Which Prostate Biopsy Method Is Best?

Choosing a biopsy method for prostate cancer diagnosis is a critical decision for doctors and patients. Although the traditional transrectal (TR) prostate biopsy has been used for many years, transperineal (TP) biopsy has attracted attention recently for its important safety advantages.

• Transrectal biopsy (TR): This procedure involves passing a needle through the rectum behind the prostate. Samples of prostate tissue are collected as the needle passes through the rectum, with a potential risk of infection.
• Transperineal biopsy (TP): In this method, the needle reaches the prostate through the perineum (the area between the anus and genitals) rather than the rectum. This greatly lowers infection risk and makes the procedure safer.

On September 19, 2024, JAMA Oncology published a multicenter randomized study showing that transperineal biopsies were safer than the transrectal approach and reduced infection risk to zero , adding a new dimension to the debate. The findings suggest that TP should be adopted as the new standard for prostate biopsy.

The Transperineal Approach Eliminates Infection Risk

No infections occurred in patients undergoing TP biopsy, whereas infection was detected in 1.6% of the TR biopsy group . This is a striking difference, as infection risk with TR biopsy had previously been reported at 5% to 7%. Lead investigator Dr. James Hu states that TP biopsies offer zero infection risk and could prevent infections without antibiotics. This is a major advantage for antibiotic stewardship, an important strategy to reduce the spread of antibiotic-resistant bacteria.

TP biopsy passes the needle through the perineum, between the anus and scrotum. This directly affects infection risk: in TR biopsy, the needle passes through the rectum to reach the prostate and can carry bacteria from that region to the tissues around it. TP avoids this risk completely, providing more sterile access to prostate tissue.

Clinical Study Details: Comparison with TR Biopsy

The study included a large sample of 742 patients with suspected prostate cancer. Participants were divided into TP biopsy without antibiotics and TR biopsy with antibiotic treatment. Neither group had sepsis, while infections in the TR group were generally classified as urinary tract infections and did not cause serious complications. The study nevertheless highlights the complete elimination of infection risk with TP biopsy.

Cancer Detection: No Difference Between TP and TR

Cancer detection rates were among the most notable findings. High-grade prostate cancer was detected in 55% of TP biopsies and 52% of TR biopsies. The difference was not statistically significant (difference: 2.9%; P = 0.40). This shows that, alongside its safety advantages, TP biopsy is as effective as TR in detecting cancer.

We know that TP biopsies are more successful at detecting clinically significant cancers, particularly in the anterior (front) and apical (tip) regions of the prostate. TR may miss some cancers in these areas, whereas TP can cover a wider region effectively.

TP Biopsy: A Method That Needs Wider Adoption

Although TP biopsy is already recommended by the European Association of Urology, the American Urological Association and National Comprehensive Cancer Network (NCCN) still give equal weight to both methods. However, TP's advantages, such as an infection-free process without the need for antibiotics, suggest that it should be adopted more widely.

Conclusion: Is a New Standard Emerging?

The advantage of TP biopsy in infection risk signals a new era in prostate biopsy. This approach, which may also address global health problems such as antibiotic resistance, delivers effective results in safety and cancer detection. In light of these findings, making TP the standard prostate biopsy method worldwide would be an important step toward minimizing future infection risk and improving healthcare quality.