I have had three transrectal biopsies - this was before I was aware of transperineal.

They were uncomfortable but not too painful. I had local anesthesia, though on the 3rd biopsy with a new urologist/surgeon he suggested nitrous oxide, which helped calm me down. I had to pay $125 out of pocket for that. (I had told him that I was "jumpy" on the first two.). At the time I felt it was worth it, but now I'm a bit on the fence if I'd bother next time.

I was fine afterwards for all three and drove myself home on the first two. I could have driven myself on the 3rd but my wife wanted to be there, so she drove.

I don't think they'll keep you overnight and I don't think there's a need to do so.

Transperineal does appear to be the preferred method, though some have said that it was more painful for them. So, it might just be a factor on your pain threshold. Mine isn't very high.

That said, your MRI results seem to indicate that you can wait on a biopsy - but I'm no expert on this. There are so many other factors to consider with PCa. If there's another factor that has you concerned - like family history - then I would proceed with the biopsy.

And I personally would go with transperineal.

All the best to you.