Erectile dysfunction following prostate biopsy: a comparative analysis of transrectal versus transperineal approaches.

Introduction and objectives: Erectile dysfunction (ED) is a concern for men undergoing prostate biopsy. With the increasing adoption of transperineal (TP) biopsy over transrectal (TR) biopsy, it remains unclear which approach carries a lower risk of erectile dysfunction. This study aims to be the first meta-analysis to evaluate erectile dysfunction following TR versus TP prostate biopsy at 1, 3 and 6 months intervals, thereby providing clinicians with evidence-based guidance for patient counseling and shared decision-making.

Materials and methods: This review was prospectively registered on PROSPERO (CRD42024541557) and followed PRISMA guidelines, with searches conducted in PubMed, Scopus, and the Cochrane Library databases up to July 2024. A total of 22 studies reporting erectile function outcomes (IIEF scores) at baseline and 1, 3 and 6 months post-biopsy were identified. After applying inclusion and exclusion criteria, 12 studies were included in the final meta-analysis. TR and TP biopsy methods were compared using a random-effects model to assess standardized mean differences (SMD) in erectile function at each follow-up point. The risk of bias for each study was evaluated to ensure result reliability.

Results: At 1 month follow-up, a significant decline in erectile function was observed overall (SMD: - 0.3785, p = 0.038). The TP approach showed a slightly more significant decline than the TR approach; however, this difference was not statistically significant (p = 0.074). At 3 months follow-up, no significant differences were observed between methods overall (SMD: - 0.1663, p = 0.132), although TP biopsy alone showed a modest yet considerable decline (SMD: - 0.1868, p = 0.03). At 6 months, erectile function had generally returned to baseline, with no significant differences observed between biopsy techniques (p = 0.41).

Conclusion: Both TR and TP prostate biopsies are associated with a transient decline in erectile function. These effects typically resolve by 6 months in most patients, with no significant long-term impact observed. While the initial functional impact may be slightly greater with the TP technique, this difference attenuates over time. These findings are crucial for managing patient expectations post-biopsy.