Transperineal versus transrectal systematic prostate biopsy in routine clinical practice: a real-world comparative study

Purpose Prostate biopsy is the reference standard for confirming prostate cancer in men with clinical suspicion. The transrectal (TR) route is widely used but carries a risk of infectious complications and may sample anterior regions less effectively. Transperineal (TP) biopsy has emerged as a safer alternative with lower infectious risk. However, real-world comparative evidence between the routes is limited in some settings. The objective is to compare the diagnostic yield, tissue quality, and complications of systematic TR versus TP prostate biopsy in a Moroccan tertiary center. Methods In this retrospective study, 139 men with suspected prostate cancer underwent systematic biopsy via TR or TP biopsy. Analyses were restricted to systematic cores. Biopsy quality was assessed by median core length. Complications were graded using the Clavien–Dindo classification. Results A total of 139 men underwent systematic biopsy. Baseline clinical characteristics were similar across most variables, except DRE, between groups. TP yielded a longer median core length than TR (p = 0.02). In contrast, detection rates of clinically significant prostate cancer (csPCa) were similar (40.3% for TR vs 38.9% for TP). Several clinical factors were associated with csPCa detection, including higher PSA, higher PSA density, suspicious DRE, and higher PI-RADS category. In contrast, anterior lesion location was associated with a lower risk of csPCa. Regarding complications, infectious complications were more common after TR biopsy (7.5% compared to 1.4%). Additionally, acute urinary retention was seen in 6.0% of TR cases and 8.3% of TP cases. No Clavien–Dindo grade III or higher events were reported. Conclusion TP systematic biopsy provides csPCa detection comparable to TR biopsy, yields longer cores, and shows a lower observed rate of infectious complications, supporting TP adoption to reduce infectious morbidity without compromising diagnostic performance.