Objective:To investigate the potential roles of preoperative multiparametric magnetic resonance imaging (mpMRI) in identifying aggressive apical prostate cancer (APCa), thereby helping to facilitate patient counseling and surgical planning.Patients and Methods:We performed a retrospective analysis of 662 patients who underwent radical prostatectomy (RP) between January 2010 to October 2019. All patients underwent a preoperative biopsy and mpMRI of the prostate. APCa was defined as any malignant lesions in the prostatic apex. Clinical, pathological and mpMRI variables were retrieved. Univariate, multivariate, and receiver operating characteristic (ROC) analyses were performed.Results:A total of 214 (32.3%) patients had APCa. Patients presenting APCa were more likely to harbor adverse clinicopathological features (allp< 0.05). On univariable analysis, serum prostate-specific antigen (PSA) (p< 0.001), mpMRI-based PSA density (PSAD) (p< 0.001), Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) score (p< 0.001), number of positive cores (p< 0.001), percentage of positive cores (p< 0.001), max core involvement (p< 0.001) and biopsy GG (p= 0.001) were significant predictors of APCa. On multivariable analysis, mpMRI-based PSAD ≥ 0.27 ng/ml/cm3(odds ratio [OR]: 2.251,p= 0.003), PI-RADSv2 score > 4 (OR: 1.611,p= 0.023) and percentage of positive cores (OR: 2.333,p= 0.041) were independently predictive of APCa during RP. The AUC values of mpMRI-based PSAD and PI-RADSv2 score were 0.646 (95% Confidence Intervals [CI]: 0.608-0.682) and 0.612 (95% CI: 0.568-0.656), respectively.Conclusion:Preoperative mpMRI-based PSAD and PI-RADSv2 score help identify the presence of APCa and may be useful for surgical decision-making during RP.