Transperineal Prostate Bx: The way forward?

The PREVENT multicenter randomised trial compared the infectious complications between transperineal (TP) and transrectal (TR) MRI-targeted and systematic biopsy in a biopsy-naive settings.(1) A total of 658 patients were randomised but the follow-up data of 449 patients was evaluated, 226 in TP arm and 223 in TR arm, with an 80% response rate. Both the procedures were carried out under local anaesthesia and no antibiotic prophylaxis was prescribed in the TP arm. The patients in TR arm received rectal culture guided targeted prophylaxis. The authors recorded complications and other parameters upto 7days after the Bx. The incidence of infections were higher in the TR arm, however, it did not reach a statistical significance (TP- 0% vs TR- 1.4%, p=0.059). All infections were febrile but none required intensive care. The incidence of all other complications such as bleeding, urinary retention was small and similar between the two groups. The rates of cancer detection was also similar between the two groups (TP-53% vs TR-50%). The incidence of immediate post-biopsy severe pain (score of >7) was higher in the TP group (12% vs 7%), however, pain scores became similar in the two arms at the 7th day. A similar RCT, the ProBE PC randomised control trial, also compared the 30 day infectious complication rates in 718 men undergoing TP vs TR Bx under local anaesthesia.(2) Similar to the PREVENT trial, the TP biopsy arm did not receive any prophylaxis, whereas the TR arm received augmented prophylaxis instead of a targeted one. The authors noted a similar infectious complication rate between the two arms (TP - 2.7% vs TR  - 2.6%) and none of the patients developed sepsis in either of the arms. The other non-infectious complications were also similar between the two groups (TP- 2.2% vs TR - 1.7%). Of interest is the rates of infectious complications and sepsis in both these RCTs, which  are much lower that what is usually cited in the literature (5-7% and 0.3-3%).(3) To conclude both these RCT show a similar complication and cancer detection rate between TP and TR Bx. However, the TP Bx completely avoids the use of antibiotics and subsequent concerns of allergic reaction and side effects and obviates the possibility of development of resistance and need of antibiotic stewardship, a factor which should be considered while choosing the Bx technique.