# Transition from Transrectal Systematic to Transperineal Lesion-Focused Prostate Biopsy: A Real-World Comparative Analysis

## TL;DR

Switching from transrectal to transperineal prostate biopsy improved detection of significant prostate cancer while reducing overdiagnosis of low-risk disease.

## Contribution

Demonstrated that transperineal lesion-focused biopsy improves diagnostic accuracy in real-world prostate cancer detection.

## Key findings

- Transperineal biopsy increased detection of clinically significant prostate cancer by 2.52-fold compared to transrectal biopsy.
- Transperineal biopsy reduced detection of low-risk Gleason Grade Group 1 cancer by half.
- Improved results were observed in patients with prior negative biopsies and anterior/apical lesions.

## Abstract

Prostate biopsy is essential for diagnosing prostate cancer, but the optimal biopsy technique remains debated. In our centre, we transitioned from a traditional transrectal biopsy approach to a transperineal biopsy strategy focusing on MRI-visible lesions. In this real-world study, we show that this change improved the detection of clinically significant prostate cancer while reducing the diagnosis of low-risk disease. These findings suggest that modern transperineal biopsy strategies may improve diagnostic accuracy in routine clinical practice.

Background/Objectives: The transperineal (TP) approach has progressively replaced the transrectal (TR) approach for prostate biopsy because of its improved safety profile. However, its impact on the detection of clinically significant prostate cancer (csPCa), particularly within modern lesion-focused biopsy strategies that combine targeted and perilesional sampling, remains uncertain. We aimed to evaluate the real-world diagnostic impact of transitioning from a TR systematic-based biopsy strategy to a TP lesion-focused approach. Methods: We conducted a retrospective single-centre study including consecutive men who underwent image-guided prostate biopsy between 2018 and 2025. Only patients with a single MRI-visible lesion (PI-RADS ≥ 3) were included. Two biopsy strategies were compared: TR systematic biopsy (TR–SBx), combining targeted and systematic cores, and TP lesion-focused biopsy (TP–LFx), combining targeted and perilesional cores. The primary outcome was the detection of csPCa (Gleason Grade Group ≥ 2). Secondary outcomes included detection of Gleason Grade Group 1 cancer and negative biopsies. Inverse probability of treatment weighting (IPTW) based on a propensity score was applied to adjust for baseline differences. Doubly robust weighted logistic regression models were used, with predefined subgroup and sensitivity analyses. Results: Among 1032 included patients, 931 underwent TR–SBx and 101 TP–LFx. After restriction to the region of common support, 528 patients were retained for IPTW analyses. In the IPTW-adjusted analysis, TP–LFx was associated with higher csPCa detection compared with TR–SBx (adjusted odds ratio [OR] 2.52, 95% confidence interval [CI] 1.40–4.52; p = 0.002) and with lower detection of Gleason Grade Group 1 cancer (OR 0.50, 95% CI 0.27–0.92; p = 0.03). Subgroup analyses suggested a stronger association in patients with prior negative biopsy and in anterior or apical lesions. Conclusions: In routine clinical practice, transitioning from a transrectal systematic-based biopsy strategy to a transperineal lesion-focused approach was associated with improved detection of csPCa and reduced overdiagnosis. These findings support the consideration of transperineal, lesion-focused MRI-guided biopsy strategies in contemporary prostate cancer diagnostics.