© 2018 Elsevier Inc. Objectives: To assess management choices in patients who undergo magnetic resonance imaging (MRI)/ultrasound (MRI/US) fusion-guided prostate biopsy compared to patients who undergo systematic biopsy. Methods: We compared men who underwent MRI/US fusion-guided prostate biopsy to those who underwent systematic 12-core biopsy from 2014 to 2016. Patient demographics and pathologic findings were reviewed. The highest grade group per case was considered for analysis. Results: Follow-up was available on 133 patients who underwent MRI/US targeted biopsy and 215 patients who underwent systematic biopsy. There was no difference in prebiopsy prostate-specific antigen (PSA) (10.1 ± 10.0 vs. 12.9 ± 20.5, P = 0.11) between the 2 cohorts. Patients in the MRI cohort were more likely to have had a previous prostate biopsy (P<0.0001). Overall, more patients in the MRI cohort choose active surveillance compared to the standard cohort (49.6% vs. 24.2%, P<0.0001), confirmed on multivariate logistic regression model adjusting for age, PSA density, prior biopsy history, race, grade group, and provider (P = 0.013). This finding held true independently for patients with grade groups 1 and 2 tumors (P = 0.02 and P = 0.005, respectively) and in a multivariate logistic regression model adjusting for grade group 1 and 2 tumors (P = 0.0051). In the standard cohort, more patients chose radiation over prostatectomy (47.2% vs. 24.4%, P<0.0001). On multivariate analysis, race was an independent predictor of active surveillance, with African Americans less likely to undergo active surveillance. Conclusions: Patients who undergo MRI/US targeted biopsy are more likely to choose active surveillance over early definitive treatment compared to men diagnosed on systematic biopsy when adjusting for tumor grade, PSA density, prior biopsy history, race, and provider.