PI-QUAL in Clinical Practice: Rationale and a Step-by-Step Approach to Implementation

Prostate MRI has become integral to prostate cancer diagnosis and management, extending beyond prebiopsy triage to biopsy guidance, local staging, active surveillance, focal therapy planning, posttreatment surveillance, and evaluation of biochemical recurrence. As MRI use expands, image quality has emerged as a critical determinant of diagnostic reliability. Suboptimal prostate MRI quality can reduce cancer detection, increase equivocal PI-RADS assessments, compromise staging and longitudinal assessment, and undermine referring clinician confidence in MRI-directed care. The Prostate Imaging Quality System, or PI-QUAL, provides a standardized framework for assessing the diagnostic adequacy of prostate MRI examinations. Initially developed as a research quality-control tool using data from the multicenter PRECISION trial, PI-QUAL has been refined by the European Society of Urogenital Radiology into a more practical version applicable to both multiparametric and biparametric MRI examinations. In this Special Series Review, we describe the rationale for PI-QUAL, summarize evidence linking image quality with prostate MRI performance and patient management, and propose a stepwise approach for clinical implementation, including multidisciplinary training, retrospective audits, protocol optimization, structured reporting, quality dashboards, benchmark development, and artificial intelligence tools. Incorporating PI-QUAL into routine practice can make prostate MRI quality easier to measure, communicate, and improve.