Safety and efficacy of thulium laser enucleation of the prostate within two weeks following transperineal biopsy.

Prostate biopsy is needed for diagnosing prostate cancer, the commonest cancer affecting men. Due to its lower rates of post-procedural infection compared to transrectal approaches, the use of transperineal approaches may increase. There is limited current evidence of serum biomarker changes following transperineal template prostate biopsy (TTPB) and their correlation with clinical outcomes. A within-group, repeated-measures observational study was employed. Venous blood samples were taken pre-TTPB (baseline) and at 30 and 240 min post-TTPB in 6 patients (median age 67 years, age range 63-76). The serum concentrations of 13 selective human growth factors were measured using the Luminex® Performance Assay. Patient medical notes were reviewed to assess clinical outcomes. Following TTPB, significant increases were demonstrated in the serum concentration of PDGF-AA and TGF-alpha (p ≤ 0.05). Significant decreases were observed in the serum concentration of EGF and Flt3 ligand (p ≤ 0.05). There were no significant differences in the serum concentrations following TTPB in: CD40 Ligand, G-CSF, GRO-beta, IL-8, IL-33, MIP-3 beta, PDGF-AB/BB, TRAIL, and VEGF (p ≥ 0.05). There were no significant post-operative complications. The significant increases in serum PDGF-AA and TGF-α, and significant decreases in serum EGF and Flt3 ligand could be explained by post-procedural inflammatory or paraneoplastic mechanisms. Further research into these biomarkers with larger cohorts may enable further understanding of their role pre- and post-operatively in TTPB and their correlation with clinical outcomes. This may be used to develop a clinical tool to predict or identify patients at risk of early post-TTPB complications.

Perioperative and periinterventional antibiotic prophylaxis remains fundamental to infection prevention in surgical and interventional urology, yet its overuse and unjustified prolongation continue to drive antimicrobial resistance and expose patients to avoidable harm. The newly finalized German interdisciplinary AWMF S3 Clinical Practice Guideline establishes an evidence-based, risk-adapted, and stewardship-oriented framework that redefines antibiotic prophylaxis as a rigorously justified and time-limited intervention. This manuscript distills the urology-specific recommendations and contrasts them with the 2025 EAU Guidelines on Urological Infections, emphasizing alignment, procedural nuance, and practical relevance. The AWMF S3 framework mandates strict indication, intravenous administration 30 to 60 minutes before incision, single-dose prophylaxis for most clean and clean-contaminated procedures, and redosing only when pharmacokinetically warranted, with discontinuation at wound closure as a universal standard. Within urology, resistance-adapted prophylaxis with rectal antisepsis is recommended for transrectal prostate biopsy, whereas transperineal biopsy may be safely performed without antibiotics in low-risk patients with sterile urine and proper antisepsis. Prophylaxis confers no consistent benefit for ureterorenoscopy or cystoscopy in sterile urine, but remains indicated for percutaneous nephrolithotomy, transurethral resection of the prostate, and major open or laparoscopic procedures such as radical prostatectomy and cystectomy, where broad-spectrum single-dose coverage with intraoperative redosing may be required in prolonged surgery. Across all procedures, the AWMF S3 and EAU 2025 recommendations show high concordance, differing primarily in granularity and evidence grading. A risk-adapted, single-dose strategy unites patient safety with antimicrobial stewardship and positions urology as a model discipline for rational, quality-assured infection prevention in modern surgery.

Comparison of transperineal and transrectal biopsy approaches for prostate cancer diagnosis

Introduction. Prostate biopsy remains the gold standard for the diagnosis of prostate cancer. In contemporary practice, increasing preference is given to fusion biopsy, which is more reliable and informative than conventional ultrasound‑guided systematic biopsy. Fusion prostate biopsy can be performed via transrectal or transperineal access, and the superiority of one approach over the other is still under investigation. Objective. To assess and compare the diagnostic performance of transrectal versus transperineal fusion prostate biopsy for the detection of prostate cancer. Materials & methods. A comparative study was conducted between October 2024 and January 2025 at St. Luke’s Clinical Hospital, Saint Petersburg. A total of 162 men with suspected prostate cancer were enrolled. Group 1 comprised 115 patients who underwent transrectal fusion prostate biopsy. Group 2 included 47 patients who underwent transperineal fusion prostate biopsy using a stabilized technique with a stepper and stabilizer. Results. In the transrectal fusion biopsy group, prostate cancer was identified in 54 cases (46.95%) on targeted cores and in 81 cases (70.4%) on standard systematic cores. Systematic cores alone detected cancer in 44 patients (38.26%), whereas targeted cores alone did so in 5 patients (4.34%); in an additional 6 patients (5.22%), targeted cores upgraded the Gleason score. Omitting systematic sampling in transrectal fusion biopsy would have reduced overall cancer detection by 38.26%, including omission of clinically significant (aggressive) disease in 9.57% of cases. In the transperineal fusion biopsy group, cancer was detected in 31 patients (65.96%) on targeted cores and in 25 patients (53.19%) on systematic cores. Targeted cores alone identified cancer in 9 cases (19.15%), whereas systematic cores contributed only 3 additional cases (6.38%), all ISUP grade group 1. Targeted sampling led to Gleason score upgrading in 4 patients (8.51%). Conclusions. For the transperineal fusion technique, omitting systematic biopsies may reduce the number of cores without materially compromising diagnostic accuracy. In contrast, for transrectal fusion biopsy, systematic sampling remains crucial, particularly for detecting aggressive cancers and improving overall diagnostic yield. These approach‑specific differences warrant further investigation to refine diagnostic pathways for prostate cancer.

Limitations of Large Language Models in Assisting PI-RADS Scoring on Prostate Biparametric MRI Text Reports.

Introduction Transperineal (TP) prostate biopsy offers several advantages over transrectal (TR) prostate biopsy, including a reduced risk of infection and improved accessibility to hard‐to‐reach areas of the prostate. This retrospective study aims to present our clinical experience and compare the outcomes of TP and TR prostate biopsy methods. Materials and Methods We retrospectively analyzed patients who underwent TP or TR prostate biopsy between January 2024 and September 2024 at the Department of Urology, Manisa Celal Bayar University Hospital. A total of 40 patients underwent TP biopsy, and 40 patients underwent TR biopsy. Data extracted included prostate‐specific antigen (PSA) levels, prostate size, Prostate Imaging Reporting and Data System (PI‐RADS) scores obtained from multiparametric magnetic resonance imaging (mpMRI), pain scores, postprocedural complications (e.g., infection, lower urinary tract symptoms [LUTS], and hematuria), and pathological outcomes such as overall cancer detection rates and the percentage of cancerous nuclei. Results In the TP biopsy group, cancer was detected in 62% of patients, compared to 45% in the TR biopsy group. Concordance between MRI imaging findings and pathology was observed in 57% of the TP group, whereas this rate was 40% in the TR group. Regarding complications, no infections were reported in the TP group, while hematuria occurred in 7% and LUTS in 17%. In the TR group, infection occurred in 7%, hematuria in 10%, and LUTS in 5% of patients. Pain scores during the procedure differed between the groups. In the TP group, the highest pain score was 4, and the most commonly reported score was 2. During probe insertion, the pain score was most frequently 2, with a maximum of 4. In the TR group, the highest pain score during the procedure was 5, and the most common score was 3. During probe insertion, the most frequent score was 3, with a maximum score of 4. Conclusion These findings highlight the advantages of TP biopsy, including a higher diagnostic yield, lower complication rates, and better patient‐reported satisfaction. Therefore, TP biopsy should be considered the primary method for prostate biopsies in clinical practice.

ResumenIntroducción:el cáncer de próstata (CaP) es la neoplasia más común en hombres. La biopsia de próstata transrectal es el estándar para diagnosticar el CaP, pero presenta complicaciones. La biopsia transperineal ha ganado popularidad debido a sus mejores tasas de detección y menores complicaciones.Objetivo:comparar la eficiencia y la tasa de complicaciones entre la biopsia prostática transperineal de un punto de acceso único (BTPP) y la biopsia prostática transrectal (BTRP), guiadas por ultrasonido en pacientes con sospecha de CaP.Material y métodos:se recolectó y analizó información de 241 pacientes con sospecha de CaP, divididos en dos grupos: 171 en el de BTPP y 70 en el de BTRP. Se recolectaron los resultados de patología y se identificaron las complicaciones.Resultados:de los 241 pacientes, 132 tuvieron biopsia positiva (54.77%) y 109 negativa (45.22%). La BTPP fue positiva en 60.2% en comparación con 41.4% de la BTRP (p = 0.008). Las complicaciones en BTPP fueron hematuria (53.8%), dolor (6.4%), hemospermia (6.4%) y retención aguda de orina (2.3%). La BTPP mostró ser un factor protector para complicaciones (odds ratio [OR] 0.028, intervalo de confianza del 95% [IC 95%] 0.009-0.9; p < 0.001), en comparación con la técnica de la BTRP (OR 35.5, IC 95% 10.7-117.6; p < 0.001).Conclusiones:la BTPP ofrece una mejor tasa para detección del CaP y debe adoptarse como método de primera elección para el diagnóstico del CaP, dado que tiene menor tasa de complicaciones y puede realizarse sin necesidad de preparación intestinal ni profilaxis antibiótica.

Transperineal Prostate Biopsy Without Antibiotic Prophylaxis: The New Gold Standard? Recommendations from the European Association of Urology Guidelines on Prostate Cancer and Urological Infections.

Transperineal 3T MRI-guided and transrectal MRI-ultrasound fusion prostate biopsies: Do lesion location and size impact diagnostic yield?

This systematic review and meta-analysis compared the diagnostic performance and complication profiles of transperineal biopsy (TPBx) versus transrectal biopsy (TRBx) for prostate cancer, incorporating recent randomized and large observational studies. Following PRISMA 2020 guidelines, PubMed, Scopus, Embase, and Cochrane Library were searched till April 2025. Studies directly comparing TPBx and TRBx were included. Risk of bias was assessed using RoB 2.0 for randomized trials and the Newcastle - Ottawa Scale for observational studies. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models. Subgroup analyses and a GRADE assessment were performed to evaluate the certainty of evidence. Twenty-nine studies (n = 90,621) were included. TPBx showed higher PCa detection (RR 1.08; 95% CI 1.01-1.15; p = 0.02) and csPCa detection (RR 1.14; 95% CI 1.05-1.24; p = 0.001), though the certainty of evidence was low to moderate. Heterogeneity was moderate to high. TPBx also showed lower infection-related complications and comparable overall events, though procedure-related pain was slightly higher. TPBx offers improved diagnostic yield and lower infection risk compared with TRBx, with comparable safety. However, given the moderate heterogeneity and limited high-quality RCTs, further confirmatory trials are necessary. https://www.crd.york.ac.uk/PROSPERO identifier is CRD420251035763.

Prostate cancer is the second most commonly diagnosed cancer worldwide. Prostate biopsy, essential for definitive diagnosis, has evolved significantly with new technologies and techniques. Transrectal ultrasound-guided biopsy (TRUS-Bx) has been the gold standard but carries substantial infectious risks due to rectal mucosal penetration. Rising antibiotic resistance, emerging safety protocols, and novel imaging-guided methods have driven a shift toward safer alternatives. Following PRISMA guidelines, we systematically searched PubMed and PubMed Central for studies published between 2014 and 2025 on prostate puncture complications. Eligible articles included original studies with ≥2 patients, emphasizing infectious complications, antibiotic prophylaxis, and modern innovations. From 639 records screened, 78 met inclusion criteria. Thematic synthesis was used to classify findings into complication types, prophylaxis approaches, and technological advancements. Infectious complications after TRUS-Bx ranged from 0.5 to 9.4% for sepsis and 0.3 to 4.9% for febrile urinary tract infections, largely driven by multidrug-resistant organisms and increased sampling density. Transperineal biopsy (TP-Bx), bypassing rectal flora, consistently reported infection rates <1%. Targeted prophylaxis based on rectal cultures, combination antibiotic regimens (e.g., fluoroquinolone with fosfomycin or ceftriaxone), and adjunct measures such as rectal cleansing significantly reduced post-biopsy infections. Technological innovations such as MRI-ultrasound fusion, robotic-assisted approaches, and PSMA PET/CT-guided techniques improved cancer detection rates (up to 71.8%) while maintaining low complication rates ( < 5%). Emerging non-antibiotic TP protocols and advanced anesthetic techniques further enhanced safety and patient tolerance. Modern evidence supports a paradigm shift toward TP-Bx combined with targeted or multidrug prophylaxis to mitigate infectious risks. Imaging-guided and robotic-assisted techniques enhance diagnostic accuracy and safety but remain limited in resource-constrained settings. TRUS-Bx retains utility where TP access is unavailable; however, adapting infection prevention strategies is critical. Future large-scale trials and cost-effectiveness analyses are needed to optimize biopsy protocols globally.

French recommendations from the AFU Cancer Committee for prostate cancer: 2025 summary of changes.

IntroductionIdeal candidates for focal therapy (FT) for prostate cancer (PCa) have mpMRI‐visible ISUP Grade Group 2–3, localized disease. Transperineal (TP) prostate biopsies provide superior positional information of PCa in the transverse axis, and possibly higher PCa detection rates—important in choosing FT modalities. Here, we describe the frequency of optimal FT candidates among a large cohort of men with proven PCa identified from MRI‐guided targeted and systematic TP biopsy.MethodsWe queried the Northwestern data warehouse for men with newly diagnosed PCa who had a positive mpMRI (PI‐RADS 3–5) and a TP biopsy prior to diagnosis from January 2018 to June 2024. Patients with disease optimal for FT were determined using modified FALCON consensus guidelines with emphasis on mpMRI and biopsy findings. We also explored the disparity in FT candidacy when using only target cores compared to combined target and systematic cores.ResultsWe identified 1342 men diagnosed with PCa on combined targeted and systematic TP biopsy after a positive mpMRI, of which 888 men had intermediate‐risk PCa. Of these 888 men, 439 patients (49.4%) had unilateral‐dominant disease, while 329 patients (37%) had unilateral‐dominant and anterior (106; 11.9%) or posterior‐dominant (223; 25.1%) disease. Up to half of the patients considered good candidates on target cores were considered FT‐ineligible on review of systematic cores.ConclusionsFT may be considered in up to 50% of patients with intermediate risk disease, while ideal candidates for functional preservation constitute a smaller number. Review of both targeted and systematic biopsy cores is crucial in determining FT candidacy.

AimTo evaluate the feasibility, participation rate, diagnostic pathway performance, and early detection outcomes of the first year of the Croatian pilot prostate cancer screening program (CROState) implemented in Zagreb.MethodsThis prospective pilot program invited men aged 55-69 years without a prior prostate cancer diagnosis or prostate-specific antigen (PSA) testing in the past 12 months. Recruitment was conducted by general practitioners. Men with PSA>4 ng/mL underwent repeat testing, and if PSA was elevated again, they were referred to one of two university hospitals for further evaluation. The diagnostic pathway included multiparametric magnetic resonance imaging, urological examination, and transperineal fusion biopsy when indicated. All confirmed cancer cases were reviewed by a multidisciplinary team.ResultsA total of 5251 men were invited to the program, of whom 4930 (93.9%) participated in PSA testing. Elevated PSA was detected in 419 (8.5%). Only 157 (37.5%) men completed repeat PSA testing, and 123 men were referred for hospital evaluation. Eighty-eight patients completed advanced diagnostics, with 83 undergoing magnetic resonance imaging. Forty-two men proceeded to biopsy, of whom 27 had positive results (64.3%). Most cancers were clinically significant; only two men fulfilled criteria for active surveillance. The main challenge was incomplete adherence to repeat PSA testing.ConclusionThe CROState pilot demonstrated high initial participation and high detection rate of prostate cancer, with a few clinically insignificant tumors, when combining PSA testing with advanced imaging and targeted biopsy. Limited compliance with repeat PSA testing must be addressed before wider national implementation.

Background/Objectives: Multiparametric MRI (mpMRI) and targeted biopsies have revolutionized prostate cancer (PC) detection through the Prostate Imaging Reporting and Data System (PIRADS). However, the effect of prostate volume on cancer detection and the predictive accuracy of PIRADS in the mpMRI-guided biopsy era remains unclear. The aim was to assess whether prostate volume affects detection rates of clinically significant prostate cancer (CSPC) and high-risk prostate cancer (HRPC) and modifies the predictive performance of the PIRADS score. Methods: We retrospectively analyzed 361 biopsy-naïve men who underwent mpMRI-fusion transperineal biopsies between 2016 and 2023. Lesions graded PIRADS ≥ 3 were targeted alongside systematic sampling. A receiver-operating characteristic (ROC) curve (AUC = 0.74) defined a 44 mL cutoff separating small (<44 mL; n = 160) and large (≥44 mL; n = 193) prostates. Logistic regression and cubic-spline analyses evaluated associations between prostate volume, PIRADS, and cancer outcomes. Results: Any cancer was detected in 74.3% of small versus 35.5% of large prostates (p < 0.001); CSPC in 42.5% vs. 19.6% (p < 0.001); HRPC in 14.3% vs. 5.5% (p < 0.001). Small prostate volume independently predicted any cancer (OR 7.31; 95% CI 4.22–12.7), CSPC (OR 5.08; 95% CI 2.87–8.99), and HRPC (OR 4.50; 95% CI 1.80–11.3). Between 40 and 70 mL, each 10 mL increase in volume reduced CSPC risk by 61% (p = 0.008). Prostate volume significantly modified PIRADS accuracy: in large glands, PIRADS 3 lesions carried only 2% risk for CSPC and 0% for HRPC, while in small prostates, PIRADS 3 conferred a 16.9-fold increased CSPC risk. Conclusions: Prostate volume inversely correlates with cancer detection and aggressiveness. PIRADS performance is volume-dependent; PIRADS 3 lesions in large prostates rarely represent significant cancer and may not warrant biopsy.

Non-White patients are poorly represented in prostate cancer trials. MRI PI-RADS scoring was developed in primarily White populations, but prostate cancer differs in non-White men. We aimed to explore differences in PI-RADS calibration for Asian and Black men. This is a secondary analysis of PREVENT, a multi-institutional study of infection rates for transrectal vs. transperineal biopsy. We compared cancer detection for self-identifying Asian and Black men. We compared detection rates on a per-person basis, stratified by index PI-RADS lesion, to White men, using Fisher's exact and logistic regression. Of 665/752 trial patients with PI-RADS 3-5 lesions, 88 (13%) were Black and 36 (6%) were Asian. Black men were younger at diagnosis with increased rates of overall (70% vs. 43%%, P = 0.004) and clinically significant prostate cancer (60% vs. 27%, P = 0.003) and Asian men had decreased rates of overall (0% vs. 47%, P = 0.004) and clinically significant prostate cancer (0% vs. 27%, P = 0.003) in PI-RADS 3 lesions compared to White men. On multivariable regression, Black men with PI-RADS 3/4 lesions had higher odds of overall (OR 1.17, P = 0.009) and clinically significant prostate cancer (OR 1.20, P = 0.004) and Asian men had lower odds of overall (OR 0.79, P = 0.01) but not clinically significant prostate cancer (OR 0.94, P = 0.5). Black men with PI-RADS 3/4 lesions had 20% higher odds of clinically significant prostate cancer than White men while all PI-RADS 3 lesions in Asian men were negative. These findings suggest PI-RADS may require differential interpretation when assessing prostate cancer risk in non-White men. Registered at ClinicalTrials.gov ( NCT04843566 , https://clinicaltrials.gov/study/NCT04843566 ).

Concerns over infection have driven a shift from transrectal to transperineal prostate biopsy, while pre-biopsy MRI has promoted a move from systematic to targeted sampling. These changes may impact patient selection, treatment planning, and risk stratification in active surveillance. To compare active surveillance outcomes of patients diagnosed primarily by targeted transperineal (tTP) biopsy versus standard transrectal (sTR) biopsy. Prospectively collected data of men who underwent prostate biopsy between January 2018 and May 2022 who were included into active surveillance in our institution. Comparison of patient characteristics, clinical and radiological features, positive and total number of biopsies, biopsy Gleason grade group (GG) at inclusion using simple descriptive statistics, groups compared using Wilcoxon rank sum test; Fisher's exact test; Pearson's Chi-squared test. Time to transition to curative treatment was calculated using the Kaplan-Meier plot. There were 112 and 167 patients in the tTP and sTR groups, respectively. No significant differences in age, BMI, ECOG, Charlson Comorbidity Index, PSA, radiological T-stage or GG at inclusion was seen. Number of positive biopsy cores were unchanged between tTP and sTR at 2 (1-3) (median (IQR); p = 0.2), while total cores were reduced significantly to 3 (3-5) from 12 (8-12) (p < 0.001), respectively. Overall, there was no difference in progression from surveillance to active treatment (p = 0.084), but when separated by biopsy type and GG, there was a significantly higher rate of transitioning to curative treatment after 1 year in the sTR group with GG2+ at inclusion (p < 0.0001), compared to the other three. Using targeted transperineal biopsy of the index lesion(s) alone does not lead to increased treatment of patients included in active surveillance.

Transperineal versus Transrectal Prostate Biopsy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

To evaluate the cancer detection rate (CDR), tolerability, and safety of transperineal prostate biopsy (TPPB) performed under local anesthesia (LA) without antibiotic prophylaxis in an outpatient setting via a freehand technique. Between January 2015 and April 2024, 763 consecutive patients underwent TPPB at a single center. Of these, 538 patients received no antibiotics. Biopsies were performed via a freehand MRI/ultrasound fusion technique under LA. Patient discomfort was assessed using a visual analogue scale (VAS), and complications were recorded using the Clavien-Dindo classification. Statistical analysis was conducted using non-parametric methods (α = 0.05). Among the 538 patients without antibiotic prophylaxis, the overall CDR was 61.7%, with clinically significant prostate cancer (ISUP ≥ 2) detected in 47.4% of the patients. No infectious complications occurred. The level of pain was generally low (mean VAS 2.7), and 91.6% of patients reported no or only mild pain. Complications were rare (1.1%), with urinary retention being the most common (0.9%), associated with larger prostate volume (> 50mL). Combining systematic and targeted biopsy yielded the highest diagnostic accuracy (CDR 65.9%, p = 0.023). TPPB using a freehand technique under LA, without antibiotic prophylaxis, is a safe, effective, and well-tolerated in-office procedure. It achieves high diagnostic yield without infectious complications, offering a viable, cost-efficient alternative to traditional transrectal approaches-especially relevant amid increasing antibiotic resistance.