INTRODUCTION: With level 1 evidence now available on the diagnostic accuracy of multiparametric magnetic resonance imaging (MRI) we must now utilise this data in developing an MRI-stratified diagnostic pathway for the early detection of prostate cancer. Areas covered: A literature review was conducted and identified seven randomised control trials (RCT's) assessing the diagnostic accuracy of such a pathway against the previously accepted systematic/random trans-rectal ultrasound guided (TRUS) biopsy pathway. The studies were heterogeneous in their design. Five studies assessed the addition of MRI-targeted biopsies to a standard care systematic TRUS biopsy pathway. Three of these studies showed either an increase in their diagnostic accuracy or the potential to remove systematic biopsies. Two studies looked specifically at a targeted biopsy only pathway and although the results were again mixed, there was no decrease in the diagnostic rate and overall significantly fewer biopsy cores were taken in the MRI group. Expert commentary: Results from these RCT's together with multiple retrospective and prospective studies point towards either an improved diagnostic rate for clinically significant cancer and/or a reduction in the need for systematic biopsies with a MRI-stratified pathway. The challenge for the urological community will be to implement pre-biopsy MRI into a routine clinical pathway with likely independent monitoring of standards.