Transperineal versus transrectal prostate biopsy in cancer detection rate for patients with gray-zone prostate-specific antigen: a multicenter, real-world study

Abstract Background: The knowledge about the effect of different prostate biopsy approaches on the prostate cancer detection rate (CDR) for patients with gray-zone PSA is limited. We aimed to compare CDR in different biopsy approaches for patients with rising prostate-specific antigen (PSA) levels in the gray zone. Methods: In this retrospective study, we identified 228 patients receiving transrectal prostate biopsy (TRB) compared with 216 receiving transperineal prostate biopsy (TPB) between 2016 and 2022. We also identified 110 patients receiving additional targeted biopsies following the systematic TPB. Clinical parameters were recorded, including age, PSA derivates, prostate volume (PV), and needle cores. Data was fitted into a propensity score matching (PSM), adjusting for potential confounders. Results: TPB outperformed TRB in CDR (49.6% vs. 28.3%, P = 0.001). The clinically significant prostate cancer (CSPCa) detection rate showed no significant difference between TPB and TRB (78.6% vs. 68.8%, P = 0.306). In stratified analysis, TPB outperformed TRB in CDR when the age of patients was 65-75 years (59.0 % vs. 22.0%, P < 0.001), when PV was 25-50ml (63.2% vs. 28.3%, P < 0.001), and when needle cores were no more than 12 (58.5% vs. 31.4%, P = 0.005). The CDR (P = 0.712) and the detection rate of CSPCa (P = 0.993) showed no significant difference among systematic, targeted, and combined biopsies. Conclusion: TPB outperformed TRB in CDR for patients with gray-zone PSA. However, targeted biopsy added no additional benefits following systematic TPB.