Stangl Fabian Peter, Day Elizabeth, Vallée Maxime, Bilsen Manu P, Grossmann Nico C, Falkensammer Eva, Tapia-Herrero Ana-Maria, Pilatz Adrian, Wagenlehner Florian, Tandogdu Zafer, Bjerklund Johansen Truls Erik, Gross Tobias, Medina-Polo Josè, Marschall Jonas, Lusuardi Lukas, Bonkat Gernot, Köves Bela, Schneidewind Laila, Kranz Jennifer
Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Urology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany; Department of Urology and Andrology, Salzburg University Hospital, Paracelsus Medical University, Salzburg, Austria.
Department of Urology, University College London Hospital, London, UK.
Eur Urol Focus. 2025 Aug 6. doi: 10.1016/j.euf.2025.07.005.
Prostate biopsies remain a key step in the diagnosis of prostate cancer and are performed either via a transrectal (TR) or a transperineal (TP) route. In general, the approaches are considered to provide similar diagnostic power. However, infectious complications appear to differ in favour of the TP approach. Furthermore, antibiotic prophylaxis is felt to have limited additional value in a TP biopsy, which aligns with antimicrobial stewardship principles. Urology association guidelines have provided conflicting recommendations on the best approach for a prostate biopsy. This systematic review aims to compare the infectious complications and antibiotic usage of the two approaches.
A systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines after registration with PROSPERO (CRD42024513309). MEDLINE, Embase, Scopus, and Web of Science were searched for articles published until April 1, 2025. Randomised controlled trials (RCTs) assessing infectious complications (fever, urinary tract infection, and hospitalisation with infectious complications) following a prostate biopsy were included. The risk of bias was assessed with the RoB 2 tool, and statistical analyses included visualisation through funnel and forest plots and assessing the publication bias via Egger's regression test.
Ten RCTs were included in the analysis, encompassing 4188 prostate biopsies. Of seven studies reporting hospitalisation for infectious complications, the TP route showed significantly lower odds (odds ratio 0.23, 95% confidence interval [CI] 0.10-0.54; graphical abstract), reducing hospitalisation risk by 77% compared with the TR route. Postinterventional fever occurred less frequently, with an odds ratio of 0.68 (95% CI 0.52-0.89). There was no statistically significant difference in infectious complications after a TP biopsy with or without antibiotics. All TR route biopsies utilised antibiotic prophylaxis. The small number of eligible studies and the high risk of bias, as well as sparse data on bias in most studies, limit the power of our manuscript.
TP biopsy is associated with a lower admission risk due to postprocedural infection compared with TR biopsy. TP biopsy seems to be a safe procedure without antibiotics in patients without risk factors, advocating for enhanced antimicrobial stewardship in urology.
前列腺活检仍是前列腺癌诊断的关键步骤，可通过经直肠（TR）或经会阴（TP）途径进行。一般来说，这两种方法被认为具有相似的诊断能力。然而，感染性并发症似乎在TP途径方面更具优势。此外，人们认为抗生素预防在TP活检中的附加价值有限，这与抗菌药物管理原则相符。泌尿外科协会指南对于前列腺活检的最佳方法给出了相互矛盾的建议。本系统评价旨在比较这两种方法的感染性并发症及抗生素使用情况。
在PROSPERO（CRD42024513309）注册后，根据系统评价和Meta分析的首选报告项目指南进行系统评价和Meta分析。检索MEDLINE、Embase、Scopus和Web of Science数据库，查找截至2025年4月1日发表的文章。纳入评估前列腺活检后感染性并发症（发热、尿路感染和因感染性并发症住院）的随机对照试验（RCT）。使用RoB 2工具评估偏倚风险，统计分析包括通过漏斗图和森林图进行可视化，并通过Egger回归检验评估发表偏倚。
分析纳入了10项RCT，共涉及4188例前列腺活检。在7项报告因感染性并发症住院情况的研究中，TP途径的住院几率显著更低（优势比0.23，95%置信区间[CI] 0.10 - 0.54；见图形摘要），与TR途径相比，住院风险降低了77%。介入后发热发生频率较低，优势比为0.68（95% CI 0.52 - 0.89）。在使用或不使用抗生素的TP活检后，感染性并发症方面无统计学显著差异。所有TR途径活检均使用了抗生素预防。符合条件的研究数量较少且偏倚风险较高，以及大多数研究中关于偏倚的数据稀少，限制了本研究的效力。
与TR活检相比，TP活检因术后感染导致的住院风险更低。对于无危险因素的患者，TP活检似乎是一种无需使用抗生素的安全操作，这支持在泌尿外科加强抗菌药物管理。
