To examine regional variation in prostate biopsy practices in the United States and identify specific provider characteristics associated with performing different types of prostate biopsy.

Weighted data from the 2022 American Urological Association Annual Census regarding urologists’ conduct of prostate biopsies, including transrectal (TR), transperineal (TP), and magnetic resonance imaging (MRI)-fusion biopsies were analyzed. Prostate biopsy utilization was examined overall and at the state level. Multiple logistic regression was used to examine the association between provider characteristics and the odds of performing each type of biopsy.

In 2022, 78% (n = 10,729) of practicing urologists reported performing diagnostic prostate biopsies. TR and TP biopsies were performed by 99.4% and 37.2% of these providers, respectively, and MRI-fusion biopsies by 60.8%. Variation was observed in prostate biopsy utilization at the state level, including up to 2.7, 6.8, and 8.9-fold differences in the use of TR, TP, and MRI-fusion biopsy, respectively. Certain states were routinely in the bottom 5 in terms of reported use of TP and/or MRI-fusion biopsy. Urologists with fellowship training in urologic oncology, who had a primary subspeciality of urologic oncology, robotics, or laparoscopy, who were younger, and who were busier were more likely to perform each biopsy approach.

Substantial variation exists in the use of different approaches to prostate biopsy across the U.S. Prostate biopsy approach is currently highly dependent on where and whom patients see for their urologic care.