Objective: To compare the safety profiles of transrectal ultrasound-guided (TRUS) and transperineal (TP) prostate biopsy. This systematic review and meta-analysis evaluates the incidence and severity of complications, including infection, hemorrhage, and urinary retention.
Methods: Following PRISMA guidelines, databases including Medline were searched for studies comparing TP and TRUS complications. Two reviewers independently screened titles, abstracts, and full texts using Covidence. Quality was assessed via RoB2 and the Newcastle-Ottawa Scale. Data synthesis utilized a random-effects model, with effect sizes expressed as Odds Ratios (OR) and 95% Confidence Intervals (CI). Statistical heterogeneity was quantified using the I^2 statistic.
Results: Sixteen studies (1992–2024) comprising 158,220 participants were included. Preliminary pooled analysis demonstrated a significant reduction in infectious complications for the TP approach compared to TRUS (OR: 0.71; 95% CI: 0.58–0.86; I^2=0\%). Mean infection rates were 1.64% for TP versus 3.17% for TRUS. TP roughly halved the risk of sepsis (0.36% vs 0.75%) and nearly eliminated rectal bleeding (0% vs up to 21.1%). While TRUS required heavier antibiotic prophylaxis (e.g., fluoroquinolones), TP favored skin-flora coverage or no antibiotics. Conversely, TP was associated with higher rates of hematuria (54.7% vs 43.1%) and a significantly increased risk of acute urinary retention (OR: 1.19; 95% CI: 1.02–1.38; I^2=6.46%), likely due to increased core sampling and perineal swelling. Recent data indicate TP is now successfully performed under local anesthesia, addressing historical concerns regarding pain and general anesthesia.
Conclusion: TP biopsy demonstrates a superior safety profile regarding infectious complications and rectal bleeding. Although associated with slightly higher rates of urinary retention and hematuria, the reduced reliance on intensive antibiotic prophylaxis and successful implementation under local anesthesia suggest TP may eventually supersede TRUS as the clinical gold standard.