Impact of PI-RADS During Active Surveillance for Prostate Cancer on Pathological Findings at Repeat Biopsy

Preoperative Magnetic Resonance Imaging Findings of the Transition Zone Predict Incidental Prostate Cancer in HoLEP

Background/Aim To assess the effectiveness of magnetic resonance imaging (MRI) of the transition zone (TZ) for predicting incidental prostate cancer (iPCa) detected after holmium laser enucleation of the prostate by comparing cases with and without iPCa. Patients and Methods We retrospectively evaluated 136 patients who underwent holmium laser enucleation for benign prostatic hyperplasia (BPH) between June 2022 and April 2025. After excluding seven patients with biopsy-confirmed prostate cancer, data from 114 patients were analyzed and divided into two groups: iPCa (n=17) and BPH (n=97). The preoperative and postoperative outcomes were compared. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of iPCa. MRI assessment focused exclusively on the TZ according to version 2.1 of the Prostate Imaging-Reporting and Data System (PI-RADS). Results MRI-TZ findings of a PI-RADS score of 3 or more were significantly more prevalent in the iPCa group than in the BPH group (64.7% vs. 16.5%, p<0.0001). Univariate analysis identified both positive MRI-TZ findings, a prostate-specific antigen (PSA) level greater than 6.2 ng/ml and TZ-adjusted PSA level greater than 0.18 ng/ml/ml as significant predictors of iPCa. However, multivariate logistic regression identified only positive MRI-TZ findings as an independent predictor of iPCa (odds ratio=8.96, 95% confidence interval=2.68-29.9; p=0.0004). No significant differences in postoperative urinary outcomes were observed between the two groups. Conclusion Preoperative positive MRI-TZ findings may predict iPCa in patients undergoing holmium laser prostate enucleation and potentially guide individualized perioperative risk stratification.

The role of magnetic resonance imaging in the active surveillance of prostate cancer: state of the art.

POURPOSE To provide an update on the role of multiparametric magnetic resonance imaging (mpMRI) in active surveillance (AS) of prostate cancer, with particular focus on standardizing image acquisition and reporting through PI-RADS v2.1, PI-QUAL v2, and PRECISE v2, as well as their clinical implications in risk stratification and follow-up. MATERIALS AND METHODS Narrative review of the literature and the most recent international guidelines on the use of mpMRI in patients undergoing AS. Selection criteria, follow-up protocols (12-24 months), imaging quality parameters (PI-QUAL v2), the longitudinal assessment system PRECISE v2, and the main radiological triggers for re-biopsy and multidisciplinary discussion were analyzed. RESULTS Baseline mpMRI improves candidate selection and reduces the risk of underestimating clinically significant disease. During follow-up, radiological progression shows a sensitivity of approximately 59% and specificity of approximately 75%, with a high negative predictive value (81-88%) but moderate positive predictive value. PRECISE v2 introduces updated categories, mandatory integration of image quality assessment, and systematic comparison with prior examinations, thereby improving reproducibility and comparability. CONCLUSIONS The standardized integration of mpMRI, PI-QUAL v2, and PRECISE v2 enables more structured patient monitoring and supports multidisciplinary decision-making. However, mpMRI does not replace scheduled biopsies. The implementation of radiomics and artificial intelligence may further enhance the objectivity and effectiveness of active surveillance.

Reducing the burden of active surveillance monitoring examinations in prostate cancer: Insights from real-world data to inform clinical practice.

A model using simple, routine parameters and PSA doubling time can identify those at minimal risk of reclassification, enabling a safe reduction in biopsy intensity, and advocates for a risk-adaptive AS protocol.

[Diagnostic performance analysis of targeted biopsy versus combined targeted and systematic biopsy in patients with PI-RADS 4-5 lesions].

Effect of MRI and site variation on surgical treatment for prostate cancer.

BACKGROUND Increased utilization of prostate magnetic resonance imaging (MRI) over the past decade may have led to a system shift in the patient population selected for radical prostatectomy (RP). We evaluated whether the initial use of MRI before biopsy resulted in the selection of lower-risk patients for RP. MATERIALS AND METHODS We evaluated patients undergoing RP in the Veterans Health Administration from 2014 to 2024. We compared patients receiving MRI-informed initial biopsy to those who had initial biopsy without MRI. For the primary analysis, multivariable mixed-effects ordinal regression evaluated whether prebiopsy MRI utilization was associated with stage or grade at RP. We secondarily evaluated rates of upgrading/downgrading at RP and rates of treatment for Grade Group (GG) 1 disease. RESULTS Adjusting for CaP risk factors, Veterans Health Administration site, and year of treatment, MRI-informed initial biopsy was associated with higher pathologic T stage (OR 1.12, 95% CI 1.01-1.26, P = 0.048) and GG (OR 1.13, 95% CI 1.02-1.25, P = 0.015) at RP. We observed no difference in downgrading between groups (difference: -0.8%, 95% CI -0.9% to 2.5%, P = 0.4). However, patients with MRI-informed initial biopsy had slightly lower rates of upgrading (difference: -4.2%, 95% CI, -5.6% to -2.8%, P < 0.001). The median frequency of GG1 on RP was 2.6% (IQR 1.4%-4.5%) and varied significantly by site (P < 0.001). CONCLUSIONS MRI utilization prior to biopsy was overall associated with higher T stage and grade at the time of prostatectomy. Overall decreased rates of upgrading at RP, however, may reflect greater biopsy concordance with use of MRI or the selection of higher-risk patients for multimodal or systemic therapies.

Association of PI-RADS Score with Clinically Significant Prostate Cancer and Histopathological Upgrading in Patients Undergoing Radical Prostatectomy: A Retrospective Single-Centre Study

Background and Objectives: Multiparametric magnetic resonance imaging (mpMRI) is widely used in prostate cancer diagnosis, but biopsy findings may still underestimate tumor aggressiveness. This study evaluated the association of Prostate Imaging Reporting and Data System (PI-RADS) assessment with clinically significant prostate cancer (csPCa) and histopathological upgrading after radical prostatectomy. Methods: The retrospective analysis comprised 564 patients who underwent mpMRI–transrectal ultrasound fusion-guided biopsy followed by radical prostatectomy between 2021 and 2025. All included patients subsequently underwent radical prostatectomy, so the cohort represents a surgically selected population. Clinical variables, PI-RADS score, biopsy ISUP Grade Group, and final prostatectomy pathology were assessed. Clinically significant disease was defined as ISUP Grade Group ≥ 2. Histopathological upgrading was defined as an increase of at least one ISUP Grade Group between biopsy and final prostatectomy pathology. Results: csPCa was found in 385 patients (68.3%). Patients with csPCa had higher prostate-specific antigen density (PSAD) values than those without csPCa. PI-RADS score was significantly associated with csPCa and remained independently associated with csPCa in multivariable analysis. Histopathological upgrading occurred in 164 patients (29.1%), and PI-RADS score was also independently associated with upgrading. Model discrimination was limited. Conclusions: Preoperative mpMRI with PI-RADS assessment was associated with both csPCa and biopsy underestimation. Although PI-RADS was independently associated with both outcomes, its modest discriminatory performance indicates that it should be interpreted together with other clinical and pathological parameters rather than as a standalone predictive tool.