Prostate biopsy in patients without rectal access: a systematic review and proportional meta-analysis

Historically, the anal canal plays a substantial role in both screening and diagnosis of pro-state cancer with digital rectal examination (DRE) and transrectal ultrasound (TRUS) guided biopsy, respectively. However, in patients with a prior history of abdominoperineal resection the transrectal route towards the prostate capsule cannot be utilized and thus alternative approaches have to be employed. The aim of this systematic review and proportional meta-analysis is to evaluate the available alternative prostate biopsy techniques in patients without rectal access.

The systematic literature review was performed using MEDLINE, Scopus, EMBASE, and the CENTRAL register for randomized controlled trials (RCTs). The following search algorithm was used: "resection of rectum" OR "abdominoperineal resection" OR "without rectal access" AND "prostate biopsy" (PROSPERO 2023 CRD42023459080).

A total of 21 studies and 203 patients were included in this systematic review and meta-analysis, while 6 different prostate biopsy techniques were detected in the current literature. The transperineal approach under transperineal US (TPUS) and the transgluteal approach guided by computed tomography (CT) were associated with 0.74 [0.48; 0.94] and 0.70 [0.49; 0.89] pooled diagnostic yield estimates as well as 0.01 [0.00; 0.01] and 0 [0.00; 0.01] pooled complication rate estimates. The performance of multiparametric magnetic resonance imaging (mpMRI) prior to transgluteal CT-guided prostate biopsy seemed to significantly affect the biopsy result (p = 0.0002).

Based on current data, the TPUS-guided prostate biopsy has the highest pooled diagnostic yield estimate. However, this conclusion is based on poor evidence and more reliable and well-organized studies are needed to thoroughly explore this problem.