Accuracy and safety of in-office transperineal freehand cognitive fusion prostate biopsy under local anaesthesia without antibiotic prophylaxis

To evaluate the cancer detection rate (CDR), tolerability, and safety of transperineal prostate biopsy (TPPB) performed under local anesthesia (LA) without antibiotic prophylaxis in an outpatient setting via a freehand technique. Between January 2015 and April 2024, 763 consecutive patients underwent TPPB at a single center. Of these, 538 patients received no antibiotics. Biopsies were performed via a freehand MRI/ultrasound fusion technique under LA. Patient discomfort was assessed using a visual analogue scale (VAS), and complications were recorded using the Clavien-Dindo classification. Statistical analysis was conducted using non-parametric methods (α = 0.05). Among the 538 patients without antibiotic prophylaxis, the overall CDR was 61.7%, with clinically significant prostate cancer (ISUP ≥ 2) detected in 47.4% of the patients. No infectious complications occurred. The level of pain was generally low (mean VAS 2.7), and 91.6% of patients reported no or only mild pain. Complications were rare (1.1%), with urinary retention being the most common (0.9%), associated with larger prostate volume (> 50 mL). Combining systematic and targeted biopsy yielded the highest diagnostic accuracy (CDR 65.9%, p = 0.023). TPPB using a freehand technique under LA, without antibiotic prophylaxis, is a safe, effective, and well-tolerated in-office procedure. It achieves high diagnostic yield without infectious complications, offering a viable, cost-efficient alternative to traditional transrectal approaches-especially relevant amid increasing antibiotic resistance.