To review the technique of transperineal saturation prostate biopsy and to update our results on patients at high risk of prostate cancer. A total of 210 men who met the study inclusion criteria underwent systematic transperineal ultrasound-guided template biopsy of the prostate. All patients had previously undergone at least one set of transrectal prostate biopsies and 170 (81%) had undergone two or more. The mean number of prostate cores obtained before the template biopsy was 17.4. A mean of 21.2 cores (range 12 to 41) were obtained at the template biopsy, depending on prostate size. The study inclusion criteria included prostate-specific antigen level of 10 ng/mL or greater, prostate-specific antigen velocity of 0.75 ng/mL per year or greater, or the presence of prostatic intraepithelial neoplasia and/or atypical small cell acinar proliferation on the previous biopsy. Adenocarcinoma was detected in 78 men (37%). Cancer was detected in the transition zone in 60 (77%) of these 78 men, including 36 (46%) in whom cancer was identified uniquely in the transition zone. Gleason sum 6 (range 3 to 9) was the most common biopsy grade. Thirty patients underwent radical prostatectomy, and 27 (90%) had pathologic Stage pT2 disease as the final pathologic stage. Complications from biopsy were limited to postprocedural urinary retention in 11% of patients. A systematic transperineal template biopsy provides uniform sampling of the entire prostate. This technique appears to enhance the identification of transition zone cancers not detected by previous transrectal prostate biopsy in patients at high risk of prostate adenocarcinoma.