025.2585749](https://doi.org/10.1080/20905998.2025.2585749)  \nLETTER TO THE EDITOR     \nA response to Nasrallah et al.“Infection rates of trans-perineal versus transrectal prostate biopsy: A Middle Eastern tertiary center experience—Time fora change?”  \nMinesh Patel and Joseph Norris  \nUrology Department, Imperial College Healthcare NHS Trust, London, UK  \nDear Professor,  \nWe read with great interest the article by Nasrallah et al.,‘Infection rates of trans-perineal versus trans-rectal prostate biopsy: A Middle Eastern tertiary center experience – Time for a change?’. The authors should be commended for addressing the increasingly important issue concerning infection risks in prostate biopsies and presenting their data from a tertiary centre in the Middle Eastern region. The data from this work supports the growing body of evidence favouring the transperineal (TP) approach over the transrectal (TRUS) route, demonstrating fewer urinary tract infections (1.2% vs 4.1%, p = 0.03) and lower hospitalisation rates.  \nHowever, several aspects of the study merit further consideration. Firstly, is the heterogeneity in antibiotic prophylaxis, ranging from fluoroquinolones to aminoglycosides and cephalosporins. This introduces a significant degree of confounding and without stratified subgroup analysis or adjustment for antibiotic regime, it is difficult to attribute infection rate differences solely to biopsy approach. Additionally, the study reports that several operators transitioned from TRUS to TP during the study period. Even for experienced urologists, the transperineal approach requires adaptation to new access routes, needle trajectories and anaesthetic methods. This introducesa learning curve in which infection rates in the TP cohort may have been higher in the initial phase following this transition. Further to this, it is worth exploring whether there was a selection bias in which potentially higher risk patients were preferentially assigned to one technique. Nevertheless, both aspects could have influenced the outcomes recorded.  \nFurthermore, it is worth noting that previous trials such as PROBE-PC and PREVENT have found no discernible difference between the techniques in terms of infectionrelated complications [1,2](PROBE-PC: n = 718, 3%[10/ 367] LATP vs 3%[9/351] TRUS; PREVENT: n = 567, 0%[0/ 287] LATP vs 1%[4/280] TRUS, p = 0·059). Fewer infections  \nin the TP group were recorded in the TRANSLATE trial however this was not statistically significant and as infection-related complications were a secondary outcome, the study was not powered on this [3]. In this context, other aspects of the debate between the TRUS and TP biopsy techniques are worth exploring. This includes comparative data on diagnostic yield and accuracy, sampling adequacy which would add more value and context. In particular, the TRANSLATE trial has demonstrated a greater detection of Gleason grade group 2 (GGG2) or higher disease with TP biopsies in comparison to TRUS in biopsy-naïve patients [3].  \nDespite these limitation, Nasrallah et al have contributed valuable regional evidence that supports the global transition between TP biopsy as the safer standard of care. This work highlights the need for further multicentre studies with standardised antibiotic and procedural protocols to better our understanding of infection risk and to develop universal best practice for prostate biopsy.  \nDisclosure statement  \nNo potential conflict of interest was reported by the author(s) .  \nReferences  \n[1] Mian BM, Feustel PJ, Aziz A, et al. Complications following transrectal and transperineal prostate biopsy: results of the ProBE-PC randomized clinical trial. J Urol. 2024;211 (2):205–213. doi: 10. 1097/JU.0000000000003788  \n[2] Hu JC, Assel M, Allaf ME, et al. Transperineal versus transrectal magnetic resonance imaging-targeted and systematic prostate biopsy to prevent infectiou","cbCail249Bvvos4M","https://ap.wps.com/l/cbCail249Bvvos4M","pdf",178461,"English","# Letter to the Editor\n## Response overview\n## Antibiotic prophylaxis and confounding\n## Operator transition and learning curve\n## Selection bias considerations\n## Context from prior trials (PROBE-PC, PREVENT, TRANSLATE)\n## Implications and need for further studies\n## Disclosure statement and references","[{\"question\":\"How do the authors address concerns about heterogeneity in antibiotic prophylaxis?\",\"answer\":\"They note that antibiotic prophylaxis varied across fluoroquinolones, aminoglycosides, and cephalosporins, creating confounding. Without stratified subgroup analysis or adjustment for antibiotic regimen, infection-rate differences cannot be attributed solely to biopsy approach.\"},{\"question\":\"Why might operator transition from TRUS to TP affect infection outcomes?\",\"answer\":\"Several operators switched from TRUS to TP during the study period. The TP approach requires adaptation in access routes, needle trajectories, and anaesthetic methods, potentially introducing a learning curve that could elevate infection rates early in the TP cohort.\"},{\"question\":\"What evidence from prior trials is used to compare TRUS vs TP outcomes?\",\"answer\":\"The letter cites PROBE-PC and PREVENT, which found no clear discernible differences in infection-related complications, and discusses TRANSLATE, which reported greater detection of higher-risk disease (Gleason grade group 2 or higher) with TP in biopsy-naïve patients, though infection-related differences were not statistically significant.\"}]","A response to Nasrallah et al. - Infection rates of trans-perineal versus trans-rectal prostate biopsy - A Middle Eastern tertiary center experience—Time for a change? - Letter to the Editor | PDF"]