This study assessed the impact of PI-RADS upgrading rules on MRI-directed diagnostic pathways for prostate cancer. Analyzing data from 716 patients, it compared clinically significant prostate cancer (csPCa) detection rates between dominant and upgraded lesions and evaluated the net benefit of MRI-focused and risk-based biopsy strategies. Results showed that disregarding upgrading rules decreased the net clinical benefit of risk-based pathways, suggesting that adhering to PI-RADS upgrading rules is beneficial for optimizing biopsy selection and balancing csPCa detection with biopsy avoidance.
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