Introduction: Prostate biopsy results are crucial for guiding patient care, but significant discordance exists between biopsy histology and final radical prostatectomy (RP) pathology. This discordance can lead to mismanagement, missing clinically significant cancer, and delaying treatment. Advances such as pre-biopsy multiparametric MRI (mpMRI) have improved risk stratification and enabled targeted biopsies. Despite multiple reviews on MRI-targeted biopsies, upgrading remains a concern. Aim: Assess the impact of pre-biopsy MRI on changes in NCCN risk stratification. Methods: A retrospective audit of 2,994 men with non-metastatic prostate cancer diagnosed between 2010-2019 who underwent RP within a year without alternative treatment was conducted using the South Australia Prostate Cancer Clinical Outcomes Collaborative registry. Histological grading between biopsy and RP was compared, analyzing upgrading/downgrading rates in patients with and without pre-biopsy MRI. Data on confounding variables (age, PSA, time to RP, T-stage, number of cores, prostate size, tumor volume, procedure type) were included. Results were assessed using cross-tabulation and uni-/multivariate logistic regression adjusting for confounders. Results: On univariate analysis, pre-biopsy MRI significantly reduced upgrading of pathology (p=0.026, OR 0.83, CI 0.71-0.98) and NCCN risk stratification (p=0.049, OR 0.82, CI 0.64-1.01). However, this significance was lost after adjusting for confounders. Conclusions: Pre-biopsy MRI did not significantly impact NCCN risk stratification when accounting for multiple variables. Upgrading at prostatectomy remains a key consideration, influencing treatment decisions and patient counseling.