The PROMIS and PRECISION trials have redefined prostate cancer diagnostics by advocating for pre-biopsy multiparametric MRI (mpMRI), interpreted using the Prostate Imaging Reporting and Data System (PI-RADS), to guide biopsy decisions. These studies support omitting biopsy in patients with negative MRI (PI-RADS ≤2), thereby reducing unnecessary procedures. This audit evaluated the diagnostic performance of PI-RADS scoring in patients undergoing either transperineal biopsy (TPB) or transrectal ultrasound-guided biopsy (TRUS).

Patients with prior prostate cancer treatment were excluded. Data collected included age, PSA, PI-RADS score, and histological outcomes. Cancer was classified as benign, clinically insignificant (Gleason 3+3), or clinically significant (Gleason >3+3). Diagnostic accuracy was assessed via sensitivity, specificity, and positive/negative predictive values (PPV/NPV).

A total of 51 patients were included: 47 underwent TPB and 14 TRUS. Clinically significant cancer detection rates for PI-RADS 3, 4, and 5 were 23%, 36.4%, and 52.9%, respectively. Sensitivity for detecting clinically significant cancer in PI-RADS ≥4 was 92.9% (95% CI 66.1–99.8) in the TPB group and 90.0% (95% CI 55.5–99.8) in the TRUS group. Specificity was 21.1% (TPB) and 25.0% (TRUS). PPV and NPV were 46.4% and 80.0% (TPB), and 80.0% and 50.0% (TRUS).

PI-RADS scoring correlates with cancer significance, supporting an MRI-first approach. However, diagnostic variability highlights the ongoing need to refine imaging interpretation and biopsy strategy. Exclusively relying on mpMRI over clinical examination to determine need for biopsy could result in patients with significant prostate cancer going undetected. Further robust studies are needed to determine the optimal method of diagnostics for prostate cancer.