In-bore MRI-guided prostate biopsy: current evidence, clinical applications, and future directions

Prostate cancer is the second most common malignancy in men and a leading cause of cancer-related mortality worldwide. Accurate diagnosis is essential to guide therapeutic decision-making and to avoid the overtreatment of indolent tumors. In-bore magnetic resonance imaging-guided prostate biopsy (IB-MRGB) represents the most precise magnetic resonance imaging (MRI)-targeted technique for detecting clinically significant prostate cancer (csPCa). This review summarizes the current evidence, technical aspects, clinical relevance, and future perspectives of IB-MRGB. A comprehensive literature review was performed using PubMed, Scopus, and Embase, including studies that evaluated diagnostic performance, procedural workflow, and integration with focal therapies. IB-MRGB demonstrates high sensitivity (80-96%) and specificity (82-90%) for the detection of csPCa. It is particularly effective in biopsy-naïve patients with Prostate Imaging Reporting and Data System (PI-RADS) ≥ 3 lesions, in men with prior negative transrectal ultrasound-guided biopsies but persistent clinical suspicion, and in the context of active surveillance or focal therapy planning. Key advantages include superior lesion targeting and a reduction in the overdiagnosis of Gleason 3 + 3 tumors, whereas the main limitations are higher cost, longer procedure duration, and limited MRI availability. IB-MRGB aligns closely with the principles of precision oncology by enabling accurate diagnosis, risk stratification, and optimized treatment planning. Ongoing developments in artificial intelligence, radiomics, and MRI-guided interventions are expected to further enhance diagnostic efficiency and expand the clinical role of this technique.