The combined targeted and systematic biopsy (CTSBx) was the standard scheme for patients with visible suspicious lesions on MRI in recent years. 2024 European Association of Urology (EAU) guideline recommended targeted and perilesional biopsy (TPLBx) for the diagnosis of patients with MRI visible suspicious lesions. This RCT aims to comprehensively evaluate the efficacy and safety profiles of TPLBx and CTSBx schemes. A single-center non-inferiority RCT (NCT06482658) consecutively enrolled 380 biopsy-naïve patients (CTSBx: n=190, TPLBx: n=190) with a single unilateral suspicious lesion on prostate MRI from June 2024 to November 2024. The non-inferiority margin was -15%. All biopsies were undertaken transrectally through the cognitive fusion technique. The primary outcome was Grade Group (GG) ≥2 cancer (GG≥2-PCa) detection rate. The GG≥2-PCa [58% vs 58%, risk difference (RD): 0.53% (95%CI: -9.4%-11%)], and GG≥3-PCa [30% vs 30%, RD: 0.53% (95%CI: -8.7%-9.7%)] detection rates of TPLBx were non-inferior to that of CTSBx (p0.050). The complication rate of TPLBx was significantly lower than that of CTSBx group (Clavien-Dindo scale≥1: 62% vs 74%, p=0.023), especially for bleeding-related complications (rectal bleeding: 34% vs 48%, p=0.003; hematuria, 39% vs 56%, p<0.001) and rectal pain (25% vs 34%, p=0.018). TPLBx could significantly shorten the procedure time and saved the pathological cost (p<0.001). For patients with a single unilateral suspicious lesion on prostate MRI, TPLBx achieved the non-inferior diagnostic efficacy of csPCa and better safety than the CTSBx scheme.