What Prostate Biopsy is Best?

Overview of Prostate Biopsies

While there are better methods nowadays to learn if a patient has prostate cancer, the gold-standard way to find malignancies in the gland is only through a prostate biopsy.

Some reason’s why men want to avoid a prostate biopsy include; the procedure is uncomfortable and even painful in some cases, side effects associated with it like rectal bleeding and blood in the urine, and fear of cancer spreading ( a process referred to a seeding.)

Since 1989 the most common form of prostate biopsy has been the transrectal, guided ultrasound prostate biopsy (TRUS – prostate biopsy). This form of biopsy is up to 30% accurate because the ultrasound technology does a less-than-optimal job in showing suspicious, cancerous areas in the prostate. That’s why TRUS biopsies are also known as “blind” biopsy.

The Transperineal prostate biopsy was the original form of biopsy for the prostate back in the day but lost favor about three decades ago. Now, a transperineal prostate biopsy is working its way back in popularity.

A recent study suggests that a likely more accurate method for a prostate biopsy is a targeted, MRI-guided biopsy where the MRI images are fused with a modern ultra-sound so that the areas where cancer might be located “light up” and the physician can “target” those areas suspicious for cancer.

There are two types of prostate biopsies performed, transrectal prostate biopsy and transperineal prostate biopsy.  

Transperineal Vs. Transrectal prostate biopsy

Transrectal (TR) biopsy, where an ultrasound needle removes prostate tissue through the rectum, may have a 49% false-negative rate (meaning the biopsy can miss cancer present in the prostate).

Possible side effects from TR include; rectal bleeding, fever, infection requiring hospitalization for up to four days), and urinary retention.

If fever occurs within one week after a prostate biopsy of any type that requires an immediate trip to the emergency room.

Transperineal prostate (TP) biopsies are performed in the body between the scrotum and the anus (perineal area) and may be better able to detect cancerous cells than TR. Infections are very unlikely through this form of prostate biopsy since the needle is not going through the rectum. 

Which is better Transperineal prostate biopsy or Transrectal Prostate Biopsy?

First off, TR prostate biopsies are more available than TP biopsies – many practitioners are not yet doing TP biopsies because it involves general anesthesia (more complicated, higher cost, etc.)

So, for many of you reading this who may undergo a prostate biopsy, you may not have the option for a transperineal biopsy.

If a TR prostate biopsy is your only option, get a targeted MRI (fusion) biopsy, if possible so that your doctors are better able to find meaningful, potentially lethal cancer cells and avoiding false-positive results.

One of the benefits of a transperineal biopsy is that there is almost no possibility for infection, fever, or rectal bleeding, but it may be more painful than TR biopsy.

If a transrectal biopsy is your only choice,  you will be asked to do an enema before the procedure and take an antibiotic the day before, the day of and the day after the biopsy. With transperineal biopsies, no enema or antibiotic is needed.

Despite the use of enema and antibiotics, the rate of infection after a TR biopsy is up to 3%.

The two approaches have no difference in patients who have blood in the urine (hematuria) – hematuria will occur with both prostate biopsy type.

Blood in the urine (and semen) may last up to one week.

In terms of efficacy, a TP might be better if cancer is in areas of the prostate challenging to get to with a biopsy needle through a TR biopsy – the difficult areas of the prostate to get to with TR are called the transitional zone and the apex.

Dr. Geo’s Recommendations on what Type of Prostate Biopsy to Get

There is no easy answer as to what prostate biopsy is best for you.

It becomes a matter of preference and what options you have available to you. Transperineal biopsies are not as accessible as transrectal biopsies.  

From my analysis of the research and multiple conversations with urologists who perform both types of biopsies ( I do not perform biopsies) at the institution I am employed, I would suggest the following:

  • If the only option you have is a transrectal ultrasound prostate biopsy, then get a 3T MRI of the prostate followed by a targeted biopsy (as opposed to an ultrasound-guided biopsy)
  • If a transperineal biopsy is available, get an MRI before the biopsy, and consider it a TP as a good option. The downside, at this time (July 2020) is that you may have to undergo general anesthesia and the biopsy is often done in a hospital setting compared to a urologist clinic.
  • I suspect TP biopsies will soon be performed with local anesthesia (as opposed to general anesthesia) in the near future. Stay tuned.

All the best to you!



Xiang et al, W J of Sur Onc, 2019

De Rooij et al, Eur Urol, 2016

Stabile et al, Nat Rev Urol, 2019

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