Refining biopsy strategies stratified by PI-RADS score in men: a systematic review and network meta-analysis

Prostate cancer is the second most common cancer in men globally. Advances in diagnostic techniques, particularly multiparametric magnetic resonance imaging and the Prostate Imaging Reporting and Data System, have enhanced detection precision. However, optimal biopsy strategies for lesions with Prostate Imaging Reporting and Data System scores of 3-5 remain uncertain. Here we show that saturation targeted biopsy and ipsilateral systematic biopsy combined with targeted biopsy achieve comparable detection rates of clinically significant prostate cancer to the combined systematic and targeted biopsy approach for Prostate Imaging Reporting and Data System 3-5 lesions, while reducing unnecessary biopsies. Targeted biopsy alone remains insufficient, and omitting systematic biopsy in Prostate Imaging Reporting and Data System 5 lesions is not supported. These findings support tailored biopsy strategies based on Prostate Imaging Reporting and Data System scores, optimizing resource allocation and minimizing overdiagnosis. Further validation in larger cohorts with standardized protocols is necessary.