Diagnostic accuracy and safety of image-guided transperineal versus transrectal prostate biopsy for clinically significant prostate cancer: a GRADE-assessed systematic review and meta-analysis

INTRODUCTION: 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. METHODS: 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. RESULTS: = 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. CONCLUSION: 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. PROTOCOL REGISTRATION: https://www.crd.york.ac.uk/PROSPERO identifier is CRD420251035763.