Objectives To report our early experience with manually controlled targeted biopsy with real‐time multiparametric magnetic resonance imaging and transrectal ultrasound fusion images for the diagnosis of prostate cancer. Methods A total of 20 consecutive patients suspicious of prostate cancer at the multiparametric magnetic resonance imaging scan were recruited prospectively. Targeted biopsies were carried out for each cancer‐suspicious lesion, and 12 systematic biopsies using the BioJet system. Pathological findings of targeted and systematic biopsies were analyzed. Results The median age of the patients was 70 years (range 52–83 years). The median preoperative prostate‐specific antigen value was 7.4 ng/mL (range 3.54–19.9 ng/mL). Median preoperative prostate volume was 38 mL (range 24–68 mL). The number of cancer‐detected cases was 14 (70%). The median Gleason score was 6.5 (range 6–8). Cancer‐detected rates of the systematic and targeted biopsy cores were 6.7 and 31.8%, respectively (P < 0.0001). In six patients who underwent radical prostatectomy, the geographic locations and pathological grades of clinically significant cancers and index lesions corresponded to the pathological results of the targeted biopsies. Conclusion Prostate cancers detected by targeted biopsies with manually controlled targeted biopsy using real‐time multiparametric magnetic resonance imaging and transrectal ultrasound fusion imaging have significantly higher grades and longer length compared with those detected by systematic biopsies. Further studies and comparison with the pathological findings of whole‐gland specimens have the potential to determine the role of this biopsy methodology in patients selected for focal therapy and those under active surveillance.