The AUA and European Association of Urology (EAU) guidelines for proper prostate biopsy technique are dissimilar. The AUA does not take a firm stance on the recommended route of prostate biopsy (transrectal or transperineal) or whether MRI-fusion methods should be prioritized.¹ Alternatively, the EAU recommends transperineal over transrectal biopsy due to the lower associated infection risk and higher sensitivity for detecting prostate cancer, particularly within the anterior aspect of the gland.^2,3 The EAU also recommends an MRI prior to biopsy and the use of MRI-fusion methods for any PI-RADS (Prostate Imaging Reporting and Data System) ≥ 3 lesions.²

Discordance between major societal guidelines can result in unwarranted variation and inconsistent biopsy practices amongst urologists. For example, such variation can result in the same patient undergoing a 12-core transrectal ultrasound biopsy by one urologist, while another may perform an MRI-targeted transperineal prostate biopsy with 12 or more cores depending on the presence of any PI-RADS ≥ 3 lesions. In addition to conflicting guidelines, differences in prostate biopsy technique are also likely highly dependent on urologist-specific factors (eg, fellowship training, practice setting) rather than patient-specific ones. This can result in patients undergoing what is available for prostate biopsy rather than what may be the most high-quality and evidence-based approach. Similarly, patient preference, which is often influenced by the degree of discomfort and risk of infectious and noninfectious complications associated with each type of biopsy, becomes irrelevant when only 1 technique is available.

Given the above points, we suspect that substantial variation exists in the use of different prostate biopsy techniques across the US. We plan to utilize AUA Census data to help characterize the degree of this variation amongst practicing urologists. Urologist-specific factors that may impact the use of MRI-targeted and transperineal prostate biopsy will also be investigated.

In addition, it is well known that African American men are adversely affected by prostate cancer. These men present earlier with more aggressive disease and experience higher rates of cancer-specific mortality.⁴ This disparity is at least partially due to inequalities in prostate cancer screening, diagnosis, and treatment.⁴ It is critically important to understand barriers to high-quality urologic care in this population. One potential reason for delays in diagnosis may be a lack of access to prostate biopsy and different biopsy techniques in African American communities. Thus, we also plan to leverage AUA Census data to understand how prostate biopsy is being utilized within vulnerable communities across the US.

We are honored to be awarded an AUA Data Grant to investigate these important questions. The debate between the pros and cons of transrectal and transperineal prostate biopsy is very timely. Many urologists are wondering if and when they should start incorporating transperineal prostate biopsy into their clinical practice. We anticipate that our findings will (1) allow us to understand patient access to MRI-targeted and transperineal biopsy in the US, (2) identify which urologists are already performing different types of prostate biopsies, (3) locate regions of the country where workforce development and additional training may be needed to increase the use of MRI-targeted and transperineal biopsy, and (4) assist patients in understanding what regions of the country have the most options available for prostate biopsy.

Editor’s Note: The team of principal investigator Micael Rezaee, MD, MPH, and co-investigator Christan Pavlovich, MD, was one of 6 research groups awarded a 2024 AUA Data Research Program Grant. Awardees use clinical data from the AUA Quality (AQUA) Registry or AUA Annual Census data to conduct clinical and workforce studies. Applications for the 2025 AUA Data Research Program will open in May.