Pain and patient-reported experience after freehand transperineal prostate biopsy under local anaesthesia

To characterise patient-reported pain, anxiety, satisfaction and willingness to undergo a repeat procedure, along with complication rate and diagnostic yield, in a large consecutive single-centre cohort of freehand transperineal prostate biopsies (TPPB) performed under local anaesthesia (LA) alone.

Consecutive freehand TPPB cases entered into a single-centre clinical registry between 27 April 2022 and 12 January 2026 were reviewed. Cases performed under general anaesthesia or under LA with intravenous sedation were excluded. The primary outcome was patient-reported overall procedural pain on a 0-10 cm visual analogue scale (VAS), completed immediately after the procedure. Secondary outcomes were VAS scores for anxiety, distress, physical needs, emotional needs and satisfaction; association between pain and anxiety; procedural failure; complication rate; and detection of clinically significant prostate cancer (csPCa, ISUP grade group ≥2). The tertiary outcome was willingness to undergo a repeat biopsy if clinically indicated.

Of 800 consecutive cases, 777 (97.1%) performed under LA alone formed the analytic cohort. Median overall procedural pain was 2.0 (IQR 1.0-3.0), and severe pain (VAS ≥ 7) was reported by 45 of 760 patients (5.9%). Anxiety was moderately correlated with pain (Spearman ρ = 0.51, 95% CI 0.44-0.57), and severe pain was ten times more common above than below the median anxiety score (10.8% vs. 1.0%). Overall, 748 of 756 patients (98.9%, 95% CI 97.9-99.5%) would undergo the procedure again if clinically indicated, including 42 of the 45 (93%) who reported severe pain. Procedural failure occurred in 5 of 777 cases (0.6%) and a complication was noted in 26 of 776 (3.4%). CsPCa was identified in 477 of 769 patients (62.0%), rising stepwise with PI-RADS score (1-2: 18.3%; 3: 22.6%; 4: 70.0%; 5: 88.4%).

Freehand TPPB under LA alone is well tolerated in the outpatient setting. Pain is low overall, severe pain is uncommon, and almost all patients would undergo the procedure again as indicated. Patient-reported anxiety is moderately associated with procedural pain and is a plausible modifiable target.