MRI quality and csPCa confirmation in MRI-positive examinations

Prostate MRI quality may influence interpretation and cancer yield, but published studies use heterogeneous populations, thresholds, reference standards, and units of analysis. To synthesize evidence on the association between MRI image quality and histopathologically confirmed clinically significant prostate cancer (csPCa) among MRI-positive patients, lesions, or regions. PubMed was searched from inception through 22 March 2026 using a reproducible Boolean strategy, supplemented by backward reference screening. Eight studies met the eligibility criteria. The primary outcome was standardized as the proportion of MRI-positive units with csPCa confirmation, not overall diagnostic accuracy. Because the extractable comparative data comprised one patient-level, one region-level, and one lesion-level study, these statistically non-interchangeable units were not pooled. Risk of bias was evaluated with QUADAS-2, and findings were synthesized by unit of analysis. Eighteen records were screened, 12 underwent full-text assessment, and 8 were included. Among studies with extractable comparative counts, higher- versus lower-quality MRI was associated with csPCa confirmation of 48.0% versus 35.3% at the patient level (unadjusted RR 1.36, 95% CI 0.92–2.02), 56.1% versus 36.2% at the region level (descriptive unadjusted RR 1.55), and 45.4% versus 48.0% at the lesion level (descriptive unadjusted RR 0.95). Cluster-aware confidence intervals could not be derived for the region- or lesion-level estimates, and no pooled estimate was calculated. Across the wider evidence base, results were directionally inconsistent and affected by selection, verification, and applicability concerns. Available evidence does not establish that higher MRI quality improves overall PI-RADS diagnostic accuracy. Some studies suggest higher csPCa confirmation among MRI-positive units, but the evidence is sparse and heterogeneous and constitutes very-low certainty evidence. Prospective multicenter studies with unit-consistent reporting and complete 2 × 2 data are required. No protocol was prospectively registered. This is acknowledged as a limitation.