This study provides a novel nomogram predicting clinically significant prostate cancer (csPCa) in patients with suspected imaging according to different locations. Prostate Imaging-Reporting and Data System (PI-RADS) score integrated with other clinical parameters displayed a robust predictive ability for csPCa before prostate biopsy. New nomogram consisting of prebiopsy data, including prostate-specific antigen (PSA), prostate volume (PV), age, and PI-RADS score, can aid clinical decision-making to prevent unnecessary biopsy.

• In this retrospective study, 688 patients who had ultrasound-guided transperineal magnetic resonance imaging fusion prostate biopsy were included to built nomograms combining PI-RADS score and clinical variables (PSA, PV, age, free/total PSA, and PSA density) to detect cases eligible for biopsy.

• A diagnosis of csPCa was made in 320 of 688 included patients, and csPCa was defined as Gleason score ≥7.

• Good performance was demonstrated by the receiver-operating characteristic and concordance-index.

• The nomogram yielded area under the curves of 0.867, 0.889 and 0.757 for predicting csPCa at the peripheral zone, transitional and apex zones, respectively.

• There was statistical significance between fusion biopsy and systematic biopsy for PI-RADS score >3 lesions and lesions at the peripheral and transitional zones.