Pretreatment MRI as a Prognostic Factor After Radical Prostatectomy

Importance: Accurate pretreatment prostate cancer risk assessment is essential to balance long-term treatment benefits and harm. Although some clinical and pathological parameters are established prognostic factors, the role of imaging parameters in prognostication is unclear. Objective: To assess the prognostic value of pretreatment magnetic resonance imaging (MRI) parameters for oncological outcomes in men undergoing radical prostatectomy. Data Sources and Study Selection: A systematic literature search of MEDLINE, Embase, and Scopus was performed from inception through March 2025. Studies were included if they evaluated pretreatment prostate MRI in men undergoing radical prostatectomy and reported multivariable, time-to-event analyses for the outcomes of biochemical recurrence, metastatic failure, and prostate cancer-specific mortality. Data Extraction and Synthesis: Two reviewers independently extracted data and assessed study quality using the Quality in Prognostic Studies tool. Random-effects meta-analysis was performed to pool hazard ratios (HRs). Main Outcomes and Measures: The primary outcome was biochemical recurrence. Secondary outcomes included metastatic failure and prostate cancer-specific mortality. Results: Forty studies were included (comprising 24 941 patients). Extraprostatic extension (mrT3a disease) detected with MRI was independently associated with biochemical recurrence (pooled HR, 2.16 [95% CI, 1.84-2.54]), metastatic failure (HR, 3.18 [95% CI, 2.04-4.97]), and prostate cancer-specific mortality (HR, 10.93 [95% CI, 5.05-23.65]). Seminal vesicle invasion (mrT3b disease) detected with MRI was also independently associated with biochemical recurrence (HR, 2.74 [95% CI, 2.06-3.65]) and metastatic failure (HR, 5.58 [95% CI, 1.15-27.13]). The following quantitative MRI features were prognostic for biochemical recurrence: Prostate Imaging Reporting and Data System score of 4 or 5 (HR, 2.15 [95% CI, 1.82-2.55]), large tumor size (tumor diameter ≥20 mm; HR, 2.35 [95% CI, 1.71-3.24]), and apparent diffusion coefficient values less than 0.9 × 10-3 mm2/s (HR, 2.39 [95% CI, 1.82-3.14]). Heterogeneity was moderate (I2 < 65% for mrT3a and mrT3b disease) and no significant publication bias was detected. Conclusions and Relevance: This systematic review and meta-analysis found that pretreatment MRI provides independent prognostic value for biochemical recurrence, metastatic failure, and prostate cancer-specific mortality in men undergoing radical prostatectomy, even when adjusted for established clinicopathologic factors.