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Introduction New technologies to improve quality of prostate biopsies are appearing in clinical practice. We evaluate the performance of a micro-ultrasound device and the Prostate Risk Identification using MicroUltraSound (PRI-MUS) score in detecting clinically significant prostate cancer (csPCa). Material and methods We retrospectively reviewed data of 139 biopsy- naïve patients with suspicion of prostate cancer, who underwent diagnostic MRI and micro-ultrasonography (microUS), followed by transrectal prostatic biopsy (systematic ±targeted) under local anesthetic. The main objective was to evaluate the performance of the Prostate Risk Identification using MicroUltraSound (PRI-MUS) score in detecting csPCa, defined as International Society of Urological Pathology (ISUP) ≥2. Results Of all patients, 97 (70%) were found to have PCa, and 62 (45%) having csPCa. Among 100 patients with positive microUS (PRI-MUS score ≥3), 23 (23%) had ncsPCa and 57 (57%) were diagnosed with csPCa (ISUP ≥2); and in 39 patients with negative microUS, 12 (31%) were diagnosed with ncsPCa and 5 (13%) with csPCa. A PRI-MUS score ≥3 presented a sensitivity, specificity, positive predictive value and negative predictive value of 92%, 44%, 57% and 95%, respectively, for the detection of csPCa. The PRI-MUS score had higher areas under the curve than Prostate Imaging Reporting & Data System (PI-RADS) both for targeted (AUC 0.801 vs 0.733) and systematic + targeted (AUC 0.776 vs 0.694) biopsies for csPCa detection. Conclusions In our cohort, microUS performed well as a diagnostic tool through an easily implementable scale. MicroUS presented similar sensitivity and higher specificity than MRI in detecting csPCa. Further multicenter prospective studies may clarify its role in prostate cancer diagnosis. [ABSTRACT FROM AUTHOR]