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

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 clinical implications: TP-Bx and TR-Bx yield similar diagnostic performance for csPC in MRI-targeted procedures. However, in settings without MRI targeting, TP-Bx may offer better detection and a substantially lower infection risk. Although TP-Bx is associated with greater procedural discomfort, it can be performed safely under local anesthesia and without antibiotics, which aligns with antibiotic stewardship principles. These findings suggest that biopsy route selection should be individualized according to MRI availability, infection risk, and patient tolerance. Patient summary: We compared evidence for two prostate biopsy methods: transperineal (TP) and transrectal (TR). Both were similar in detecting prostate cancer, but the TP method had fewer infections and may not require antibiotics. TP may cause slightly more discomfort, but pain is generally manageable with local anesthesia. Which approach is best may depend on factors such as the availability of MRI (magnetic resonance imaging), the risk of infection, and the patient's preference.