To evaluate MR-targeted TRUS prostate biopsy using a novel local reference augmentation method.Tracker-based MR-TRUS fusion was applied using local reference augmentation. In contrast to conventional whole gland fusion, local reference augmentation focuses the highest registration accuracy to the region surrounding the lesion to be biopsied. Pre-acquired multi-parametric MR images (mpMRI) were evaluated using PIRADS classification. T2-weighted MR images were imported on an ultrasound machine to allow for MR-TRUS fusion. Biopsies were targeted to the most suspicious lesion area identified on mpMRI. Each target was biopsied 1-5 times. For each biopsied lesion the diameter, PIRADS and Gleason scores, visibility during fusion, and representativeness were recorded.Included were 23 consecutive patients with 25 MR suspicious lesions, of which 11 patients had a previous negative TRUS-guided biopsy and 12 were biopsy naïve. The cancer detection rate was 64 % (Gleason score ≥6). Biopsy was negative (i.e., no Gleason score) in seven patients confirmed by follow-up in all of them (up to 18 months). After MR-TRUS fusion, 88 % of the lesions could be visualized on TRUS. The cancer detection rate increases with increasing lesion size, being 73 % for lesions larger than 10 mm.Tracker-based MR-TRUS fusion biopsy with local reference augmentation is feasible, especially for lesions with an MR maximum diameter of at least 10 mm or PIRADS 5 lesions. If this is not the case, we recommend in-bore MR-guided biopsy.