Transperineal Versus Transrectal Prostate Biopsy: A Systematic Review and Meta-analysis of Randomized Controlled Trials Across Settings With and Without Magnetic Resonance Imaging Targeting

Abstract

Background and objective: While transperineal prostate biopsy (TP-Bx) is increasingly being used to mitigate infection risk, its diagnostic equivalence to transrectal biopsy (TR-Bx) remains under investigation. Our aim was to comprehensively compare the diagnostic performance and complication profiles of TP-Bx and TR-Bx across settings with and without magnetic resonance imaging (MRI) targeting using data from randomized controlled trials (RCTs). Methods: We performed a systematic review and meta-analysis of 12 RCTs comprising 4244 patients. Outcomes included detection of clinically significant prostate cancer (csPC), anterior tumor detection, procedural pain, infection-related complications, urinary retention, and bleeding, each analyzed in groups with and without MRI targeting for biopsy. Key findings and limitations: Overall csPC detection rates were comparable between TP-Bx and TR-Bx (odds ratio [OR] 1.15, 95% confidence interval [CI] 0.95-1.39). There was no difference in MRI-targeted studies (OR 1.08, 95% CI 0.85-1.36), whereas TP-Bx showed superior csPC detection in settings without MRI targeting (OR 1.41, 95% CI 1.02-1.95). TP-Bx was associated with significantly fewer infectious complications (OR 0.70 for any infection; OR 0.35 for grade >= 3 infections), although procedural pain was higher (OR 2.05). No significant differences in urinary retention or bleeding were observed. Heterogeneity in analgesia protocols and MRI use across studies is a limitation. Conclusions and clinic al implications: TP-Bx and TR-Bx yield similar diagnostic performance for csPC in geting, TP-Bx may Although TP-Bx is formed safely unde MRI-targeted procedures. However, in settings without MRI tar-offer better detection and a substantially lower infection risk. associated with greater procedural discomfort, it can be per-r local anesthesia and without antibiotics, which aligns with antibiotic stewards hip ivi tion should be ind patient tolerance. Patient summary: We transperineal (TP) and cer, but the TP metho may cause slightly mo anesthesia. Which app of MRI (magnetic res preference. (c) 2025 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativeprinciples. These findings suggest that biopsy route selecdualized according to MRI availability, infection risk, and compared evidence for two prostate biopsy methods: transrectal (TR). Both were similar in detecting prostate can-d had fewer infections and may not require antibiotics. TP re discomfort, but pain is generally manageable with local roach is best may depend on factors such as the availability onance imaging), the risk of infection, and the patient's commons.org/licenses/by-nc-nd/4.0/).