Objective The aim of this study was to investigate the risk correlation between suspicious areas of TRUS images and prostate lesions under the real-time fusion of volume-navigated transrectal ultrasound （TRUS） and multiparametric magnetic resonance imaging （MP-MRI）.Methods A retrospective analysis of 114 patients with pathologically confirmed prostate cancer by volume-navigated TRUS/MP-MRI image fusion guided targeted biopsy was performed，and the relationship between the presence of suspicious areas in TRUS images and MP-MRI PIRADS score and pathological Gleason score was analyzed.Results Among 114 patients, 70 were in the positive group and 44 were in the negative group. There were 114 lesions in total, PI-RADS score 5 accounted for 41.23%, score 4 accounted for 37.72%, PIRADS 3 accounted for 15.79%, and PIRADS 2 accounted for 5.26%. Of the PI-RADS 3 and lower lesions, 25% (6/24) were positive on ultrasound; 71.1% (64/90) of the PI-RADS 4 and 5 lesions were positive on ultrasound; and 89% (42/47) of the PI-RADS 5 lesions were positive on ultrasound, with a statistically significant difference between the two distributions (P < 0.01). In the positive group, 77.1% (54/70) of the prostate cancer puncture specimens had a pathological Gleason score of 7 (4+3) or higher, while 36.3% (16/44) of the negative group had a pathological Gleason score of 7 (4+3) or higher, with a statistically significant difference (P < 0.01). Conclusion Among the prostate lesions with PIRADS score of 4 and 5，suspicious areas were more likely to be found in TRUS images；most of the lesions with suspicious areas in TRUS images were mostly high-risk prostate cancer，suggesting a greater risk of high-risk prostate cancer.