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Objective: Prostate biopsy is associated with a risk of significant infectious complications including sepsis. We investigated the risk of infections after transrectal (TR) biopsy compared to transperineal (TP) biopsy.

Materials and methods: Men who had undergone prostate biopsy and diagnosed with prostate cancer were identified in the National Prostate Cancer Register (NPCR) of Sweden. Linkage with Swedish health care registers provided information on hospitalization, antibiotic prescriptions and comorbidities. Rate ratios for hospitalization, for infections, afterTR and TP biopsies over day 1-7, 1-14, and 1-30 were estimated with Poisson regression. Filled prescriptions for urinary tract related antibiotics were also assessed.

Results: Thirty-one thousand two hundred twenty-two men underwent biopsy between 1 January 2020 and 31 December 2023. 87% underwent TR and 13% TP biopsy. Hospitalization occurred in 0.6% of men (n = 24) after TP biopsy and 2.0% (n = 548) after TR biopsy. Rate ratios for hospitalization in the TR group compared to TP were 8.0 (95% confidence interval [CI]: 4.0-16.2) for day 1-7, 6.2 (3.2-11.9) for day 1-14, and 4.1 (2.4-6.8) for day 1-30. Filled antibiotic prescriptions were found for 4.5% of men (n = 187) afterTP biopsy and 6.9% (n = 1,883) afterTR biopsy. For antibiotic prescriptions, the rate ratios were 2.3 (1.8-2.9) for day 1-7 as well as day 1-14, and 1.6 (1.3-1.9) for day 1-30.

Conclusions: A transrectal prostate biopsy was associated with a significantly higher risk of post-biopsy infectious complications compared to transperineal biopsy. These findings support the use of transperineal biopsy.