PURPOSE To evaluate the diagnostic accuracy of mpMRI and mpMRI / transrectal ultrasound (TRUS) fusion-guided targeted biopsy (FTB) against transperineal template saturation prostate biopsy (TTSPB) for the detection of prostate cancer (PCa). PATIENTS AND METHODS Retrospective analysis of 415 men consecutively presenting for prostate biopsy between 11/2014 and 9/2016 at our tertiary care centre. MpMRI (3-Tesla, without endorectal coil) was performed followed by TTSPB with the BiopSee® fusion system. Additional FTB was carried out in men with a suspicious lesion on mpMRI (Likert score 3-5). Any Gleason pattern 4 was defined as clinically significant PCa (csPCa). Detection rates of mpMRI and FTB were compared with the detection rate of TTSPB using the McNemar test. RESULTS The median numbers of TTSPB and FTB cores taken were 40 (range 30-55) and three (2-4), respectively. Among 124 patients (29.9%) without suspicious lesion on mpMRI, 32 (25.8%) were found to have csPCa on TTSPB. Among 291 patients (70.1%) with a Likert score 3-5 on mpMRI, FTB detected 129 (44.3%), TTSPB 176 (60.5%) and the combined approach 187 patients (64.3%) with a csPCa. Overall, 58 cases (19.9%) of csPCa would have been missed if FTB was performed exclusively. Sensitivities of mpMRI and FTB for csPCa were 84.6% and 56.7%, with a negative likelihood ratio of 0.35 and 0.46, respectively. CONCLUSIONS MpMRI alone should not be used as a triage test due to a substantial number of false-negative cases with csPCa. Systematic biopsy outperformed FTB and will therefore remain crucial in the diagnostic pathway of PCa.