Background: To determine the impact of pre-biopsy prostate MRI followed by a targeted biopsy (TBx) approach for initial diagnosis on oncological outcomes after prostate cancer (PCa) treatment. Methods: We performed a retrospective review of all patients who underwent prostate biopsy followed by radiation therapy (RT) or radical prostatectomy (RP) as their first treatment from 2014-2020. Patients were separated into two cohorts based on the diagnostic approach: pre-biopsy prostate MRI during the initial evaluation and those who did not receive MRI. Patients with positive MRI findings underwent a combination of TBx and systematic biopsy (SBx) to confirm the diagnosis, while those without MRI underwent SBx only. Patients with PSA >20 were excluded. Kaplan-Meier curve analysis was used to compare biochemical recurrence (BCR, defined as PSA > 0.2ng/ml after RP or a rise of 2ng/ml after RT) between cohorts. Cox proportional hazard analysis was done to determine the predictors of the BCR. Results: 366 patients (174 diagnosed by SBx only, and 192 diagnosed by pre-biopsy MRI and TBx) with a median follow-up of 40 months were included in the study. 245 men (67%) had RP as their first treatment. Median age and PSA were 64.7 and 7.9, respectively in the SBx cohort and 65.0 and 8.3, respectively in the TBx cohort. There was a significant difference in BCR rate between the TBx (7.98%) versus SBx (19.28%, p<0.05 by log-rank). After adjusting for age, race, PSA, biopsy path, DRE, and family hx, pre-biopsy the MRI and TBx approach for diagnosis was found to be an independent negative predictor (p=0.001); with patients diagnosed with the above approach 71% less likely to have BCR during the study period. Conclusions: Our study shows that patients undergoing pre-biopsy MRI followed by TBx have lower rates of biochemical recurrence compared to men diagnosed without pre-biopsy MRI. To our knowledge, this study is the first to show the positive impact of pre-biopsy MRI on oncological outcomes, likely due to its role in risk stratification, treatment selection, surgical staging, and planning. Further longitudinal studies are needed to discern the true long-term benefits of pre-biopsy MRI on oncological outcomes.