Perspectives on technology – prostate cancer: is local anaesthetic transperineal prostate biopsy really better than transrectal biopsy?

Abstract

For many years, transrectal ultrasound‐guided (TRUS) prostate biopsies have been performed to establish a histological diagnosis of prostate cancer. This has been the recommended standard of care procedure, but has always carried risks, in particular the risk of post‐procedural sepsis, and the associated antibiotic burden and risk of development of antibiotic resistance. Transperineal (TP) prostate biopsies performed under local anaesthetic (LA) have been proposed as a possible solution to these issues, with potentially lower infectious complications, and avoidance of need for antibiotic prophylaxis. The European Association of Urology produced guidance in 2023 with ‘weak’ recommendations in favour of LATP biopsy as a new standard of care, citing its safety profile. Both the National Institute for Health and Care Excellence in the UK, and the American Urological Association in the United States, have concluded for now that the body of evidence is inadequate and not offered a similar recommendation. We discuss the available evidence, pros and cons of each technique, and the status of current trials in the field. We believe that clinical equipoise remains necessary, given the disparity in national and international guidelines highlighting the need for large randomised controlled trials to answer the question: is LATP biopsy really better than TRUS biopsy?

Transition from Transrectal to Transperineal MRI-Fusion Prostate Biopsy Does Not Comprise Detection Rates of Clinically Significant Prostate Cancer at a Tertiary Care Center

“…However, due to uprising efforts to minimize side effects and (infectious) complications following transrectal prostate biopsy, a transition towards a transperineal prostate biopsy approach has been seen in the recent past. In 2023, the European Association of Urology (EAU), as the only guideline association, ‘strongly’ recommended transperineal biopsies as the preferred technique, primarily because of comparable detection rates, yet their lower risk of severe urinary tract infections in comparison to more conservative recommendations (Grade C level) ushered by the National Institute for Health and Care Excellence (NICE) in the United Kingdom or by the American Association of Urology (AUA) [ 2 , 8 , 9 ]. With emerging insights indicating a reduction in infectious complications favoring the transperineal approach over the transrectal approach [ 10 ], both trial-derived and real-world data comparing the detection rate of clinically significant prostate cancer between transrectal and transperineal biopsy is still inconclusive and partly controversial [ 10 , 11 , 12 , 13 , 14 , 15 , 16 ].…”