Diagnosis of prostate cancer (PCa) hinges on the cornerstone of prostate biopsy, as this remains the definitive means of confirming the presence of disease and determining the critical International Society of Urological Pathology (ISUP) grade group (GG) [1]. Integration of magnetic resonance imaging (MRI) into the PCa diagnostic pathway has ushered in a new era, with three pivotal studies and a meta-analysis comparing MRI-targeted biopsy (MRI-TBx) and systematic biopsy (SBx) for detection of clinically significant PCa (csPCa) [2], [3], [4], [5]. A notable paradigm shift in the choice of prostate biopsy approach has subsequently emerged, with a transition from transrectal biopsy (TRBx) to transperineal biopsy (TPBx). The European Association of Urology (EAU) now recommends TPBx as the preferred technique, primarily because of the lower risk of severe urinary tract infection [6]. This reduction in infection leads to a subsequent decrease in antibiotic resistance and associated costs [7], [8], [9]. Nevertheless, the impact of this shift on detection of csPCa remains a subject of debate [10]. To date, no high-quality study has compared the two approaches, and recent meta-analyses have produced conflicting results [11], [12].

Considering these advances and ongoing debates, the aim of the present study was to contribute to the body of knowledge by evaluating csPCa detection in a large, multi-institutional and contemporary cohort of European patients who underwent TRBx or TPBx in a setting that included MRI-TBx and SBx.