More prostate cancers caught with transperineal vs transrectal biopsy

When sampling prostate tissue using ultrasound guidance and local anaesthesia, going by the transperineal (LATP) approach results in greater detection of clinically significant prostate cancers relative to the transrectal (TRUS) approach, as shown in the TRANSLATE trial.

In a UK cohort of biopsy-naïve men with clinical suspicion of prostate cancer, the primary outcome of Gleason Grade Group (GGG) 2 or higher tumour was detected in 60 percent of men who underwent LATP vs in 54 percent of those who underwent TRUS (odds ratio [OR], 1.32, 95 percent confidence interval [CI], 1.03–1.70; p=0.031). [Lancet Oncol 2025;doi:10.1016/S1470-2045(25)00100-7]

However, LATP took longer to perform than TRUS (median time in the room, 28 vs 22 minutes; median time to perform the biopsy, 12 vs 8 minutes). Furthermore, LATP biopsy was perceived to be more problematic than TRUS biopsy (38 percent vs 27 percent; OR, 1.84, 95 percent CI, 1.40–2.43), with men who underwent LATP more frequently reporting higher post-procedure pain and embarrassment.

According to the investigators, the difference in GGG 2 or higher prostate cancer detection rates between LATP and TRUS was lower than the 10 percent hypothesized for the sample size calculation, but the difference still reached statistical significance. The difference may be explained by the improved targeting of radiological lesions via LATP, as well as the improved detection of clinically significant prostate cancer with LATP in men with anterior lesions on prebiopsy MRI, they added.

Postbiopsy infections

Infections requiring hospital admission after biopsy occurred in <1 percent of participants in the LATP arm and in 1 percent of those in the TRUS arm at 7 days (OR, 0.14), in <1 percent and 2 percent at 35 days (OR, 0.22), and in 1 percent and 2 percent at 4 months (OR, 0.45), respectively.

An analysis that used a broader definition of symptoms or signs of infection with or without hospital admission showed no evidence of a statistically significant difference in the 4-month postbiopsy period (20 percent with LATP vs 21 percent with TRUS; OR, 0.93, 95 percent CI, 0.70–1.25).

“Infectious complications from biopsy, and concerns regarding the development of post-biopsy urinary sepsis, have driven the transition from TRUS to LATP,” the investigators said.

They emphasized that the findings on postbiopsy infections hold important implications for antibiotic stewardship. In TRANSLATE, 89 percent of LATP biopsies were performed without antibiotic prophylaxis, whereas TRUS biopsy was performed with antibiotics as standard-of-care. This demonstrates that most LATP biopsies can be safely performed without antibiotics, according to the investigators.

These data from TRANSLATE were presented by lead investigator Prof Richard Bryant from the University of Oxford in Oxford, UK, at the EAU meeting in Madrid, Spain.

Evidence of trade-offs

In an editorial piece, Dr Badar Mian from the Albany Med Health System in Albany, New York, US, and colleagues commended the TRANSLATE investigators for conducting a large randomized controlled trial (RCT) that provided valuable evidence of trade-offs between transperineal and transrectal biopsies to inform clinical practice. [Lancet Oncol 2025;doi:10.1016/S1470-2045(25)00160-3]

The detection rates of GGG 2 or higher prostate cancer with LATP vs TRUS in biopsy-naïve men in TRANSLATE were consistent with those reported in other large RCTs, namely PROBE-PC (62 percent vs 59 percent, respectively), PREVENT (53 percent vs 50 percent), and PERFECT (47 percent vs 54 percent), Mian and colleagues noted. However, these difference between the two approaches were not statistically significant, they added.

“Overall, previous strong recommendations favouring LATP, based on observational studies, might have been premature. High-quality evidence from multiple RCTs conducted across diverse healthcare systems has shown no large difference in outcomes between LATP and TRUS. This finding is ultimately reassuring for both patients and clinicians,” according to Mian and colleagues.

“Based on the cumulative evidence from four RCTs (encompassing a total of nearly 3,000 participants), patients and practitioners can be confident that both TRUS and LATP procedures can be performed accurately and safely, with the choice guided by local circumstances,” they said.

TRANSLATE cohort

TRANSLATE included 1,126 men (median age 66 years) with elevated age-specific prostate-specific antigen or abnormal digital rectal examination and had received pre-biopsy MRI. They were randomly assigned to undergo LATP (n=562) or TRUS (n=564) biopsy.

Of the men, 92.7 percent were White British, 71.0 percent were overweight or obese (BMI ≥25 kg/m²), 78.6 percent had two or more comorbidities, 2.4 percent were taking finasteride, and 23.4 percent had a first-degree family history of prostate cancer.

At least one biopsy-related complication was documented in 81 percent of participants in the LATP arm and in 77 percent in the TRUS arm (OR, 1.23, 95 percent CI, 0.93–1.65) at 4 months after biopsy. The median International Prostate Symptom Score was 8 in both arms (OR, 0.36, 95 percent CI, –0.38 to 1.10), while the medial International Index of Erectile Function score was 5 in the LATP arm vs 8 in the TRUS arm (OR –0.60, 95 percent CI, –1.79 to 0.58).

Serious adverse events occurred in 2 percent of participants in the LATP arm and in 4 percent in the TRUS arm, the most common being renal and urinary disorders and infection.