Objective To investigate the clinical effect of mpMRI-TRUS image fusion biopsy under transperineal 3D image registration combined with AI electromagnetic navigation. Methods A retrospective analysis was performed for 178 patients who underwent prostate biopsy in Yongchuan Hospital Affiliated to Chongqing Medical University from January 2022 to February 2024，and according to the puncture method，they were divided into transrectal cognitive group and transperineal AI group. The two puncture methods were compared in terms of the detection rate of clinically significant prostate cancer（csPCa） and complications，and the multivariate Cox analysis was used to determine the influencing factors for the detection rate of csPCa. Results A total of 94 patients underwent transperineal AI fusion biopsy，and 84 patients underwent transrectal cognitive fusion biopsy. Transperineal AI fusion biopsy was superior to transrectal cognitive fusion biopsy in identifying csPCa（67.0% vs. 53.5%，P=0.048）. The multivariate regression analysis showed that age，PI-RADS score>3，and transperineal puncture were significant predictive factors of csPCa. Transperineal biopsy had a significantly higher urinary retention rate than with transrectal biopsy（18.5% vs. 4.7%，P=0.009）. Conclusion AI-guided fusion biopsy has a better detection rate of csPCa than transrectal cognitive fusion biopsy，and in addition，transperineal biopsy has a relatively low risk of infectious complications.