You will get many opinions on this subject of TRUS vs Transperineal biopsies.
But regardless of the differences in pain levels, bleeding or risk of infection, there is one single overwhelming advantage to a Transperineal biopsy: greater access to more areas of the gland.
It’s been established that you cannot simply biopsy the suspicious area of the MRI since that doesn’t tell the whole story, and sometimes trying to access these other distant areas using TRUS can lead to complications such as excessive bleeding, bladder involvement, etc.
If you are really concerned about just the idea of a biopsy in general, my advice (as a layman only!) as someone who had a painless transperineal, fully awake with local anesthesia only (bilateral nerve blocks) is to have the TP done with sedation. You’ll feel nothing, you’ll know nothing, and the results will probably tell you everything.
BTW, if your urologist is resistant - and many of them are since they are trained in TRUS - find another one. It may be the best decision you make. Best,
Phil