The time to prevent infectious complications is now: why transperineal prostate biopsies should be the new gold standard worldwide

Almost a century has passed since Young et al. in 1926 (1) described the first approach of collecting prostate tissue via an open transperineal way. In the following decades needle biopsies especially the transrectal approach became the standard of care. Nowadays, more than two million prostate biopsies are performed annually in the USA and Europe (2) with the vast majority of transrectal biopsies as summarized by Hu et al. (3,4). The PREVENT trial tried to shed light on the question whether an office-based magnetic resonance imaging guided transperineal prostate (TP) biopsy is a possible and safe alternative for the traditionally used transrectal approach (4,5). Therefore, 658 participants were recruited between March 2021 and May 2023 at ten centers, and finally randomized either into the TP arm or the transrectal biopsy arm. As primary endpoint, infectious complications were analyzed by a post-biopsy medical consultation and a patient report on day 7 after biopsy. Secondary endpoints included cancer detection rate, noninfectious complications, and a numerical scale (0–10) for biopsy-related pain and discomfort during the procedure and 7 d after biopsy. Noteworthy, patients randomized into the TP group received no antibiotic prophylaxis, whereas patients in the transrectal arm received targeted prophylaxis based on a rectal culture screening using fluoroquinolones if possible. Hu et al. demonstrated that infectious complications of office-based TP and transrectal biopsy are similar. In their study, no infectious complication occurred in the TP arm versus four infectious complications (1.4%) in the transrectal biopsy group (P=0.059). Although, this P value does not reach statistical significance, a trend seems to be obvious. Furthermore, these results might underestimate the true rate of infectious complications as mentioned by the authors themselves and could arise due to the wide range of definitions for infectious complications in other studies (6). However, the superiority of the transperineal approach in terms of infectious complications and sepsis has been proven in large multicenter randomized controlled studies (7-10). Further potential risks associated with this procedure do not differ significantly compared to the transrectal approach, i.e., post-intentional urinary retention or hematuria. Nevertheless, transition to the transperineal approach is slowed down by logistical challenges such as costs, complexity, training requirements and lack of experience (11), but should still be forced despite all these challenges. Generally, TP is a procedure that under supervision can be learned and safely conducted within several weeks of training.

TP do not only prevent infectious complications and thereby finally have the potential to save lives, it also promotes antibiotic stewardship. Additionally, antibiotics can have severe side effects, may evoke allergies and favour the existence of resistant bacteria. Given the dilemma of growing multi-resistant bacteria and its complex therapy reducing unnecessary antibiotics could have a vast positive impact.

Reduced infectious complications, a comparable cancer detection rate (4,12) and the effective reduction of antibiotics should motivate the urological community to prefer the transperineal over the transrectal approach. Improvement of radiological imaging techniques can help to maximize cancer detection rate and minimize invasiveness of prostate biopsy procedures by reducing the number of biopsy cores (13), for instance.

Besides the discussion mentioned above a more fundamental question finally appears: will future urological specialists still be using invasive approaches to diagnose prostate cancer? Upcoming significant developments in radiological imaging such as prostate-specific membrane antigen positron emission tomography/magnetic resonance imaging (PSMA-PET/MRI) (14) especially in combination with artificial intelligence or more experimental procedures like liquid biopsies (15) may have the potential to replace the common prostate biopsy in the future or at least reduce the number of biopsies to a minimum. Indeed, it is not clear if new technologies will completely displace prostate biopsies, but for now the TP biopsy is the best approach which we have and which we should use for our patients.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article has undergone external peer review.

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-50/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-50/coif). The authors have no conflicts of interest to declare.

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