Due to its high prevalence, prostate cancer represents worldwide the leading and consequently the most debated oncologic entity within the field of Urology. Traditionally, back in the days ruling in prostate cancer represented more or less the major goal of early detection or screening activities. Conversely, today based on the growing prospectively derived evidence, multiple relevant aspects prior to an individual prostatic biopsy recommendation need to be considered. The main drivers within this ongoing debate are mainly dominated by the keywords: potential “overdiagnosis” and consequential “overtreatment.” In fact, this ongoing debate includes not only a clinical but a health-economical/health-political level, respectively [1–3]. It is of note that urologic key opinion leaders suggest within a NCCN symposium a new terminology for indolent and precancerous disorders stating that “… prostate cancer is probably the tumor with the greatest risk for overdiagnosis and overtreatment …” as recently published in Lancet Oncology [4]. As a consequence, to improve prostate biopsy indication, technique and treatment strategies, multiple novel diagnostic as well as therapeutic concepts are being developed and promoted. With these notions in mind, the aim of the current WJU issue was to give clinicians an update on these much debated aspects in prostate biopsy by inviting state-of-the-art reviews as well as selecting adequate original articles related to prostate biopsy.

Of the invited reviews, pre-operative risk stratification, up-to-today standard randomized biopsy schemes as well as evaluation of different novel imaging technologies are being critically discussed. Firstly, Hansen and colleagues discuss which and how established/novel prostate cancer biomarkers and risk factors prior to prostate biopsy should be used. We believe that this topic is timely and important since the panel of potential biomarkers is constantly changing. The authors made an effort in organizing this wealth of markers and selecting and emphasizing which of those risk factors are promising and indeed how they can be used in clinical practice.

Certainly, it is of utmost importance to know the current recommended randomized biopsy gold standard to situate oneself in relation to the novel imaging technique. In order to do so, the group of Scattoni et al. did an excellent job in summarizing this current status-of-care in different biopsy scenarios as well as in relation to the number and to the direction of randomized biopsy cores. Thus, after reading this review, the clinician will know: why, when, how many and where to take randomized biopsy cores.

Next, despite exciting developments of novel diagnostic tools, two reviews of Pummer and colleagues as well as Walz et al. address the existing body of literature of elastography, contrast enhanced ultrasound, histoscanning, computer-based analysis of the transrectal ultrasound signal (C-TRUS) and multiparametric MRI. One of the several strengths of these meticulous reviews resides in the fact that they clearly demonstrate that in the near-future visualization of prostate cancer lesions is—by far—not far fetched. However, the authors emphasize that currently no recommendation for their routine use can be made. Moreover, there seems to be a clear need of standardization of study designs and study protocols when comparing randomized versus targeted novel imaging-based biopsy protocols in order to achieve an optimal level of prospective evidence, which is key within this exciting field.

Nevertheless, it is important to mention that the future of prostate imaging obviously has already begun. This applies specifically to the MRI technology and may also in part explain its current momentum. For example, the Standards of Reporting for MRI-targeted Biopsy Studies (START) consortium explicitly addressed this debate. The START authors concluded that implementation of their suggested checklist will improve the quality of reporting in MRI-targeted biopsy studies as well as their comparison [5]. Moreover, the European Society of Urogenital Radiology (ESUR) has published a guideline for multiparametric MRI recommending a structured reporting scheme called Prostate Imaging Reporting and Data System (PI-RADS) generating a score which reflects a patient’s individual risk profile [6].

Beyond these efforts, other MRI-based technologies such as MRI/TRUS fusion-guided prostate biopsy and even therapeutic concepts such as active surveillance or focal therapy are clearly on the rise. As a prerequisite, these concepts demand high-quality multiparametric MRI pictures. For example, in the detection setting, Rastinehad et al. [7] and Sonn et al. [8] have recently demonstrated improved detection using the fusion technology in detecting clinically significant prostate cancer over standard-randomized biopsies. This finding is of note since prediction of significant disease by clinical variables seems to be insufficient [9] and novel markers still await large-scale validation [10].

As a result, based on these imaging developments, multiple novel areas in urology are being/will be created. For example, novel risk stratification tools will be available, profound MRI knowledge on the urologists’ side will be key as well as adoption of novel therapeutic concepts such as active surveillance where imaging may truly reflect surveillance/trigger reflex biopsy or focal therapy in select men where only the “index lesion” is being (re-) treated in order to preserve quality of life and tumor control will be matters of future debates [11–14].

In contradistinction to these truly exciting concepts, the downsides of novel technologies also need a mention. Certainly, multiparametric 3 Tesla MRI does not represent a “one size fits all”—solution in all men with prostate cancer suspicion and is clearly not equally available around the globe. Additionally, efforts to shorten the MRI procedure time beyond 30 min, management of biopsy artifacts, as well as other confounders such as concomitant BPH/infections need to be addressed. Moreover, the personal and logistic efforts are increasing and so do the associated healthcare costs [13, 15, 16].

Taken together, the prostate biopsy scenario is currently becoming distinctively complex. It has clearly moved far beyond any prostate cancer detection, or avoiding biopsy-related complications such as infections or patients’ anxiety. Importantly, the future of prostate imaging especially of multiparametric MRI-based technology has already begun. Therefore, as a urologic society, it should be within our own interest to be actively participating within this process and not leaving this field to interventional radiologists/oncologists.