Diagnostic accuracy and safety of image-guided transperineal versus transrectal prostate biopsy for clinically significant prostate cancer: a GRADE-assessed systematic review and meta-analysis

This systematic review and meta-analysis compared the diagnostic performance and complication profiles of transperineal biopsy (TPBx) versus transrectal biopsy (TRBx) for prostate cancer, incorporating recent randomized and large observational studies. Following PRISMA 2020 guidelines, PubMed, Scopus, Embase, and Cochrane Library were searched till April 2025. Studies directly comparing TPBx and TRBx were included. Risk of bias was assessed using RoB 2.0 for randomized trials and the Newcastle – Ottawa Scale for observational studies. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models. Subgroup analyses and a GRADE assessment were performed to evaluate the certainty of evidence. Twenty-nine studies (n = 90,621) were included. TPBx showed higher PCa detection (RR 1.08; 95% CI 1.01–1.15; p = 0.02) and csPCa detection (RR 1.14; 95% CI 1.05–1.24; p = 0.001), though the certainty of evidence was low to moderate. Heterogeneity was moderate to high. TPBx also showed lower infection-related complications and comparable overall events, though procedure-related pain was slightly higher. TPBx offers improved diagnostic yield and lower infection risk compared with TRBx, with comparable safety. However, given the moderate heterogeneity and limited high-quality RCTs, further confirmatory trials are necessary. https://www.crd.york.ac.uk/PROSPERO identifier is CRD420251035763 Prostate cancer is one of the most common cancers in men, and doctors often need to take a small sample of the prostate, called a biopsy, to check for cancer. There are two main ways to do this. One is through the skin between the anus and the scrotum (called the transperineal method). The other is through the rectum (called the transrectal method). Both methods use imaging, such as ultrasound or MRI, to guide the needle. In this study, we examined results from 29 prior studies that included more than 90,000 men. We compared how well each biopsy method detects important prostate cancers and how safe each method is. We found that the transperineal method was slightly better at finding clinically significant prostate cancer, which is the type of cancer that needs treatment. It also found overall prostate cancer a bit more often than the transrectal method. One of the biggest differences was safety. The transrectal method has a higher chance of causing infections, because the needle passes through the rectum, where bacteria are present. The transperineal method avoids the rectum, so the risk of infection, fever, and serious complications like sepsis is much lower. The risk of rectal bleeding was also lower with the transperineal approach. Both methods had similar rates of overall complications, although the transperineal biopsy may cause slightly more short-term discomfort or inability to completely empty the bladder in some men. Overall, our findings suggest that the transperineal biopsy is a safer and more effective choice for many patients, with fewer infections and better cancer detection.