Micro-ultrasound versus mpMRI for targeted prostate biopsy: A systematic review, meta-analysis, and clinical integration.

Abstract

Background: In the era of precision prostate cancer diagnostics, the role of emerging imaging modalities requires redefinition within integrated diagnostic pathways. Micro-ultrasound (mUS) has emerged as a potential alternative to multiparametric magnetic resonance imaging (mpMRI) for targeted prostate biopsy; however, comparative evidence remains methodologically heterogeneous.

Objectives: We aimed to re-evaluate the comparative detection performance of mUS versus mpMRI-targeted biopsy for clinically significant prostate cancer (csPCa), with particular attention to contemporary evidence and study design considerations.

Design: Systematic review with meta-analysis.

Data sources and methods: A systematic review of PubMed/MEDLINE, Web of Science, ScienceDirect, and the Cochrane databases was conducted up to February 28, 2026, in accordance with the PRISMA guidelines to identify studies comparing mUS- and mpMRI-targeted prostate biopsies. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. The primary outcome was the pooled detection ratio (DR) for csPCa, defined as the ratio of detection rates between mUS- and mpMRI-targeted biopsy.

Results: Fifteen studies comprising 2,512 patients were included. mUS-targeted biopsy detected csPCa in 654/2181 participants, compared to 691/2391 with mpMRI-targeted biopsy. The pooled DR for csPCa detection was 1.06 (95% CI 0.97-1.15; p=0.20), indicating no significant difference between modalities. Similarly, detection of clinically insignificant prostate cancer did not differ significantly (DR 0.89, 95% CI 0.72-1.10; p=0.28). Across studies, heterogeneity in design and potential within-patient correlations were identified as important contextual factors influencing interpretation. The inclusion of the OPTIMUM randomized trial provided complementary evidence from independently assigned diagnostic pathways, supporting the overall consistency of findings.

Conclusion: No statistically significant difference was observed between mUS-targeted and mpMRI-targeted biopsies in the detection of clinically significant prostate cancer. Beyond a binary comparison, these findings support a shift toward integrated diagnostic pathways in which mUS may serve as a complementary or alternative tool depending on the clinical context. Further prospective and methodologically robust studies are needed to refine its role in precision prostate cancer diagnostics.