Instalab ResearchOne of the main advantages of the transperineal approach is its improved ability to detect clinically significant cancers. The transrectal route often misses tumors in the anterior and apical regions, which can harbor aggressive disease. Multiple clinical studies have shown that transperineal prostate biopsy improves detection in these areas, particularly in men who have previously had negative transrectal biopsies but remain at risk.
In active surveillance populations, where monitoring low-risk prostate cancer is essential, transperineal biopsy has been shown to upgrade a higher proportion of cases to clinically significant disease. This is likely because it can sample the anterior and transitional zones more effectively. Randomized and prospective studies comparing transperineal and transrectal approaches confirm that overall detection rates of prostate cancer are similar, but the transperineal approach provides a diagnostic edge in identifying aggressive cancers that matter most for treatment planning.
Perhaps the strongest argument in favor of transperineal biopsy is safety. The transrectal approach introduces bacteria from the rectum into the prostate and bloodstream, leading to infections and sometimes sepsis. These risks have grown more concerning in the context of increasing antibiotic resistance.
The transperineal technique avoids the rectal wall entirely. Large prospective series and randomized controlled trials show that infection rates are near zero, even when patients do not receive antibiotic prophylaxis. This not only improves patient safety but also contributes to antibiotic stewardship by reducing unnecessary use of antibiotics. When scaled nationally, this could lower healthcare costs and help combat antimicrobial resistance.
Historically, transperineal biopsies were performed under general anesthesia with rigid grid systems, which limited accessibility and raised concerns about cost and complexity. Today, new techniques allow the procedure to be done in outpatient settings under local anesthesia with similar levels of patient comfort compared to the transrectal method.
Prospective cohort studies confirm that pain scores and tolerability are equivalent between the two techniques. Most discomfort comes from the administration of local anesthesia rather than the biopsy itself. Real-world hospital series have further demonstrated that transperineal biopsy is well tolerated, effective, and safe, with low complication rates and no need for hospitalization.
The introduction of multiparametric MRI into prostate cancer diagnosis has changed biopsy practices. MRI identifies suspicious lesions, which can then be targeted during biopsy. The transperineal route is especially well suited to this, as it allows precise sampling of lesions in any part of the prostate without restriction.
Combining systematic and targeted transperineal biopsy has been shown to increase detection of clinically significant prostate cancer compared to either method alone. This combination reduces the risk of both overdiagnosis and underdiagnosis, aligning with modern goals of precision cancer care.
For men with borderline PSA levels in the diagnostic gray zone, the transperineal approach has demonstrated higher cancer detection rates compared to transrectal biopsy. This ensures earlier diagnosis of clinically important disease, reducing delays in treatment and improving survival outcomes.
At a population level, the benefits are broad: fewer infections, fewer hospital admissions, reduced antibiotic use, and improved diagnostic accuracy. As health systems grapple with rising costs and resistance threats, transperineal biopsy offers a more sustainable approach to prostate cancer detection.
Barriers to widespread adoption include training requirements and access to equipment. However, simplified freehand techniques and local anesthesia protocols are making transperineal prostate biopsy more practical in everyday practice. Continued research is focusing on how best to combine MRI-targeted and systematic sampling, and how to integrate artificial intelligence into image interpretation and biopsy planning.
As these advances mature, transperineal biopsy is likely to become not just an alternative but the primary pathway for prostate cancer diagnosis.
