Transperineal Versus Transrectal Prostate Biopsy in the MRI-Targeted Era: A Contemporary Narrative Review

Prostate biopsy is among the most frequently performed diagnostic procedures in men, and two shifts have reshaped it over the past decade: the incorporation of multiparametric MRI (mpMRI) with targeted sampling, and migration from the transrectal to the transperineal route. Because these changes are usually adopted together, the practical choice facing many units is between a contemporary transperineal MRI-targeted pathway and the historical transrectal systematic one. This narrative review weights cancer detection, procedure-related harms, and implementation approximately equally, drawing on evidence that isolates route from targeting wherever possible. Across randomized trials and meta-analyses, the two pathways achieve broadly comparable detection of clinically significant cancer (ISUP grade group ≥ 2), although the transperineal route samples anterior and apical tumors more effectively and the largest randomized comparison reported a modest transperineal advantage. The principal transperineal benefit is a marked reduction in infectious complications, enabling reduced antibiotic prophylaxis and improved stewardship; its main cost is greater procedural discomfort. We review mpMRI and PI-RADS with illustrative examples, fusion technique, cost-effectiveness, special populations, emerging adjuncts, and divergent guidelines, concluding that route and targeting decisions are best individualized, with infection risk and lesion location dominant.