Transperineal or Transrectal Magnetic Resonance Imaging-Targeted Biopsy for Prostate Cancer Detection - Beyond the Abstract
The European Association of Urology now recommends transperineal biopsies as the preferred technique, primarily because of their lower risk of severe urinary tract infections. This reduction in infections leads to a subsequent decrease in antibiotic resistance and associated costs. However, the impact of this transition on csPCa detection remains debatable due to conflicting results from recent meta-analyses. The study aims to contribute to this discussion by evaluating csPCa detection in a large European patient cohort undergoing either transrectal or transperineal MRI-targeted and systematic biopsies.
Data from 4841 patients across European tertiary referral centers between January 2016 and April 2023 were retrospectively analyzed. Patients underwent MRI and subsequent biopsies, with exclusion criteria applied for missing data. MRI scans were reviewed using standardized protocols, and biopsies were performed using MRI-3D ultrasound elastic fusion technology. The primary outcome was csPCa detection, while secondary outcomes included PCa detection with ISUP grade group ≥3.
After propensity-score matching, 1301 patients underwent transrectal biopsy, and 1301 underwent transperineal biopsy. The groups showed good balance across variables. Transperineal biopsy was associated with significantly higher rates of csPCa detection (ISUP grade group ≥2 and ≥3) compared to transrectal biopsy. Similar findings were observed in MRI-targeted biopsy alone. Subgroup analyses showed consistent results, with the exception of patients presenting PI-RADS 3 or lesions and those with a preoperative PSA value >10 ng/ml and/or positive. Sensitivity analyses, excluding centers with lower biopsy experience and incorporating previously excluded patients, yielded comparable outcomes.
These results underscore the potential for a personalized diagnostic pathway that can be tailored to the patient when a prostate biopsy is deemed necessary. The transrectal approach is likely to remain relevant, particularly for its convenient access to suspicious lesions situated in the posterior zone and at the base, especially in cases of a large prostate. Although European Urology Association guidelines advocate for a shift towards a transperineal approach to mitigate infection risks, there is a lack of randomized controlled trial support for this assertion. Furthermore, the recent RCT by Mian et al. revealed no discernible differences in infectious or noninfectious complications between the two approaches performed under local anesthesia. This underscores the imperative for high-quality comparative studies to thoroughly validate the adjustment in our daily practice.
The study suggests transperineal biopsy's superiority in detecting csPCa, supporting its adoption as the preferred technique, although further research is warranted to validate these findings.
Written by: Romain Diamand, MD, PhD, MCU, FEBU, Jules Bordet Institute, Hôpital Universitaire de Bruxelles, Brussels, Belgium
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