Comparison of cancer detection rates, complications, effects on sexual function, and pain experienced during transperineal and transrectal prostate biopsies

This study aimed to compare the diagnostic efficacy of transrectal and transperineal prostate biopsy techniques in the detection of prostate cancer. In this context, the relationship between radiological, clinical, and histopathological parameters and biopsy outcomes was evaluated to improve diagnostic accuracy. This retrospective, observational, and comparative clinical study was conducted at the Department of Urology, Pamukkale University Faculty of Medicine, between January 2024 and September 2025. A total of 290 patients were retrospectively analyzed and divided into two groups according to the biopsy technique: transrectal (TR) and transperineal (TP). In both groups, clinical parameters including Prostate Imaging–Reporting and Data System (PI-RADS) score assessed by multiparametric magnetic resonance imaging (mpMRI), prostate-specific antigen (PSA) level, and PSA density were evaluated. All patients underwent a 12-core systematic biopsy, with additional targeted sampling performed when indicated. Histopathological outcomes such as cancer detection rate, clinical significance, positive core ratio, and maximum cancer core length were compared between the groups. The overall cancer detection rate was 72.1% in the TR group and 70.4% in the TP group, with no statistically significant difference between the two methods (p>0.05). The rate of clinically significant prostate cancer was 47.1% in the TR group and 43.2% in the TP group, also without a significant difference (p>0.05). Among patients with PI-RADS 5 lesions, cancer detection rates were 64.6% in the TR group and 45.3% in the TP group, while in high-risk PI-RADS lesions overall, cancer detection rates were 84.6% and 82.7%, respectively. The positive core ratio, maximum cancer core length, and PSA density were higher in the TR group, with some statistically significant differences observed (p<0.05). Regarding lesion localization, the TP approach was found to be more advantageous for anterior and apical lesions. The overall complication rate was significantly higher in patients undergoing transrectal biopsy compared with those undergoing transperineal biopsy. In particular, infectious complications such as fever, documented urinary tract infection, and the need for antibiotic treatment were observed exclusively in the transrectal biopsy group, indicating a higher infection risk associated with this approach. Rectal bleeding was also observed only in the transrectal group, supporting the presence of rectal source–related complications specific to this method. In contrast, other complications including dysuria, hematuria, hematospermia, urinary retention, and hospitalization occurred at similar rates in both groups and were mostly mild and self-limiting. Perineal pain or tenderness, observed infrequently in the transperineal biopsy group, did not result in significant morbidity. In conclusion, both biopsy techniques demonstrated comparable diagnostic performance in the detection of prostate cancer. The higher cancer detection rates observed in patients with higher PI-RADS scores and elevated PSA density suggest that multiparametric magnetic resonance imaging (mpMRI) serves as an effective and reliable guidance tool for targeted prostate biopsy.