Purpose: Climate change is the biggest global public health threat of the 21st century. Healthcare contributes 5% to global greenhouse gas emissions. Despite enthusiasm for sustainability in urology, there is little data on the environmental impact of urological practice. This study assessed the emissions associated with transperineal prostate biopsy (TPPB) performed in the clinic under local anaesthesia. Methodology: Emissions associated with TPPB at Tauranga Hospital (Aotearoa New Zealand) were estimated from electricity consumption, procurement of equipment and supplies, travel of staff and patients, waste disposal and sterilisation of linen. Local emissions coefficients were used to determine emissions in CO2 equivalents (kgCO2e). Results: TPPB was found to emit 70 kgCO2e per case, equivalent to 280 km of travel by car or an economy seat on a 90-minute flight from Auckland to Christchurch. The largest contributors were procurement of equipment (76%) and travel (23%). Electricity, waste disposal and linen sterilisation did not contribute significantly to emissions (0.4% each). 0.76 kg of waste was produced per case. Conclusion: This is the first study to evaluate the carbon footprint of a TPPB. Emissions may be mitigated by minimisation of equipment in standardised sets, adopting reusable equipment alternatives, and introducing outreach biopsy clinics to reduce patient travel distance. Reprocessing of single-use devices could also be of benefit. Adherence to pragmatic evidence-based guidelines for prostate cancer investigation may also reduce emissions from overdiagnosis and unnecessary biopsies. Further research is required to characterise the broader environmental impact of urological services.