Batsam10: I had 3+3 and 3+4 Gleason and after an mri, had a transrectal biopsy. Then I had radiation with the MRIdian linac machine. People say the transperinal lowers the risk of sepsis and other issues from 2 in 500 to 1 in 500. Obviously, transperinal does not involve the rectum so you don’t get the rectum infection risk but clearly your brother has identified his risks.

If it were me, I would go for a psma pet scan and then make my decision on treatment which is essentially what my radiation oncologist will do if my PSA rises too much. Not sure if your insurance will go for it or not but maybe.

Your biopsy material may or may not be too old to use in a decipher test which will give you and your doctors a “feel” for its aggressiveness level. I agree with jc76 to get a second and third opinion.

Inserting needles for a biopsy is important after an initial MRI but my feeling is the same as your brothers. If you do, do it again, try for the Fusion MRI guided one. Good luck.