Transperineal vs Transrectal Prostate Biopsy:
Is One Better?

Neil Osterweil

July 05, 2022

When it comes to prostate biopsy, is the transperineal or transrectal route better?

Urologists are currently awaiting results from ongoing clinical trials exploring whether transperineal prostate biopsy outperforms the transrectal approach in terms of safety and the ability to detect more clinically significant prostate cancers.

Several new studies presented at the European Association of Urology (EAU) 2022 Congress do not appear to provide definitive answers yet, but overall experts appeared to lean more towards the transperineal approach.

One study, for instance, identified similar detection rates but found the transperineal approach appeared to edge out transrectal in the safety department, while another study found the transrectal approach detected significantly more clinically significant cancers than the transperineal technique.

The Transperineal Preference

In one study, Renée Hogenhout, MD, and colleagues found that transperineal biopsy demonstrated comparable clinically significant prostate cancer detection rates to transrectal biopsy when using MRI-transrectal ultrasound-guided (TRUS) fusion.

More specifically, Hogenhout and colleagues compared the complication rates and ability to detect clinically significant tumors between the two approaches in 790 men who either had clinical suspicion of prostate cancer or were on active surveillance.

The team found no significant differences in the detection rates of clinically significant prostate cancers between the transrectal and transperineal routes in men with clinical suspicion of cancer (59% vs 58%, respectively) or among men on active surveillance with upgraded disease (44% vs 38%, respectively).

"The transperineal route is, however, preferable because of the lower infectious complications," Hogenhout, of Erasmus University Medical Center in Rotterdam, the Netherlands, said in an oral abstract session.

In a second study, Andreia Bilé Silva, MD, from the Hospital de Egas Moniz in Lisbon, Portugal and colleagues evaluated the efficacy of the transperineal approach.

The researchers conducted a prospective trial of in-office freehand transperineal prostate biopsy with patients under local anesthesia and no antibiotic prophylaxis. A total of 108 men with a median presenting prostate-specific antigen (PSA) level of 7.7 ng/mL were included.

The procedure identified prostate cancer in 67 patients, and clinically significant cancers in 42. The mean number of positive cores was 35%, and the median maximum positive core length was 60%.

The technique detected anterior zone cancers in 61% of patients with positive results. Of this group, 38% were deemed to be not clinically significant.

Only one complication required an emergency department visit: a case of febrile urinary tract infection leading to acute urinary retention. And only three patients complained of discomfort from anesthesia infiltration or introduction of the ultrasound transducer, and the global pain scores were 3 on a 10-point scale, indicating only mild discomfort.

The Transrectal Preference

Not everyone agreed, however, that the transperineal approach should be the go-to.

James Kovacic, MD, a urology research registrar at the Royal North Shore Hospital in Sydney, Australia, and colleagues used prospectively collected data from a single surgeon database to compare the techniques. Transperineal biopsies were performed with patients under general anesthesia, and TRUS biopsies were performed under local anesthesia.

A total of 708 men with preoperative multiparametric MRI were identified, of whom 261 underwent transperineal biopsy and 447 underwent transrectal biopsy.

The researchers found no differences in prostate cancer detection rates between the groups (77.9% rate with TRUS vs 77.4% with transperineal).

However, the transrectal technique identified significantly more clinically significant cancers (with an International Society of Urological Pathology score of 2 or greater) than the transperineal technique (59.1% vs 45.6%, respectively; P = .006).

In addition, the researchers found no difference in complication rates between the two groups, at approximately 6% in both.

The authors concluded that overall "TRUS biopsy remains an accurate and reliable tool in the diagnosis of prostate cancer."

In an interview with Medscape Medical News, Roderick van den Bergh, MD, who co-moderated the oral abstract session, said that several factors need to be considered when comparing the biopsy techniques and selecting the right patient for each.

"The infection rate is one of the main reasons why some of the guidelines now tend toward a recommendation to transperineal biopsy," said van den Bergh, a urologist at St. Antonius Hospital in Utrecht, the Netherlands.

He noted that infection complication rates can vary widely, with younger, healthier patients having low rates of infection with transrectal approaches, on par with those observed with the transperineal approach.

"But I think that in an 80-year-old diabetic patient, the advantage of a transperineal biopsy is much larger," van den Bergh said.

The transperineal procedure has other advantages — it's easy to perform and patients can avoid taking an antibiotic, which may make it more desirable overall. But the most important aspect of both procedures is the use of MRI, he concluded.

The studies reported here were all internally funded. All authors and van den Bergh have reported no relevant financial relationships.

European Association of Urology (EAU) Congress 2022. Abstracts A0603 (Hogenhout), A0604 (Bilé Silva), A0605 (Kovacic). Presented July 3, 2022.

Neil Osterweil, an award-winning medical journalist, is a long-standing and frequent contributor to Medscape.

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