Transperineal cognitive versus trans-rectal fusion biopsy under local anesthesia: multicenter outcomes in detection...

This multi-center retrospective study aimed to compare the diagnostic efficacy, safety, and procedural feasibility of trans-perineal cognitive biopsy (TPC) and trans-rectal-MRI fusion biopsy (TRF), both performed under local anesthesia, in patients with suspected prostate cancer.

A total of 634 biopsy-naïve patients with PI-RADS ≥3 lesions on multi-parametric MRI were included. Among them, 284 patients underwent TRF and 350 underwent TPC across two tertiary centers between January 2020 and May 2025. The primary endpoints included detection rates of clinically significant prostate cancer (csPCa) and biopsy-related complications. Secondary outcomes included overall cancer detection, proportion of clinically insignificant cancers, pain scores, and procedural feasibility under local anesthesia. Targeted versus systematic biopsy yield was additionally analyzed. Multivariable logistic regression analysis was performed to identify independent predictors of csPCa detection, adjusting for age, prostate volume, PSA density, PI-RADS score, and number of targeted cores.

The csPCa detection rates were comparable between the TRF and TPC groups (30.3% vs. 27.4%, p = 0.430). TRF demonstrated a significantly higher overall cancer detection rate (60.2% vs. 44.0%, p < 0.001) but also a higher rate of clinically insignificant cancers (29.9% vs. 16.6%, p < 0.001). After stratification by PI-RADS category, csPCa detection rates remained comparable between the two techniques across PI-RADS 3, 4, and 5 lesions (all p > 0.05). In multivariable analysis, biopsy technique was not independently associated with csPCa detection (adjusted OR 0.93, 95% CI 0.68-1.27, p = 0.642), whereas higher PI-RADS score and PSA density were independent predictors. Infectious complications were more frequent in the TRF group (3.9% vs. 1.1%, p = 0.024), while urinary retention requiring catheterization occurred at similar rates between the two groups. Both procedures were well tolerated under local anesthesia, with no significant difference in pain scores. No prophylactic antibiotics were administered in the TPC group.

Transperineal cognitive biopsy appears to offer comparable efficacy to trans-rectal-MRI fusion biopsy in detecting csPCa while potentially reducing unnecessary diagnoses and infectious complications. Given its comparable performance after risk adjustment and its feasibility under local anesthesia without the need for prophylactic antibiotics or fusion software, TPC may represent a viable alternative in selected clinical contexts. Further prospective research is warranted to confirm these findings and refine patient selection criteria.