Diagnostic Performance of Biparametric versus Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis: An Updated Systematic Review and Meta-analysis.

[BACKGROUND AND OBJECTIVE] Multiparametric magnetic resonance imaging (mpMRI) is the reference modality for detecting clinically significant prostate cancer (csPC). Biparametric MRI (bpMRI), which omits contrast, has emerged as a streamlined alternative. Recent studies have demonstrated the noninferiority of bpMRI to mpMRI for csPC detection in biopsy-naïve men. We performed an updated systematic review and meta-analysis of head-to-head studies comparing bpMRI and mpMRI for csPC detection, and conducted a noninferiority analysis.

[METHODS] Literature databases were searched up to September 2025 for head-to-head studies. Eligible studies enrolled men with suspected PC and used biopsy or prostatectomy as the reference standard. The primary outcome was diagnostic accuracy for csPC at per-patient and per-lesion levels; detection of any PC was a secondary outcome. Noninferiority was assessed using a margin of -5% applied to paired absolute differences (bpMRI - mpMRI) in sensitivity and specificity via a random-effects model.

[KEY FINDINGS AND LIMITATIONS] A total of 40 studies (9403 patients) were analyzed. For csPC, the paired absolute differences were -2.3% (95% confidence interval [CI] -4.1% to -0.5%) for sensitivity, and +1.8% (95% CI -0.4% to +4.0%) for specificity, which confirm noninferiority at the patient level. At the lesion level, bpMRI was noninferior for specificity but not sensitivity, probably because of fewer studies and greater heterogeneity.

[CONCLUSIONS AND CLINICAL IMPLICATIONS] bpMRI is noninferior to mpMRI for csPC detection at the patient level. At the per-lesion level, noninferiority was demonstrated for specificity but not for sensitivity. Broader implementation should occur in settings with assured image quality, and further work is needed to define minimum quality-control standards required for adoption.