Objectives To describe the use of a novel 'trizonal' biopsy schema in which 'near‐target' biopsies are taken adjacent to the MRI lesion, in addition to target and systematic biopsies, to determine the accuracy of prostate MRI fusion systems. Participants and Methods A trizonal biopsy technique was used to evaluate 75 men with small Prostate Imaging Reporting and Data System (PI‐RADS) 3–5 MRI lesions (<15 mm) identified from a prospective cohort of 290 men undergoing multiparametric magnetic resonance imaging (MRI) for suspected prostate cancer at a single high‐volume institution between September 2017 and May 2019. In addition to target and systematic biopsies, near‐target biopsies were taken 4 mm from the apparent border of the MRI lesion. Comparisons were made between highest International Society of Urological Pathology grade and longest tumour length. Results Fifty‐three men with significant prostate cancer in the same quadrant as the target were included in the final analysis. The percentages of positive cores from target, near‐target and MRI‐negative zones were 66%, 39% and 17%, respectively. Significant cancer was detected in the near‐target zone in 77% of cases when the target zone was positive. A total of 17% of participants were upgraded by a median (range) of 1 (1–3) grades through the addition of near‐target cores. Notably, 9% of men were diagnosed with clinically significant prostate cancer solely via the near‐target biopsy cores when the target cores were negative. Conclusion The use of near‐target biopsies as part of a trizonal biopsy schema provides a novel methodology to optimize clinically significant prostate cancer detection.

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