Cancer detection and complications of freehand cognitive MRI/US fusion transperineal biopsy of the prostate under local anaesthesia without antibiotic prophylaxis in an in- office setting: a consecutive series of 538 patients

Background: To evaluate the cancer detection rate (CDR), tolerability, and safety of transperineal (TP) prostate biopsy performed under local anesthesia (LA) without antibiotic prophylaxis in an outpatient setting via a freehand technique. Materials and Methods: Between January 2015 and April 2024, 763 consecutive patients underwent TP prostate biopsy at a single center. Of these, 538 patients received no antibiotics. Biopsies were performed via a freehand MRI/ultrasound fusion technique under LA. Patient discomfort was assessed using a visual analogue scale (VAS), and complications were recorded using the Clavien-Dindo classification. Statistical analysis was conducted using non-parametric methods (α = 0.05). Results: Among the 538 patients without antibiotic prophylaxis, the overall CDR was 61.7%, with clinically significant prostate cancer (ISUP ≥ 2) detected in 47.4% of the patients. No infectious complications occurred. The level of pain was generally low (mean VAS 2.7), and 91.6% of patients reported no or only mild pain. Complications were rare (1.1%), with urinary retention being the most common (0.9%), associated with larger prostate volume (> 50 mL). Combining systematic and targeted biopsy yielded the highest diagnostic accuracy (CDR 65.9%, p = 0.023). Conclusion: TP prostate biopsy using a freehand technique under LA, without antibiotic prophylaxis, is a safe, effective, and well-tolerated in-office procedure. It achieves high diagnostic yield without infectious complications, offering a viable, cost-efficient alternative to traditional transrectal approaches—especially relevant amid increasing antibiotic resistance.