European Society of Urogenital Radiology (ESUR) perspectives on the role of prostate MRI in active surveillance.

MRI has a central role in the diagnosis and management of prostate cancer, including active surveillance (AS) of low- and favourable intermediate-risk cancer. Robust evidence supports its use to guide biopsies and stratify the risk of progression at the inclusion stage. The Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) criteria provide the foundation for standardised assessment on serial imaging during AS. Despite potential reductions in the number of unnecessary follow-up biopsies, uncertainty about the degree to which follow-up strategies can be defined by MRI leads to variation in international guidelines and their implementation. Here, the European Society of Urogenital Radiology (ESUR)-Prostate MRI Working Group reviews the evidence for the use of MRI in AS and provides practical guidance on its use. Additional research is needed to personalise AS strategies by integrating patient-specific factors, including family history and ethnicity, as well as emerging biomarkers such as genomic profiling and technological innovations like artificial intelligence. CRITICAL RELEVANCE STATEMENT: MRI is an integral part of AS, and initiatives to standardise image acquisition and reporting are underway. Further research is needed to better define MRI's role during follow-up and to personalise AS, which could help achieve better harmonisation among international guidelines. The European Society of Urogenital Radiology (ESUR) prostate working group provides suggestions for practical implementation. Active surveillance is a safe and effective management strategy for indolent prostate cancer. It avoids complications associated with surgery and radiation treatment. MRI has a central role in selecting which patients will benefit most from active surveillance and helping choose the most appropriate follow-up strategy. Acquiring standardised images and using reporting systems like PRECISE improves prostate cancer assessment and may help reduce the number of unnecessary biopsies. KEY POINTS: MRI plays a central role during active surveillance, but its implementation varies widely across centres. This ESUR position statement offers practical guidance on MRI acquisition, reporting, and interpretation tailored to active surveillance. Use of MRI-including the PRECISE score for active surveillance and the PI-QUAL score for image quality-can improve consistency and accuracy in monitoring prostate cancer over time.