The accuracy of multi-parametric MRI (mpMRI) in pre-operative staging of prostate cancer (PCa) remains controversial. Objective: To evaluate the ability of mpMRI to accurately predict PCa extra-prostatic extension (EPE) on a side-specific basis using a risk-stratified 5-point Likert scale. This study also aimed to assess the influence of mpMRI scan quality on diagnostic accuracy. Patients and Methods: We included 124 men who underwent robot-assisted RP (RARP) as part of the NeuroSAFE PROOF study at our centre. Three radiologists retrospectively reviewed mpMRI blinded to RP pathology and assigned a Likert score (1-5) for EPE on each side of the prostate. Each scan was also ascribed a Prostate Imaging Quality (PI-QUAL) score for assessing the quality of the mpMRI scan, where 1 represents poorest and 5 represents best diagnostic quality. Outcome measurements and statistical analyses: Diagnostic performance is presented for binary classification of EPE including 95% confidence intervals and area under the receiver operating characteristic curve (AUC). Results: A total of 231 lobes from 121 men (mean age 56.9 years) were evaluated. 39 men (32.2%), or 43 lobes (18.6%) had EPE. Likert score ≥3 had sensitivity (SE), specificity (SP), NPV, PPV of 90.4%, 52.3%, 96%, 29.9%, respectively, and AUC was 0.82 (95% CI: 0.77-0.86). AUC was 0.63 (95% CI: 0.37-0.9), 0.77 (0.71-0.84) and 0.92 (0.88-0.96) for biparametric scans, PI-QUAL 1-3 and PI-QUAL 4-5 scans, respectively. Conclusions: MRI can be used effectively by genitourinary radiologists to rule out EPE and help inform surgical planning for men undergoing RARP. EPE prediction was more reliable when the MRI scan was a) multi-parametric and b) of a higher image quality according to the PI-QUAL scoring system.

surveillance based on systematic biopsy alone. The objective of this study was to analyze characteristics of patients eligible for AS based on systematic biopsy, who later underwent radical prostatectomy and were found to have Gleason Grade (GG) !3 disease.METHODS: Patients were enrolled in a nationally registered clinical trial to evaluate the use of MRI-targeted combined biopsy (NCT00102544). We queried our institutional database for patients who underwent radical prostatectomy between June 2007 and July 2020. Patients with GG1 or GG2 on systematic biopsy were included. Upgrading was determined by comparing GG on systematic and targeted biopsies, to GG on wholemount prostate specimen. Logistic regression models adjusted for age, BMI, and total prostate volume were used to identify predictors of upgrading to GG !3 disease. Chisquared tests were used to compare categorical variables.RESULTS: A total of 773 patients who underwent radical prostatectomy between June 2007 and July 2020 were identified in our institutional database. Among patients who underwent combined biopsy (n [ 495), 280 were diagnosed with GG1 (n[03) or GG2 (n[177) on systematic biopsy. The rate of upgrading to GG ! 3 was significantly higher for systematic than targeted biopsy (20.0% vs 5.0%, p<0.0001). Increased age at time of surgery was associated with increased odds of upgrading to GG! 3 (OR: 1.13, 95% CI: 1.03e1.25, p[.014). Targeted biopsy GG was associated with increased odds of upgrading to GG !3 on wholemount pathology (OR: 2.91, 95% CI: 1.74-5.38, p<0.001). Total number of lesions found on MRI was associated with lower odds of upgrading (OR: 0.41, 95% CI: 0.21-0.70, p[0.003). PSA at time of surgery, BMI, highest PIRADS score on MRI, and total prostate volume on MRI were not associated with upgrading to GG ! 3 on wholemount pathology (p>0.05).CONCLUSIONS: Approximately 1 in 5 patients eligible for AS based on 12-core TRUS-systematic biopsy portion of combined biopsy have GG !3 on wholemount histopathology after radical prostatectomy. Older age, GG on MRI-targeted biopsy, and fewer total lesions on prebiopsy MRI are associated with upgrading to GG !3 on wholemount histopathology. Our findings support the use of MRI-targeted biopsy for risk-stratifying patients on AS.