How would you manage a patient with low risk prostate cancer on active surveillance who develops high risk features but absolutely refuses a repeat biopsy?

In the setting of a suspicious mpMRI lesion, we start by acknowledging the patient's likely negative experience with their transrectal biopsy. We ask if they are referring to the one where they were rolled on their side, had a probe inserted in their rectum, and heard a bunch of loud CLICKs. We empathize with their experience and then share that this is not what we are talking about. We discuss that we are instead offering a different type of biopsy. When they ask for more information, we disclose that ours are done under monitored anesthesia and in the dorsal lithotomy position so that the biopsy can be done through the skin. This takes care of their anxieties for another transrectal biopsy, and has led to a 100% willingness to proceed wit...