Transperineal versus transrectal prostate biopsy: Aligning Indian practice with emerging evidence

SUMMARY The debate regarding the optimal route for prostate biopsy has reached a level of clarity after Marra et al. published pooled data from five contemporary randomized control trials (RCTs) comprising 3072 predominantly biopsy-naïve men undergoing multiparametric magnetic resonance imaging (MRI)-targeted sampling to compare the transperineal (TP) and transrectal (TR) biopsy approaches in a Bayesian meta-analytic framework.[1] The main finding was a 62% reduction in the infectious complications with the TP approach. Notably, this benefit was observed despite the omission of antibiotic prophylaxis in the TP arms, whereas the TR groups received targeted prophylaxis based on rectal swab cultures. The detection of clinically significant prostate cancer was similar, while TP biopsy offered superior access to anterior and apical prostatic regions. TP biopsy was associated with slightly longer procedure times and higher immediate postbiopsy perineal discomfort, both of which resolved within 7 days and were considered clinically negligible. The authors ultimately recommended adopting the TP approach as the preferred technique, highlighting its improved safety profile and alignment with the global efforts to promote responsible antibiotic use. COMMENTS The result of this study is not surprising. The safety of TP biopsy has been established in earlier trials, including the PREVENT trial[2] and the TRANSLATE trial,[3] and is now further supported by this meta-analysis. What should prompt reflection among Indian urologists is the gap between what evidence recommends and the current practice in India. This meta-analysis, however, is limited by the small number of included trials, heterogeneity in the prophylaxis protocols across TR arms, and potential selection bias inherent to trial enrolment in high-resource centers. Generalizability to Indian practice is further constrained using culture-directed targeted prophylaxis in TR arms, which is a standard unavailable at most Indian centers, suggesting that real-world Indian TR biopsies carry an even higher risk of infectious complications than reported in these trials. The Urological Society of India (USI) Collaborative Research Committee audit, published earlier this year, surveyed 2479 patients across 43 Indian institutions.[4] TR biopsy was still being used in 91.8% of the cases, while TP was used in only 6.4%. The infection rate in the TR group was 3.3%, compared with 0 in the TP group, a finding that mirrors the meta-analysis almost exactly.[4] However, what was concerning was a separate number found within this dataset: 13.4% of the patients received piperacillin-tazobactam as the biopsy prophylaxis. This likely reflects rising resistance to fluoroquinolones, particularly ciprofloxacin, which has conventionally been the standard prophylactic agent. This is where the Indian context is different from the European trial population in Marra’s meta-analysis. The 1.6% infection rate reported in the Western TR biopsy group was achieved through rigorous targeted prophylaxis: prebiopsy rectal swabs, culture-directed agents, and structured follow-up protocols that are logistically and financially beyond the reach of most Indian district hospitals and public-sector urology services. The TR needle passes through the rectal mucosa that is frequently colonized with extended-spectrum beta-lactamase-producing and carbapenem-resistant Enterobacteriaceae; in India, where carbapenem resistance is among the highest worldwide,[5] this makes the TR route inherently high risk. Although the perineal skin is colonized, it is far more amenable to effective surgical site preparation with standard antiseptics than the rectal vault. By bypassing the TR route, the TP approach avoids the direct inoculation of the prostate with resistant fecal pathogens. The freehand local anesthetic TP technique is well tolerated, with minimal infectious complications and no requirement for sedation or general anesthesia, making it feasible in an outpatient setting. While the TP approach may involve marginally higher procedural costs, these are likely offset by downstream savings from avoided infectious complications, treatment of postbiopsy urinary tract infection, urosepsis admissions, intensive care unit costs, and prolonged courses of reserve antibiotics, which represent a far greater economic burden than the higher cost of the TP technique itself. A phased adoption model – beginning at tertiary academic centers with structured mentorship before expansion to district and secondary care hospitals offers a pragmatic and scalable pathway for Indian urology. There is also an oncological argument specific to Indian patients who present at higher median prostate-specific antigen values (19.8 ng/mL in the USI audit),[4] reflecting later stage diagnosis and larger glands. The TP route also offers better access to the anterior and apical zones, which is relevant given the larger glands encountered in Indian practice. The perceived diagnostic inferiority of TP biopsy in Indian observational data is a product of selection bias and limited MRI-targeted sampling, not of the technique itself. Incorporating the local anesthetic TP technique into urology training programs is a step overdue. The learning curve can be achieved within standard training, making early curricular integration both practical and timely. A multicenter Indian RCT using antimicrobial resistance-specific infection endpoints, rather than cancer detection alone, would provide the definitive domestic evidence this transition deserves. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.