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Backround: We present our series of free-hand transperineal prostate biopsy using a novel coaxial needle introducer guide. All cases were performed in the office under local anesthesia without sedation. The majority received no prophylactic antibiotics. MATERIALS AND METHODS We retrospectively reviewed the electronic medical records of 242 consecutive free-hand transperineal prostate biopsy cases employing the PrecisionPoint® Transperineal Access System performed under local anesthesia without sedation by a single urologist (RJS) at Kaiser Permanente Southern California. We compared complication rates of this series of cases to our initial series of 62 free-hand transperineal prostate biopsy cases without the PrecisionPoint® as well as 133 transrectal prostate biopsy cases performed before we adopted the transperineal approach. RESULTS Of the 242 consecutive free-hand transperineal biopsies performed between 08/26/2016 and 12/31/2018, 212 (88%) received no antibiotic prophylaxis. Medians for age, prostate specific antigen, prostate volume, prostate specific antigen density and cores sampled were 63 years, 7.2 ng/ml, 50 ml, 0.15 ng/ml/cc and 20 cores, respectively. Detection rates of overall and clinically significant prostate cancer for screening biopsies averaged 43.4% (105/242) and 14% (35/242), respectively. Average visual analog scale pain rating was 3.9 and average procedure time was 20 minutes. Complication rates of sepsis, acute urinary retention, clot retention and perianal abscess were 0.0% (0/242), 0.4% (1/242), 1.2% (3/242) and 0.4% (1/242), respectively. CONCLUSIONS This series of office-based free-hand transperineal biopsy under local anesthesia without sedation performed with the PrecisionPoint® Transperineal Access System contains a large number of cases in which prophylactic antibiotics were not administered, yet there were no complications of post-biopsy sepsis. However, there was one case of a delayed perianal abscess. Free-hand transperineal prostate biopsy under local anesthesia enables the easy integration of transperineal biopsy into a normal outpatient clinic workflow.