Impact of MRI quality on the accuracy of targeted prostate biopsy: A prospective PI-QUAL analysis.

BACKGROUND AND OBJECTIVES: Multiparametric MRI (mpMRI) has improved the detection of clinically significant prostate cancer (csPCa). However, the diagnostic utility of mpMRI is heavily dependent on image quality, which is often inconsistent across clinical settings. We investigated the association between mpMRI quality, assessed via the Prostate Imaging Quality (PI-QUAL) score, and the accuracy of MRI-targeted biopsies (TBx) compared to systematic biopsies (SBx). METHODS: In this prospective study of 124 patients, image quality was evaluated for T2-weighted (T2W), diffusion-weighted, and dynamic contrast-enhanced (DCE) sequences using PI-QUAL v2. A biopsy "miss" was defined as a case where SBx detected a higher Gleason grade group than TBx. Statistical analyses, including Mann-Whitney U tests and multivariate logistic regression, were employed to identify predictors of TBx failure. RESULTS: A total of 15 patients (12.1%) had a TBx "miss." Univariate analysis revealed that suboptimal T2W (p = 0.003) and DCE (p = 0.015) quality were significantly associated with biopsy failure. In a multivariate model, T2W quality remained a clinically potent predictor of inaccuracy (Odds ratio: 12.1, 95% confidence interval: 0.9-164.7, p = 0.06). CONCLUSION: Suboptimal MRI quality, particularly the T2W sequence, is a primary driver of TBx failure. When faced with low PI-QUAL scores, clinicians should remain aware that MRI is less likely to improve detection of cancer compared to SBx. Ideally, low PI-QUAL score MRIs should be repeated to optimize the detection of csPCa.