Background To evaluate the efficacy of freehand transperineal prostate biopsies (FTPB) under local anaesthetic (LA) in the outpatient setting without antibiotic. Methods A total of 218 patients suspicious of prostate cancer (PCa) at the multiparametric magnetic resonance imaging (mpMRI) were analyzed retrospectively from January 2020 to September 2021. All patients were biopsy-naive and had no history of PCa. Suspicious areas on mpMRI were defined and graded using Prostate Imaging Reporting and Data System version 2 (PI-RADS v2). FTPB were performed for each suspicious lesion and followed a 12-core systematic transperineal prostate biopsy (STPB) under LA in the outpatient setting without antibiotic. Histopathological outcomes and complications were recorded. Tolerability was evaluated with a visual analog scale (VAS) assessing discomfort caused by probe, LA injections and biopsies. Results PCa was detected in 129 (59.17%) patients and 104 (47.71%) were clinically significant prostate cancer (csPCa). There was exact agreement between FTPB and STPB in 94 (72.88%) patients. FTPB diagnosed 7 cases less PCa than STPB (115 vs 108 cases, P = 0.311) and 19 cases more csPCa than STPB (93 vs 74 cases, P < 0.001). Compared to FTPB alone, the combination of systematic biopsy led to 21 more prostate cancer and 1 more csPCa diagnoses. LA FTPB was well tolerated and no patients developed severe complications (Clavien-Dindo III/IV/V). Conclusions FTPB under LA in the outpatient setting without antibiotic was safe, feasible and efficient.