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Background: Postoperative pain from transrectal ultrasound-guided prostate (TRUS-P) biopsy under sedation is often mild. Benefit of opioids used during sedation is controversial., Objective: The objective was to compare numeric rating scale (NRS) score at 30 minutes after TRUS-P biopsy between patients receiving propofol alone or with fentanyl., Methods: We randomly allocated 124 patients undergoing TRUS-P biopsy to receive either fentanyl 0.5 mcg.kg -1 (Group F) or normal saline (Group C). Both groups received titrated propofol sedation via Target-controlled infusion (TCI) with Schneider model until the Observer's Assessment of Alertness/Sedation (OAA/S) scale 0-1 was achieved. Hemodynamic variables, patient movement, postoperative pain score, patient and surgeon satisfaction score were recorded., Results: Overall, most patients (97.5%) had no to mild pain. Group F had significantly lower median NRS score at 30 minutes compared to Group C (0 [0, 0] vs. 0 [0, 0.25], p = 0.039). More patients in Group C experienced pain (90% vs. 75.8%, p =  0.038). Perioperative hypotension was higher in group F (81.7%) compared to Group C (61.3%) (p =  0.013). Thirty-five (56.5%) patients in Group F and 25 (42.7%) patients in Group C had movement during the procedure (p = 0.240). Surgeon's satisfaction score was higher in Group F (10 [9, 10]) than Group C (9 [9, 10]) (p =  0.037)., Conclusion: Combining low dose fentanyl with TCI propofol sedation may provide additional benefit on postoperative pain after TRUS-P biopsy, but results in perioperative hypotension. Fentanyl may attenuate patient movement during the procedure, which leads to greater surgeon's satisfaction., (Copyright © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.)