Background and objective: The benefits of the detection of clinically significant
prostate cancer (csPCa) and safety of magnetic resonance imaging (MRI)-targeted transperineal
(TP) prostate biopsy (TP-Tbx) versus transrectal (TR) approaches are still a matter
of debate. This review aims to compare the efficacy and safety of TP-Tbx and MRI-targeted
TR biopsy (TR-Tbx). Methods: A systematic literature search was performed in PubMed/Medline,
Scopus, and Web of Science to identify records of prospective randomized controlled
trials (RCTs) comparing TP-Tbx and TR-Tbx published until May 2024. The primary outcomes
included detection rates of csPCa (International Society of Urological Pathology [ISUP]
>= 2) and rates of complications. Key findings and limitations: Three RCTs (PREVENT,
ProBE-PC, and PERFECT) met the inclusion criteria. The TR technique was commonly administered
with antibiotic prophylaxis to mitigate infection risks or after a rectal swab. No
difference was found between TP-Tbx and TR-Tbx in terms of either csPCa (odds ratio
[OR] 0.9, 95% confidence interval [CI]: 0.7-1.1) or ISUP 1 prostate cancer (PCa; OR
1.1,95% CI: 0.8-1.4) detection. Postprocedural infection (OR 0.8, 95% CI: 0.4-1.8),
sepsis (OR 0.6, 95% CI: 0.1-4.5), and urinary retention rates (OR 0.5, 95% CI: 0.1-1.6)
were similar. Pain during the TP approach was slightly higher than during the TR approach,
but after 7 d of follow-up, the differences between the two approaches were minimal.
Variations in biopsy numbers per patient, patient selection, use of 5-alpha reductase
inhibitors, needle sizes, TP techniques, and pain scores (reported in only one RCT),
along with the multicenter nature of RCTs, limit the study. Conclusions and clinical
implications: TP-Tbx and TR-Tbx show similar results in detecting PCa, with comparable
rates of infections, urinary retention, and effectiveness in managing biopsy-associated
pain. TP-Tbx can safely omit antibiotics without increasing infection risk, unlike
TR-Tbx. The tendency to exclude from practice TR-Tbx with prophylactic antibiotics
due to infection concerns could be moderated; however, the directionality of some
key outcomes, as infections and sepsis, favor the TP approach despite a lack of statistical
significance. Patient summary: There were no significant differences in the prostate
biopsy approaches (transperineal [TP] vs transrectal [TR]) for prostate cancer detection
and complications. However, the MRI-targeted TP prostate biopsy approach may be advantageous
as it can be performed safely without antibiotics, potentially reducing antibiotic
resistance. (c) 2024 The Authors. Published by Elsevier B.V. on behalf of European
Association of Urology. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
