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.