Painless Transperineal MRI/US Fusion Prostate Biopsy: Reality or Myth? The T-PAIN (Transperineal Prostate—Analgesic Innovation) Study

Introduction and Objectives: Transperineal (TP) prostate biopsy offers reduced infection risk compared to transrectal (TR) methods, but patient discomfort remains a concern, especially under local anesthesia. This study evaluated the discomfort from a TP prostate biopsy under local anesthesia and strategies to decrease pain. Methods: This prospective study included 500 consecutive patients undergoing TP prostate biopsy between June 2023 and November 2024. Pre-biopsy magnetic resonance imaging was used to identify target lesions, followed by TP magnetic resonance imaging/ultrasound (ultrasound) fusion biopsy using the Artemis device. A survey questionnaire was administered immediately following the procedure to assess pain scores related to probe insertion, skin infiltration, deep periprostatic block, and overall discomfort, using the Visual Analog Scale (VAS). Results: A total of 450 consecutive patients underwent TP biopsy with local anesthesia, and 50 patients underwent TP biopsy with sedation. No procedures were aborted, and all patients who underwent the procedure under local anesthesia completed the survey. The median overall VAS score was 2 (interquartile range [IQR] 0–3). Ethyl chloride spray and tactile stimulation reduced skin infiltration pain ( p = 0.035), while adding sodium bicarbonate reduced deep block pain ( p < 0.001). Combined interventions lowered median overall pain from 3 (IQR 1–5) to 1 (IQR 1–3), p < 0.001. Older patients reported less pain ( p < 0.001). No association was found between pain and race, prostate size, number of lesions, lesion location, or grade group. The median duration of hematuria was 5 days (IQR 4–8). Two (0.4%) patients in the local anesthesia group developed urinary retention, and two (0.4%) experienced a vasovagal episode. No patients developed sepsis. Conclusions: TP prostate biopsy with local anesthesia is a well-tolerated outpatient procedure when optimized pain control techniques are implemented. Tactile stimulation, ethyl chloride spray, and the use of NaHCO3-buffered lidocaine significantly enhance patient comfort by reducing pain. These strategies enhance patient experience, making TP biopsy a viable outpatient option.