@brianjarvis
I echo your post.

I have PTSD anxiety/panic disorder and I wanted my biopsies done transperineally with anesthesia. My urologist (was at Mayo) wanted to do transrectal as I was a heart failure patient and pushed me to have it done transrectal. My opinion was he wanted to do transrectal as was not as complex as transperineally done in surgical section versus a special office setting.

I did not accept his insistence and contacted my heart failure doctor about his stance. My HF doctor and I knew I had no restrictions on having anesthesia as had had it several times and just weeks prior for a colonoscopy. I had my HF doctor contact the urologist and advised him cardiology had no restrictions on me having anesthesia.

My urologist informed me he had been contacted by HF doctor and would schedule me for MRI/Fusion procedure with anesthesia.

So like you said, stand up, speak, get what is best for you when you have options. I also did not want the additional increase in infection (was told 1-2%) if it could be avoided and did not want it done transrectal.

I don't think the transperineally is barbaric but a very specific and precise surgery. It confirmed I had PC when my MRI just showed suspicious areas.

Some on MCC had no problem having it done transrectal and that is their decision to make.

@brianjarvis Is it possible that you and your brother just got lucky and found extra-compassionate urologists?
Is there not a severe doctor shortage where you both live?
With the exception of the rare extra-compassionate doctor, doctors don't have to accommodate patients' needs because it is a "seller's market"...car dealers don't give discounts or concessions when there are more buyers than available cars, and doctors don't have to make concessions because there are more patients than available doctors.
And my guess is that these doctors that won't do general anesthesia would do general anesthesia if it were instead a "buyer's market".
In this "seller's market", doctors can afford to only keep the "cream of the crop" when it comes to patients, which means the most compliant patients.
I'm almost afraid to even ask my new urologist about general anesthesia during biopsy for this reason.
My primary care provider is an extremely compassionate woman who really cares about patient comfort, and if I get that feeling from my new urologist then I will ask about general anesthesia, but if I get the impression that his his attitude is going to be "oh...so this guy is going to be a troublemaker" , then I won't ask him about general anesthesia. I might casually ask one of his staff members about it on the sly, though.
Seeking out a compassionate urologist isn't really an option for me, because I would want a fusion biopsy, which already limits the selection of urologists within 3 hours of me, and then there is also the factor of "how do you know if a urologist is compassionate until you meet?".
Online reviews don't help because very few men ask for general anesthesia prior to biopsy, and if they don't ask then they don't know if the urologist would be compassionate vs. hostile regarding that particular issue.
Sorry to sound so cynical and/or negative, but I think that my description of the current situation is accurate.