A Century in the Making: How the Transperineal Biopsy is Re-Emerging as the Modern Standard

For more than 100 years, clinicians have been working to ascertain the best way to obtain prostate tissue safely, accurately, and consistently. While the earliest prostate biopsies were performed transperineally, technical modifications in the late 20th century pushed the field toward the transrectal (TR) approach. Today, however, new data, advanced procedural tools, and updated global guidelines are driving a measurable shift back to the transperineal (TP) route. ¹

The Rise of TRUS and the Dominance of the Transrectal Biopsy

The earliest prostate biopsies emerged in the early 20th century and were performed using open transperineal (TP) surgical techniques, due to concern of potential fecal contamination during the TR approach. ¹

In 1922, Benjamin Barringer described one of the first documented attempts of a PBx, using a TP “needle punch” biopsy technique.^{1 2} This approach was further refined in 1954 when Kaufman introduced a finger-guided TP needle biopsy, using rectal palpation to identify suspicious areas and obtain tissue samples. ² By the early 1980s, advances in imaging began reshaping prostate biopsy once again. In 1981, Holm and Gammelgaard demonstrated that a transrectal ultrasound (TRUS) could be used to guide biopsy needles transperineally, laying important groundwork for image-guided sampling.¹ However, a major inflection point came in 1989 when Hodge and colleagues published evidence to support TRUS-guided transrectal biopsy with systematic sextant sampling. This technique was efficient and convenient, leading to rapid global adoption. ¹ As a result, transrectal biopsy became the dominant diagnostic standard for more than three decades, until more recent concerns regarding infection risk and sampling limitations prompted renewed interest in transperineal approaches. ³

Limitations of the Transrectal Approach Become Increasingly Clear

Despite its convenience, the TR approach brought significant concerns—particularly related to infectious risk.

A TR biopsy requires the needle to traverse the rectal wall, an environment densely populated with bacteria. Over time, clinicians observed:

• Hospitalization for post-biopsy infection ⁵
• Infection rates of 3.2-4.3%, according to various studies ^{4 5}
• Sepsis rates post-biopsy across studies (ranging from 0.1-7.9%) ^{6, 14}

A 2021 meta-analysis evaluated various modifications to the transrectal prostate biopsy (TR PBx) technique and their impact on infection risk, including factors such as the number of biopsy cores obtained, needle size and type, and the use of enemas or antiseptic rectal preparation. Among the interventions assessed, only rectal preparation with povidone-iodine—and conversion to a transperineal (TP) approach—were associated with a statistically significant reduction in TR PBx infection rates. ⁷

Diagnostic Limitations

Beyond infection, TR biopsy revealed several shortcomings:

• False-negative rates up to ~49% ⁸
• Less sampling of anterior regions
   —areas where clinically significant prostate cancer (csPCa) is increasingly found ¹⁰

The Evidence Supporting a Resurgence of TP Biopsy

Contemporary studies highlighted in a recent review paper point to several advantages of the TP method:

• Lower overall infectious complications
• Requires less usage of antibiotics, which can decrease the impact of peri-biopsy antibiotics in fueling antibiotic resistance in rectal flora.
• Higher detection rates of csPCa in anterior and apical zones of the prostate

While TP biopsy does carry a modestly higher risk of acute urinary retention (1–11%), these events are generally less severe and less costly than TR-associated infections. ¹

Technical Innovations Enabling Widespread TP Adoption

Historically, TP biopsy required general anesthesia and access to an operating room. According to a recent review paper, several modern advancements have changed that, including:

1. Local Anesthesia Techniques

Refined nerve block methods now allow TP biopsy to be performed more comfortably in the office setting using local anesthesia, versus general anesthesia.

2. Freehand and Template Techniques

The freehand transperineal biopsy technique can be performed without the use of a stepper and brachytherapy grid system and has demonstrated cancer detection rates comparable to those of TRUS-guided transrectal biopsy. ¹

A Global Movement Toward Transperineal Biopsy

Several major organizations and healthcare systems have already taken clear positions in favor of TP biopsy:

• In the United Kingdom, the TRexit movement eliminated TR biopsy across multiple centers, demonstrating extremely low infection rates and strong operational feasibility. ¹
• The European Association of Urology (2021) now recommends TP as the preferred initial biopsy approach when feasible. ¹²
• In North America, adoption is accelerating and has increasingly become part of clinical practice and clinical trials. ¹

Collectively, these actions reflect a growing consensus that TP biopsy provides a safer, more accurate, and more sustainable diagnostic pathway.

Conclusion: TP Biopsy and the Future of Prostate Care

The evolution of prostate biopsy over the past century reflects a central theme: balancing diagnostic accuracy with patient safety. What began as perineal exploration, transitioned through decades of transrectal dominance, and today is returning to its roots—empowered by modern innovation.

Why TP Is the Forward Path

• Best-in-class infection profile: near-zero sepsis and lower complication rates ¹
• Improved sampling accuracy: especially in anterior and apical prostate regions ¹
• Modern procedural flexibility: office-based local anesthesia with advanced imaging ¹
• Alignment with guideline trends: growing support across global urology societies ^{13 15}

TP Pivot Pro: A Strong Choice for the Future

TP Pivot Pro exemplifies the innovations driving wide adoption of the transperineal route:

• Designed for use in both systematic and targeted biopsy workflows
• Supports procedures under local anesthesia
• Allows for performance of a freehand, minimally invasive approach.

As evidence continues to mount and practices evolve, technologies like TP Pivot Pro enable a smarter approach to transperineal prostate biopsies —helping meet the clinical demands of today while shaping a better standard of care for tomorrow.

References:

#1: Schmeusser B, Levin B, Lama D, Sidana A. Hundred years of transperineal prostate biopsy. Therapeutic Advances in Urology. 2022;14. doi:10.1177/17562872221100590

#2: Najjar S, Mirvald C, Danilov A, et al. Comparative Analysis of Diagnostic Accuracy and Complication Rate of Transperineal Versus Transrectal Prostate Biopsy in Prostate Cancer Diagnosis. Cancers. 2025;17(6). doi:10.3390/cancers17061006

#3: Sidana A, Blank F, Wang H, Patil N, George AK, Abbas H. Schema and cancer detection rates for transperineal prostate biopsy templates: a review. Therapeutic Advances in Urology. 2022;14. doi:10.1177/17562872221105019

#4: Lenihan C, Daly E, Bernard M, et al. Introduction of surgical site surveillance post transrectal ultrasound (TRUS) guided prostate biopsy and the impact on infection rates. Infection Prevention in Practice. 2022;4(4). doi:10.1016/j.infpip.2022.100247

#5: Rudzinski JK, Kawakami J. Incidence of infectious complications following transrectal ultrasound-guided prostate biopsy in Calgary, Alberta, Canada: A retrospective population-based analysis. Canadian Urological Association journal = Journal de l’Association des urologues du Canada. 2014;8(5-6):E301-5. doi:10.5489/cuaj.1751

#6: Shahait M, Degheili J, El-Merhi F, Tamim H, Nasr R. Incidence of sepsis following transrectal ultrasound guided prostate biopsy at a tertiary-care medical center in Lebanon. International braz j urol : official journal of the Brazilian Society of Urology. 2016;42(1):60-68. doi:10.1590/S1677-5538.IBJU.2014.0607

#7: Pradere B, Veeratterapillay R, Dimitropoulos K, et al. Nonantibiotic Strategies for the Prevention of Infectious Complications following Prostate Biopsy: A Systematic Review and Meta-Analysis. The Journal of urology. 2021;205(3):653-663. doi:10.1097/JU.0000000000001399

#8: Xiang J, Yan H, Li J, Wang X, Chen H, Zheng X. Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: a systematic review and meta-analysis. World Journal of Surgical Oncology. 2019;17(1):1-11. doi:10.1186/s12957-019-1573-0

#9: Meyer AR, Mamawala M, Winoker JS, et al. Transperineal Prostate Biopsy Improves the Detection of Clinically Significant Prostate Cancer among Men on Active Surveillance. The Journal of urology. 2021;205(4):1069-1074. doi:10.1097/JU.0000000000001523

#10: Ortner G, Tzanaki E, Rai BP, Nagele U, Tokas T. Transperineal prostate biopsy: The modern gold standard to prostate cancer diagnosis. Turkish journal of urology. 2021;47(Supp. 1):S19-S26. doi:10.5152/tud.2020.20358

#11: European Association of Urology – 2021 Guidelines: https://uroweb.org/guidelines/undefined/summary-of-changes/2021

#12: Pilatz A, Cornford P, Bonkat G, Kranz J. Transperineal Prostate Biopsy Without Antibiotic Prophylaxis: The New Gold Standard? Recommendations from the European Association of Urology Guidelines on Prostate Cancer and Urological Infections. European urology. 2026;89(1):91-92. doi:10.1016/j.eururo.2025.10.002

#13: Kaplan-Marans E, Zhang TR, Hu JC. Differing Recommendations on Prostate Biopsy Approach to Minimize Infections: An Examination of the European Association of Urology and American Urological Association Guidelines. European urology. 2023;84(5):445-446. doi:10.1016/j.eururo.2023.05.036

#14: H Arang, A Mehta, R Roberts, A Mehta, K Beknazirov, I Ahmed, M Lynch, 460 Prostate Biopsy Sepsis Rates – Are We Meeting National Average Levels?, BJS, Volume 109, Issue Supplement_6, September 2022, znac269.504, https://doi.org/10.1093/bjs/znac269.504

#15: PROSTATE CANCER Early Detection of Prostate Cancer: Highlights from 2023 AUA/Society of Urologic Oncology Guidelines (AUA News)

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