Transperineal (TP) Versus Transrectal (TR) Prostate Biopsy: Efficacy, Safety, and Systemic Challenges-A Narrative...

Background: Prostate cancer represents one of the greatest challenges in modern urology. The definitive diagnosis relies on prostate biopsy. The traditional transrectal (TR) approach carries a significant risk of infectious complications and drives antimicrobial resistance. For this reason, the transperineal (TP) approach is increasingly being considered the method of choice. This literature review aims to comparatively analyze both methods (TP vs. TR) in terms of oncological efficacy, infectious and non-infectious safety, patient-reported pain tolerance, and cost-effectiveness. Materials and Methods: A comprehensive search of the PubMed and Embase databases was conducted, including English-language clinical studies published after 2011. Studies directly comparing TP and TR biopsies regarding diagnostic parameters and/or complication profiles were eligible for inclusion and subsequently underwent qualitative methodological assessment. Additionally, to outline a broader background and fuller clinical context, other supplementary publications were included in the review. Results: Ultimately, 14 publications representing 10 unique clinical trials were included in the main analysis. The overall cancer detection rate is comparable for both methods; however, the TP approach demonstrates an advantage in detecting anterior zone lesions and-especially in combination with MRI-clinically significant prostate cancer (csPCa). Both techniques differ in their safety and tolerance profiles: TP minimizes the risk of infection and rectal bleeding but is associated with higher short-term discomfort during local anesthesia administration and more frequent hematuria. Conversely, TR is associated with prolonged post-procedural discomfort. Economic analyses yield inconclusive results depending on the time horizon adopted. Conclusions: The choice of biopsy technique requires a conscious clinical compromise. The TP method is becoming the preferred option due to its more favorable infectious safety profile. The development of modern urology should aim towards fully personalized diagnostics, where the decision regarding the biopsy approach is based on the patient's best interest and is individually tailored to their anatomy, risk profile, and personal preferences.