Prostate Biopsy and the Alternatives: Do You Really Need a Biopsy?

By Mr Neil Haldar, Consultant Urological Surgeon

For many years, the pathway following a raised prostate-specific antigen, or PSA, test was relatively predictable: the PSA was repeated, the prostate was examined and, if concern remained, the patient was referred for a prostate biopsy.

That pathway has changed considerably.

A raised PSA no longer leads automatically to a biopsy. Most men should now have a prostate MRI first. Clinicians consider the MRI findings alongside the PSA level, prostate size, PSA density, examination findings, family history, ethnicity, age, and general health. In some men, this information shows that the likelihood of a clinically important cancer is sufficiently low for biopsy to be deferred or avoided.

When a biopsy is required, the way it is performed has also evolved. The transperineal route—passing the needle through the skin between the scrotum and anus—has largely replaced the older transrectal approach in UK practice because it carries a lower risk of serious infection.

Newer tests are also beginning to influence the pathway. These include blood and urine biomarkers, high-resolution micro-ultrasound and, in selected cases, prostate-specific membrane antigen positron emission tomography-computed tomography, usually abbreviated to PSMA PET-CT.

None of these developments has eliminated the need for biopsy. Histology remains the only established way to confirm the type and grade of a prostate cancer. What has changed is the question.

Instead of asking, “Does every man with a raised PSA need a biopsy?”, we now ask:

• How likely is clinically significant prostate cancer?
• Would a biopsy provide information that changes treatment?
• Could the biopsy reasonably be avoided or postponed?
• What is the safest and most accurate way to obtain tissue?
• How much tissue actually needs to be sampled?

In brief

A prostate biopsy may not be necessary when:

• the MRI is reassuring;
• PSA density is low;
• the prostate examination is normal;
• there is no strong family or genetic risk;
• the PSA remains stable;
• and the patient is willing to follow a structured follow-up plan.

A biopsy is more likely to be recommended when:

• MRI identifies a suspicious lesion;
• PSA density is elevated;
• the prostate feels abnormal;
• PSA continues to rise;
• there is a strong family history or inherited risk;
• or significant clinical suspicion persists despite a normal MRI.

When biopsy is needed, a targeted transperineal biopsy is usually preferred.

What is a prostate biopsy?

A prostate biopsy is a procedure in which small samples of prostate tissue are removed using a fine needle. A specialist pathologist then examines the samples under a microscope.

The main purpose of a biopsy is not simply to determine whether cancer cells are present. It is to establish the cancer’s biological features, particularly its grade.

Prostate cancers are commonly classified using the International Society of Urological Pathology Grade Group system:

• Grade Group 1 generally represents lower-risk disease.
• Grade Groups 2 and 3 represent intermediate-risk disease with varying amounts of Gleason pattern 4.
• Grade Groups 4 and 5 represent high-grade disease.

The Grade Group is considered alongside the PSA, MRI findings, clinical stage, volume of cancer, genomic information where appropriate, the patient’s health and his preferences. Together, these factors determine whether the best approach is active surveillance, focal treatment, surgery, radiotherapy, hormonal treatment or another form of management.

At present, an MRI scan or blood test can estimate the probability that significant cancer is present, but it cannot provide a reliable histological Grade Group. That still requires tissue.

Why can a raised PSA lead to unnecessary biopsies?

PSA is produced by prostate tissue. Although prostate cancer may cause the PSA to rise, cancer is only one possible explanation.

PSA can also be increased by:

• benign enlargement of the prostate;
• inflammation or prostatitis;
• a urinary infection;
• recent urinary retention;
• recent catheterisation or instrumentation;
• ejaculation shortly before the test;
• vigorous cycling in some circumstances;
• and increasing age.

A raised PSA is therefore a marker of possible prostate disease rather than a diagnosis of prostate cancer.

This lack of specificity has historically created two connected problems.

First, men without cancer have undergone unnecessary biopsies. Secondly, biopsies have identified small, low-grade cancers that might never have affected the patient’s health or life expectancy. Once such a cancer is diagnosed, it may lead to repeated investigations, anxiety and sometimes treatment that would otherwise never have been required.

The aim of the modern diagnostic pathway is not to find every microscopic focus of prostate cancer. It is to identify cancers likely to grow, spread, or shorten life while minimising unnecessary procedures and the overdiagnosis of indolent disease.

Is there a prostate cancer screening programme in the UK?

The UK still does not recommend population-wide PSA screening for all men.

In 2026, the UK National Screening Committee recommended a targeted programme of PSA testing every two years for men aged 45 to 61 who have both a pathogenic BRCA2 variant and a relevant family history of breast, ovarian, pancreatic or prostate cancer. It continued to recommend against population-wide screening and against routine targeted screening for other groups while further evidence is gathered.

This decision illustrates the fundamental challenge of prostate cancer diagnosis. Screening can detect aggressive cancers earlier, but it can also expose large numbers of healthy men to MRI, biopsy, anxiety and the diagnosis or treatment of disease that would never have caused harm.

The current diagnostic pathway is designed to improve that balance.

Why MRI now comes before prostate biopsy

One of the most important advances in prostate cancer diagnosis has been the introduction of MRI before biopsy.

NICE recommends multiparametric MRI as the first-line investigation for people with suspected clinically localised prostate cancer. Men with a reassuring MRI may be able to avoid immediate biopsy after an informed discussion of residual risk, while suspicious MRI findings can direct biopsy needles towards the abnormal area.

Before MRI was routinely used, biopsy was usually systematic. A series of samples was taken from predetermined areas of the prostate in the hope that one of the needles would pass through any cancer that was present.

This approach had important limitations.

A typical systematic biopsy samples only a very small proportion of the prostate. Significant tumours could be missed, particularly if they were situated towards the front of the gland or in another area that was difficult to reach through the rectal route. Conversely, random sampling could identify tiny areas of low-grade cancer that were unlikely to matter.

MRI changes the procedure from largely blind sampling to image-directed sampling.

What does a prostate MRI show?

A prostate MRI examines the internal structure of the gland and identifies areas that look different from normal prostate tissue.

MRI findings are usually reported using either the five-point PI-RADS scale or, in many UK centres, a five-point Likert scale:

• Score 1: clinically significant cancer is highly unlikely.
• Score 2: clinically significant cancer is unlikely.
• Score 3: the result is equivocal.
• Score 4: clinically significant cancer is likely.
• Score 5: clinically significant cancer is highly likely.

MRI is not infallible. Some significant prostate cancers are difficult to see, and the accuracy of the scan depends heavily on image quality, scanner protocols and the experience of the reporting radiologist.

A normal MRI therefore reduces the likelihood of important cancer but does not reduce it to zero.

What is PSA density?

PSA density is one of the most useful—and simplest—tools in the modern diagnostic pathway.

It is calculated by dividing the PSA level by the volume of the prostate:

PSA density = PSA ÷ prostate volume

The prostate volume is usually measured on MRI.

PSA density matters because a large benign prostate may produce a relatively high PSA without containing cancer. A PSA of 6 ng/mL in a 100 mL prostate is less concerning than the same PSA in a 25 mL prostate.

The precise threshold used varies between guidelines and clinical pathways.

NICE identifies a PSA density above 0.15 ng/mL/cc as one factor that may increase suspicion following a low-risk MRI. The EAU guideline allows consideration of biopsy avoidance following a negative MRI when PSA density is below 0.20 ng/mL/cc, provided there is no family history and overall clinical suspicion is low. For a PI-RADS 3 MRI, the EAU uses the more cautious threshold of 0.10 ng/mL/cc when considering surveillance rather than biopsy.

These figures are not absolute dividing lines between cancer and no cancer. They are decision-support tools. Always consider PSA density alongside MRI findings and the patient’s other risk factors.

Can a prostate biopsy be avoided after a normal MRI?

In selected men, yes.

The EAU recommends that biopsy may be omitted and PSA monitoring offered when:

• MRI is negative, meaning PI-RADS 1 or 2;
• PSA density is low;
• there is no relevant family history;
• and overall clinical suspicion is low.

NICE also supports considering biopsy avoidance after a reassuring MRI, provided the risks and benefits are explained, and the decision is shared with the patient.

However, avoiding biopsy does not mean ignoring the PSA.

A structured follow-up plan is essential. This may involve:

• repeating the PSA after an agreed interval;
• monitoring PSA density or PSA change over time;
• repeating the clinical examination;
• arranging another MRI if the PSA rises;
• and reconsidering biopsy if the risk profile changes.

Biopsy avoidance is therefore better understood as active diagnostic surveillance, not as discharge without follow-up.

When might biopsy still be advised after a normal MRI?

A biopsy may still be appropriate if there is:

• a high PSA density;
• an abnormal digital rectal examination;
• a strong family history of prostate cancer;
• a known inherited cancer-predisposition gene;
• a persistently rising PSA;
• a previous biopsy showing atypical or suspicious cells;
• concern about MRI quality;
• or another reason to believe that the MRI may have underestimated the risk.

A normal MRI result must therefore be interpreted in context.

What does a PI-RADS 3 result mean?

PI-RADS 3 is the most difficult category because it means the MRI finding is indeterminate.

The abnormality may represent cancer, but it may also represent benign enlargement, inflammation, scarring or normal variation.

The original review estimated that approximately one in five PI-RADS 3 lesions may contain Grade Group 2 or higher cancer, although the true probability varies substantially by PSA density, age, clinical setting, and the population being investigated.

The decision is therefore not based on the MRI score alone.

Monitoring may be reasonable when:

• PSA density is below approximately 0.10 ng/mL/cc;
• the prostate examination is normal;
• there is no strong family history;
• PSA is stable;
• and the patient accepts the small residual risk.

Biopsy is more likely to be recommended when:

• PSA density is elevated;
• PSA is rising;
• the examination is abnormal;
• there is a strong family or genetic risk;
• or the lesion has other concerning radiological features.

This is a good example of where shared decision-making matters. Two men with the same PI-RADS 3 result may reasonably make different decisions because their wider risk profiles and attitudes towards uncertainty differ.

Multiparametric versus biparametric MRI

A conventional multiparametric prostate MRI generally includes:

• T2-weighted anatomical imaging;
• diffusion-weighted imaging;
• and a dynamic contrast-enhanced sequence following an injection of gadolinium.

Biparametric MRI omits the contrast-enhanced sequence, making the scan shorter and avoiding the need for intravenous contrast.

The international PRIME trial found that biparametric MRI was non-inferior to multiparametric MRI for detecting Grade Group 2 or higher prostate cancer when scans were of adequate quality and interpreted by experienced radiologists.

This could eventually increase MRI capacity and reduce cost.

However, it is important not to overgeneralise the result. PRIME was undertaken in centres with rigorous image-quality control and experienced prostate MRI readers. A shorter protocol does not compensate for poor image acquisition or limited reporting expertise.

Multiparametric MRI remains the explicit NICE first-line standard in the UK. Biparametric MRI is a promising evidence-supported alternative when used within a properly quality-assured service.

If biopsy is needed, which type should be performed?

There are two principal routes.

Transrectal prostate biopsy

In a transrectal biopsy, the ultrasound probe is inserted into the rectum, and the biopsy needle passes through the rectal wall into the prostate.

This was the standard technique for many years.

Its principal disadvantage is infection. The needle passes through rectal tissue containing bacteria before entering the prostate and urinary tract. Antibiotics reduce this risk but do not eliminate it, particularly as antibiotic resistance has increased.

Transperineal prostate biopsy

In a transperineal biopsy, the needle passes through the cleansed skin of the perineum—the area between the scrotum and anus—and into the prostate.

This avoids passing the biopsy needle through the rectal wall.

Current EAU guidance strongly recommends the transperineal route because of its lower infectious risk and better antibiotic stewardship. In patients without particular infection risk factors, prophylactic antibiotics may not be necessary, although local protocols differ.

Transperineal biopsy also provides good access to the anterior and apical parts of the prostate, areas that may be more difficult to sample adequately using a transrectal trajectory.

Is transperineal biopsy more accurate?

The answer is nuanced.

The UK TRANSLATE trial reported a higher detection rate for Grade Group 2 or higher cancer with local-anaesthetic transperineal biopsy than with transrectal biopsy in biopsy-naive men who had undergone MRI.

However, other randomised studies and pooled analyses have found broadly comparable overall detection rates between the routes. Differences in MRI targeting, operator experience, sampling patterns and core numbers may help explain these varying results.

The clearest proven advantage of the transperineal route is its lower infectious risk rather than a guarantee that it will always detect more cancer.

Does a transperineal biopsy hurt?

A transperineal biopsy can be performed under:

• local anaesthetic;
• local anaesthetic with sedation;
• or general anaesthetic.

Many biopsies are now completed safely as outpatient procedures under local anaesthetic. However, it should not be described as painless.

The TRANSLATE trial found that local-anaesthetic transperineal biopsy caused more immediate discomfort and took longer than transrectal biopsy.

Tolerability depends on:

• the quality of the local anaesthetic block;
• operator experience;
• prostate size;
• the number and location of samples;
• previous perineal surgery;
• the patient’s anxiety;
• and individual pain sensitivity.

Sedation or general anaesthesia may be the kinder option for some men, particularly when extensive sampling is anticipated, or anxiety is substantial.

The anaesthetic approach should be discussed rather than assumed.

Targeted, systematic and perilesional biopsies

Once MRI identifies a suspicious lesion, the next question is how much of the prostate should be sampled.

Targeted biopsy

Targeted cores are taken directly from the MRI abnormality.

The MRI image may be matched to real-time ultrasound using:

• cognitive targeting, where the surgeon mentally maps the MRI lesion onto the ultrasound image;
• MRI-ultrasound fusion software;
• or direct MRI-guided biopsy within the scanner, which is less commonly used.

Systematic biopsy

Systematic cores are taken from predetermined regions across the prostate, including areas that appear normal on MRI.

The advantage is that systematic sampling may detect an MRI-invisible cancer elsewhere in the gland. The disadvantage is that it increases the number of cores, discomfort and the likelihood of finding small-volume Grade Group 1 disease that may never have caused harm.

Perilesional sampling

Perilesional cores are taken from the tissue immediately surrounding the visible MRI lesion.

This recognises that a tumour’s microscopic boundary may extend beyond the area visible on MRI. It offers a compromise between sampling only the centre of the lesion and taking a full systematic template throughout the gland.

Current EAU guidance supports targeted biopsy with perilesional sampling for suspicious MRI lesions.

The most appropriate sampling strategy depends on whether the patient has had a previous biopsy, the MRI score, lesion position, PSA density, prostate size and the clinical consequences of potentially missing additional disease.

What are the risks of prostate biopsy?

Most men recover quickly, but biopsy is still an invasive procedure.

Blood in the urine

Haematuria is common after biopsy and usually settles without treatment. Patients should receive clear advice on how much bleeding is expected and when to seek help.

Blood in the semen

Haematospermia is also common. It can appear dark red, brown or almost black and may persist intermittently for several weeks.

Although usually harmless, it can be alarming if the patient and his partner have not been warned.

Infection

Infection is the most important historical risk of transrectal biopsy.

The risk is substantially lower following transperineal biopsy because the needle does not pass through the rectal wall. This is the principal reason the transperineal route is now preferred by the EAU and widely established in UK practice.

Difficulty passing urine

Swelling or bleeding within the prostate can temporarily obstruct urinary flow. A small proportion of patients develop urinary retention and require a temporary catheter.

The risk is higher in men with:

• a large prostate;
• significant pre-existing urinary symptoms;
• a high number of biopsy cores;
• or previous episodes of retention.

Pain and bruising

Perineal discomfort, bruising and soreness may occur for several days. Appropriate local anaesthetic technique and limiting sampling to what is clinically necessary can improve tolerability.

Temporary erectile difficulties

Some men report a temporary reduction in erectile function following biopsy. This may relate to pain, inflammation, anxiety or a combination of factors and usually improves with time.

When should urgent medical advice be sought?

Patients should follow the instructions given by their treating unit, but urgent assessment is generally required for:

• fever, rigors or feeling acutely unwell;
• inability to pass urine;
• heavy or persistent bleeding;
• passage of large blood clots;
• severe worsening pain;
• or any other concerning deterioration.

Are there blood tests that can help avoid biopsy?

Several blood-based tests have been developed to improve on PSA alone.

These include:

• Prostate Health Index, or PHI;
• 4Kscore;
• IsoPSA;
• Stockholm3;
• and Proclarix.

These tests combine different forms of PSA with other proteins, genetic markers or clinical information to estimate the probability of finding significant prostate cancer.

They may be useful when the decision remains uncertain, particularly:

• before MRI in healthcare systems with limited MRI capacity;
• after an equivocal MRI;
• following a negative MRI with persistent clinical concern;
• or before deciding whether to repeat a previously negative biopsy.

Their role in the NHS remains limited. MRI is already embedded within the UK pathway, and NICE does not currently recommend PHI or PCA3 after a negative or inconclusive biopsy.

A biomarker is useful only if the result is likely to change the decision. Paying for a test that would not alter whether MRI or biopsy is performed adds cost without necessarily adding clinical value.

Can a urine test replace prostate biopsy?

Several urinary assays assess genes or other biological markers associated with prostate cancer.

Examples include:

• PCA3;
• SelectMDx;
• ExoDx;
• MyProstateScore;
• and MyProstateScore 2.0, or MPS2.

MPS2 measures a panel of urinary markers associated with clinically significant prostate cancer.

A 2025 validation study using first-catch urine collected without a preceding digital rectal examination found that, at a high-sensitivity threshold, MPS2 could potentially have avoided approximately 36–42% of unnecessary initial biopsies and 44–53% of unnecessary repeat biopsies in the studied cohort.

These findings are promising, but they require careful interpretation.

A high negative predictive value does not guarantee that important cancer is absent. Test performance depends on:

• the population being tested;
• the prevalence of significant cancer;
• the chosen threshold;
• the MRI findings;
• and the clinical risk before the test is performed.

Urine tests may help identify men whose estimated risk is low enough to defer biopsy, but they have not replaced MRI or histology in routine UK practice.

What is micro-ultrasound?

Conventional ultrasound is used during prostate biopsy to visualise the gland, but it is relatively poor at distinguishing cancer from normal tissue.

Micro-ultrasound uses a much higher frequency and produces substantially higher-resolution images. Suspicious appearances are classified using the PRI-MUS scoring system.

The potential advantages include:

• real-time imaging;
• immediate targeted biopsy;
• no need for MRI contrast;
• lower dependence on MRI scanner availability;
• and the possibility of completing assessment and biopsy in a single visit.

The OPTIMUM randomised clinical trial compared micro-ultrasound-guided biopsy with MRI-ultrasound fusion biopsy in biopsy-naive men. Micro-ultrasound-guided biopsy was non-inferior for detecting Grade Group 2 or higher prostate cancer.

This establishes micro-ultrasound as a credible method for guiding biopsy.

It does not yet prove that micro-ultrasound can safely decide which men should avoid biopsy, because the men in OPTIMUM underwent systematic biopsy as part of the trial pathway.

Micro-ultrasound may be particularly valuable when:

• MRI is contraindicated;
• MRI is poorly tolerated;
• MRI access is limited;
• or a specialist centre has substantial micro-ultrasound expertise.

For now, it should be viewed as an emerging alternative guidance modality rather than a wholesale replacement for high-quality MRI in a well-resourced pathway.

Can PSMA PET-CT help avoid a biopsy?

PSMA PET-CT is already used to stage certain prostate cancers and to investigate suspected recurrence after treatment.

Its role before initial diagnosis is newer.

The PRIMARY2 trial studied 660 biopsy-naive men with either a PI-RADS 3 MRI or a low-suspicion MRI combined with additional risk factors. Men in the experimental group underwent PSMA PET-CT. Those with a reassuring scan avoided immediate biopsy, while positive areas were sampled using targeted transperineal biopsy.

Approximately 49% of men in the experimental arm avoided biopsy within six months. Fewer insignificant cancers were detected, and the strategy met the trial’s prespecified non-inferiority criterion for detecting clinically significant cancer.

This is important evidence, but it should not be interpreted as proving that PSMA PET-CT never misses significant prostate cancer.

The proportion of clinically significant cancers detected was numerically lower in the PSMA PET-CT pathway than in the control group. The result met a predefined statistical non-inferiority margin; that is not the same as showing identical detection.

PSMA PET-CT also:

• is considerably more expensive than MRI;
• involves exposure to ionising radiation;
• requires a radiotracer;
• and is not currently a routine NHS investigation for deciding whether an initial prostate biopsy is required.

Its most plausible near-term role is in carefully selected men who have persistent clinical risk but an equivocal or unexpectedly reassuring MRI.

Does genetic risk affect the biopsy decision?

Inherited genetic factors can significantly influence prostate cancer risk.

The best-established example is a pathogenic BRCA2 variant. Men with BRCA2 variants are at increased risk of developing prostate cancer and may develop more clinically significant disease.

The 2026 UK screening recommendation for men aged 45–61 with a BRCA2 variant and a relevant family history reflects this increased risk.

Researchers are also studying other inherited genes and polygenic risk scores.

The large UK TRANSFORM programme is investigating combinations of PSA testing, genetic risk assessment and rapid MRI. Its purpose is to identify a screening strategy that detects aggressive cancers while limiting unnecessary biopsy, overdiagnosis and treatment.

These studies may eventually determine who should enter the PSA and MRI pathway in the first place, rather than merely refining what happens after a PSA has been found to be raised.

Can artificial intelligence improve prostate cancer diagnosis?

Researchers are investigating artificial intelligence at several stages of the pathway.

AI-assisted MRI reporting

Prostate MRI depends heavily on the reader. Less experienced radiologists may classify more scans as equivocal, potentially increasing unnecessary biopsies or missing subtle significant disease.

AI may help by:

• highlighting suspicious regions;
• estimating the likelihood of clinically significant cancer;
• checking image quality;
• and reducing variation between reporting centres.

The most likely near-term use is to support radiologists rather than replace them.

AI-assisted pathology

Computer algorithms can also analyse digitised biopsy slides and assist with Gleason grading.

This could reduce variation between pathologists, improve consistency and identify small areas of higher-grade disease.

However, AI does not remove the need to obtain tissue. It may improve the reliability of MRI and biopsy interpretation.

Can repeat biopsies be avoided?

Biopsy avoidance is also relevant after an initial diagnosis.

Men with low-risk prostate cancer are often managed using active surveillance. Traditionally, surveillance protocols included repeated biopsies at fixed intervals, even when PSA and MRI remained stable.

The pathway is becoming more individualised.

In selected men who had high-quality MRI-directed sampling at diagnosis, a separate immediate confirmatory biopsy may not be necessary. During follow-up, stable MRI findings, stable PSA density and the absence of other evidence of progression may allow an individual repeat biopsy to be postponed or omitted.

However, MRI does not detect every histological change. A stable scan should not automatically mean that a patient will never require another biopsy.

Biopsy may be reconsidered if there is:

• a significant PSA rise;
• an increase in PSA density;
• a change on MRI;
• new clinical findings;
• or concern that the original sampling was insufficient.

The purpose is to avoid automatic biopsies that add little information, not to abandon histological reassessment when it could change treatment.

What happens if the biopsy is negative?

A negative biopsy is reassuring, but it does not exclude prostate cancer completely.

Possible explanations include:

• there is no cancer;
• a small cancer was missed by the needles;
• MRI underestimated or failed to show a lesion;
• or the abnormal PSA is being caused by benign enlargement or inflammation.

Before the biopsy, there should ideally be a clear plan for what will happen if the result is negative.

Follow-up may include:

• a repeat PSA after an agreed interval;
• monitoring PSA density;
• review of the original MRI;
• repeat MRI;
• a biomarker test in selected circumstances;
• or repeat targeted or systematic biopsy if suspicion remains high.

A patient should not be told the biopsy is negative and discharged without considering why the PSA rose and what future change should prompt reassessment.

Shared decision-making: choosing whether to have a biopsy

The decision to undergo biopsy is rarely based on a single number.

A meaningful discussion should cover:

• the estimated probability of clinically significant cancer;
• what the MRI does and does not show;
• PSA density;
• family and genetic risk;
• the implications of finding low-grade cancer;
• the possibility that biopsy may miss disease;
• the option of structured monitoring;
• the proposed biopsy route;
• the type of anaesthetic;
• the number and location of samples;
• and the risks of infection, bleeding, retention and discomfort.

Clinicians have a duty to discuss reasonable alternatives that are clinically appropriate for the individual patient. This does not mean that every commercially available test must be offered. A blood test, urinary biomarker or PSMA PET-CT scan is not automatically a reasonable alternative simply because it can be purchased.

The discussion should focus on options supported by the patient’s circumstances, the available evidence and responsible clinical judgement.

Good documentation should record not only the final decision but why it was reached.

A practical modern prostate biopsy pathway

Although every case requires individual assessment, the pathway can be summarised as follows.

Step 1: Confirm the PSA result

An isolated unexpected PSA elevation will often be repeated before proceeding further.

The clinical assessment should consider:

• urinary infection;
• prostatitis;
• recent catheterisation or instrumentation;
• urinary retention;
• recent ejaculation;
• medications;
• previous PSA results;
• urinary symptoms;
• family history;
• ethnicity;
• age;
• and general health.

A digital rectal examination may also be performed.

Step 2: Arrange MRI before biopsy

Men with suspected clinically localised prostate cancer should usually undergo a high-quality prostate MRI before biopsy.

The report should include an estimate of prostate volume so that PSA density can be calculated.

Step 3: Combine MRI with PSA density and clinical risk

PI-RADS or Likert 1–2

When the MRI is reassuring, and overall clinical suspicion is low, immediate biopsy may reasonably be omitted following shared decision-making.

A follow-up plan is still required.

PI-RADS 1–2 with higher clinical risk

When PSA density is high, PSA is rising, examination is abnormal or family or genetic risk is substantial, further assessment may be required despite the MRI.

Options may include:

• systematic biopsy;
• specialist MRI review;
• repeat MRI;
• a selectively used biomarker;
• or, in unusual specialist circumstances, emerging imaging such as PSMA PET-CT.

PI-RADS 3

When PSA density is very low, and there are no other risk factors, monitoring may be reasonable.

Where PSA density or other risk factors increase concern, targeted biopsy with sampling around the lesion is usually advised.

PI-RADS 4–5

A targeted biopsy is usually recommended, commonly with perilesional sampling and any additional samples judged clinically necessary.

Step 4: Choose the biopsy route

Transperineal biopsy is generally preferred because of its lower infection risk.

The anaesthetic should be selected according to:

• expected core number;
• prostate size;
• lesion position;
• patient anxiety;
• previous procedures;
• medical fitness;
• and patient preference.

Step 5: Sample proportionately

The biopsy should obtain enough tissue to answer the clinical question without automatically performing an unnecessarily extensive template.

MRI-targeted and perilesional sampling can reduce the number of random cores and limit the detection of incidental low-grade disease.

Step 6: Agree follow-up in advance

Whether the biopsy is performed, postponed or omitted, the next step should be defined.

This includes:

• when the PSA will be repeated;
• whether another MRI is expected;
• what change should trigger further investigation;
• and who is responsible for arranging follow-up.

Questions patients commonly ask

Conclusion

A prostate biopsy is no longer the inevitable next step after a raised PSA.

A modern assessment should begin by confirming the PSA result and considering the possible benign explanations. A high-quality MRI should usually be performed before biopsy, and the result should be interpreted alongside PSA density, examination findings, family history, genetic risk and the patient’s general health.

Some men can safely avoid or defer biopsy with structured follow-up. Others will still benefit from tissue sampling because only biopsy can establish the histological grade that guides treatment.

When biopsy is necessary, the transperineal route offers a substantially lower infectious risk and has become the preferred approach in contemporary European guidance. Targeting the MRI lesion and its immediate surroundings can also reduce unnecessary sampling of the remainder of the prostate.

Blood and urine biomarkers, micro-ultrasound, and PSMA PET-CT may further refine this pathway. At present, however, their role is selective or emerging rather than a replacement for high-quality MRI, clinical judgement and appropriately performed biopsy.

The biopsy has not disappeared. It has become a more considered, targeted, and individualised decision.

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This article provides general information and does not constitute individual medical advice. The need for prostate MRI, biopsy or surveillance should be discussed with a urologist familiar with the patient’s PSA history, imaging, examination findings and wider health.

Evidence and guidance reviewed: August 2026.

Unsure Whether You Need a Prostate Biopsy?

A raised PSA or abnormal MRI does not automatically mean that a prostate biopsy is necessary. The decision should take account of your PSA trend, prostate size and PSA density, MRI findings, examination, family history, previous biopsy results and your individual risk of clinically significant prostate cancer.

If you have been advised to consider a biopsy—or would like a second opinion about whether one can safely be avoided—I can review your results and explain the available options.

Where a biopsy is appropriate, I can also discuss the relative advantages of MRI-targeted, systematic and transperineal biopsy techniques, and how the result is likely to affect your subsequent management.

You can also learn more about my Rapid Access Elevated PSA Clinic and view my clinic locations.