Transperineal prostate biopsy (TPPB) under local anaesthesia has gained international traction as a safer alternative to transrectal biopsy, particularly due to its lower risk of infectious complications. The freehand technique, while technically demanding, offers flexibility and avoids the need for expensive equipment. This systematic review and meta-analysis aims to evaluate the detection rate of clinically significant prostate cancer (csPCa), tolerability (pain scores), and complication profile of TPPB using the freehand technique under local anaesthesia.

A systematic review was performed in accordance with PRISMA guidelines, and the protocol was registered with PROSPERO (CRD42024588824). Searches of PubMed, Embase, CENTRAL, and grey literature identified studies reporting outcomes of freehand TPPB under local anaesthesia. Inclusion criteria comprised prospective or retrospective studies with >10 patients reporting on csPCa detection, pain, or complication rates. Pooled proportions were calculated using a random-effects model and meta-analysed using Stata 17. Risk of bias was assessed using a modified Newcastle-Ottawa scale.

Twelve studies involving 2881 patients were included in the systematic review, with 10 eligible for meta-analysis. The pooled detection rate of csPCa was 48% (95% CI: 37%–59%). Subgroup analysis showed a higher detection rate of 52% (95% CI: 44%–60%) for combined systematic and targeted approaches, compared to 26% (95% CI: 23%–30%) for systematic biopsies alone. Pain scores reported using VAS or NRS remained low, with a pooled mean/median below 3—classified as mild pain. Complication rates were low, with pooled Clavien–Dindo grade I–II events at 2% (95% CI: 1%–4%) and only three grade III–V events (0.1%), all from a single study. The I² statistic suggested significant heterogeneity in csPCa detection (I² = 96.7%) and moderate heterogeneity for minor complications (I² = 83.6%).

Freehand TPPB under local anaesthesia is a safe, well-tolerated, and effective method for prostate cancer diagnosis. It demonstrates robust detection rates for csPCa comparable to other biopsy methods while minimising infection risk and avoiding the need for general anaesthesia. This review supports the broader adoption of freehand TPPB as a pragmatic and cost-effective approach in both outpatient and resource-limited settings.