Comparison of transrectal and transperineal prostate biopsy: a prospective comparative study

Background. Transrectal (TR) prostate biopsy remains the ”gold standard” but is associated with infectious risks; transperineal (TP) biopsy is considered a safer alternative with comparable diagnostic accuracy. Objective. To compare the diagnostic performance, complication rates, pain levels, and short-term outcomes of TR- and TP-guided prostate biopsies. Materials and methods. A prospective randomized study included 68 men aged ≥40 years with suspected prostate cancer (PSA4 ng/mL, positive DRE, and/or PIRADS≥3). Patients were randomized into the TP group (n=53) and the TR group (n=15). A 12-core transrectal ultrasound-guided biopsy was performed with targeted sampling of PIRADS 3–5 lesions. Overall and clinically significant cancer detection rates (Gleason score ≥7), complications (Clavien–Dindo classification), pain using the Visual Analog Scale (VAS), and events within 30 days were analyzed; p0.05 was considered statistically significant. Results. Prostate cancer was detected in 72.1% of patients: 75.5% in the TP group and 60.0% in the TR group (p=0.62). Clinically significant cancer accounted for 59.2% of cases (45.3% in TP vs 33.3% in TR; p=0.59). No Clavien grade III or higher complications or cases of urosepsis were observed. Minor complications occurred in 32.1% of TP and 40.0% of TR patients (p=0.69); low-grade fever requiring oral antibiotics (Clavien grade II) was reported only in 3.8% of TP cases. The procedure duration was longer for TP (20.6±5.2 min vs 10.3±3.8 min; p0.001) but was associated with lower pain scores (2.6±1.1 points vs 4.7±1.5 points; p0.01); 81% of TP patients rated the pain as minimal. No delayed complications were reported at 30-day follow-up. Conclusion. Transperineal biopsy provides comparable detection of clinically significant prostate cancer, results in less procedural pain, and demonstrates an absence of severe complications, offering a safe alternative to the TR approach, particularly for patients with a higher risk of infection or difficult-to-access magnetic resonance imaging lesions.