Urologists are increasingly performing prostate biopsies (PBx) via a transperineal (TP) approach. The two predominant methods for performing TP PBx employ either a grid template (G) or a more freehand approach, often with devices such as PrecisionPoint® (PP). As existing data are sparse, our objective was to compare the two techniques on rates of clinically significant prostate cancer (csPCa) detection and complications when MRI-fusion targeted (MRI) TP PBx is performed. We queried a prospectively maintained prostate biopsy database to identify men ages 18-89 who underwent TP MRI-PBx (including concurrent systematic PBx) between August 1, 2020 and September 30, 2022. G-MRI-PBx were performed until April 1, 2022, and PP-MRI-PBx were performed subsequently. All PBx were performed using UroNav software. The primary outcome was detection of csPCa in the MRI region of interest (ROI). 30 day complications and overall rates of csPCa were examined at the patient level. Subgroup outcomes included csPCa detection in anterior MRI ROIs (as anterior ROIs can be challenging to access due to pubic bone interference) and stratification by prior PBx status (active surveillance, prior negative biopsy, or biopsy-naive). csPCa was defined as Grade Group ≥2. 551 MRI ROIs in 452 patients were included in the analysis.;Prior biopsy status differed between groups (Table 1); however, when stratified by prior biopsy status, there was no difference in csPCa detection found between a grid or PP approach (Table 2). PP-MRI-PBx and G-MRI-PBx had similar overall and ROI csPCa detection rates (Table 2).;PP-MRI-PBx identified csPCa in 32.1% of ROIs, and G-MRI-PBx identified csPCa in 34.8% of ROIs (p = 0.57). PP-MRI-PBx identified csPCa in 48.1% of patients, and G-MRI-PBx identified csPCa in 48.9% of patients (p = 0.89). Complication rates and the ability to detect csPCa in anterior ROIs was similar between the two groups (Table 2). PP-MRI-PBx and G-MRI-PBx identified similar rates of csPCa, including in anterior MRI lesions and when stratified by prior biopsy status. Complication rates were low and did not differ based on biopsy technique. [ABSTRACT FROM AUTHOR]