Infection risks and biopsy-associated complications in prostate cancer diagnosis: a review of recent literatures.

BACKGROUND

Prostate cancer is the second most commonly diagnosed cancer worldwide. Prostate biopsy, essential for definitive diagnosis, has evolved significantly with new technologies and techniques. Transrectal ultrasound-guided biopsy (TRUS-Bx) has been the gold standard but carries substantial infectious risks due to rectal mucosal penetration. Rising antibiotic resistance, emerging safety protocols, and novel imaging-guided methods have driven a shift toward safer alternatives.

METHODS

Following PRISMA guidelines, we systematically searched PubMed and PubMed Central for studies published between 2014 and 2025 on prostate puncture complications. Eligible articles included original studies with ≥2 patients, emphasizing infectious complications, antibiotic prophylaxis, and modern innovations. From 639 records screened, 78 met inclusion criteria. Thematic synthesis was used to classify findings into complication types, prophylaxis approaches, and technological advancements.

RESULTS

Infectious complications after TRUS-Bx ranged from 0.5 to 9.4% for sepsis and 0.3 to 4.9% for febrile urinary tract infections, largely driven by multidrug-resistant organisms and increased sampling density. Transperineal biopsy (TP-Bx), bypassing rectal flora, consistently reported infection rates <1%. Targeted prophylaxis based on rectal cultures, combination antibiotic regimens (e.g., fluoroquinolone with fosfomycin or ceftriaxone), and adjunct measures such as rectal cleansing significantly reduced post-biopsy infections. Technological innovations such as MRI-ultrasound fusion, robotic-assisted approaches, and PSMA PET/CT-guided techniques improved cancer detection rates (up to 71.8%) while maintaining low complication rates ( < 5%). Emerging non-antibiotic TP protocols and advanced anesthetic techniques further enhanced safety and patient tolerance.

CONCLUSIONS

Modern evidence supports a paradigm shift toward TP-Bx combined with targeted or multidrug prophylaxis to mitigate infectious risks. Imaging-guided and robotic-assisted techniques enhance diagnostic accuracy and safety but remain limited in resource-constrained settings. TRUS-Bx retains utility where TP access is unavailable; however, adapting infection prevention strategies is critical. Future large-scale trials and cost-effectiveness analyses are needed to optimize biopsy protocols globally.