TRUS guided transperineal biopsy (TPBx) and TRUS guided transrectal biopsy (TRBx) are the two primary approaches to obtain prostate tissue for diagnosis of PCa. Their main differences lie in the puncture site, puncture route and the TRUS transducer. In TPBx, the needle punctures through skin at the perineum under the guidance of a bi-planar transducer; while in TRBx, the needle punctures through the anterior rectal wall under the guidance of an end-fire transducer. Potential drawback of the transrectal approach includes the increased febrile postprocedural urinary tract infections (UTIs). In contrast, transperineal ultrasound-guided prostate biopsies (TPPBx) have been linked to increased postprocedural urinary retention rates, appear to be more invasive than TRPBx and cannot easily be delivered in an outpatient setting, as they often need general anesthesia or sedation. Thus with the introduction of local anesthesia such as pudendal nerve block and the adoption of freehand techniques have contributed to the feasibility of performing TP biopsy.