Transperineal prostate biopsy is re-emerging after decades of being an underused alternative to transrectal biopsy guided by transrectal ultrasonography (TRUS). Factors driving this change include possible improved cancer detection rates, improved sampling of the anteroapical regions of the prostate, a reduced risk of false negative results and a reduced risk of underestimating disease volume and grade. The increasing incidence of antimicrobial resistance and patients with diabetes mellitus who are at high risk of sepsis also favours transperineal biopsy as a sterile alternative to standard TRUS-guided biopsy. Factors limiting its use include increased time, training and financial constraints as well as the need for high-grade anaesthesia. Furthermore, the necessary equipment for transperineal biopsy is not widely available. However, the expansion of transperineal biopsy has been propagated by the increase in multiparametric MRI-guided biopsies, which often use the transperineal approach. Used with MRI imaging, transperineal biopsy has led to improvements in cancer detection rates, more-accurate grading of cancer severity and reduced risk of diagnosing clinically insignificant disease. Targeted biopsy under MRI guidance can reduce the number of cores required, reducing the risk of complications from needle biopsy.