MRI Prostate – Generic Standard Protocol
Required Protocol at a Glance
Mandatory core sequences for this examination. Detailed rationale, conditional additions and optimisation notes are provided later in the protocol.
MRIninja Knowledge Base | Master / General Protocol Page Version 1.0 — May 2026
1. Executive Summary
Prostate MRI has undergone the most rapid and evidence-driven clinical transformation of any organ-specific MRI application in the past decade. The development and progressive refinement of the Prostate Imaging — Reporting and Data System (PI-RADS), from version 1 (2012) to version 2.1 (2019, the current standard) [1], has elevated multiparametric prostate MRI (mpMRI) from a specialist research tool to the primary imaging investigation in the prostate cancer detection pathway. In major European and North American guidelines, mpMRI before prostate biopsy is now mandatory or strongly recommended for all men with clinical suspicion of prostate cancer [2, 3].
The clinical and diagnostic stakes are high: prostate cancer is the most common non-cutaneous malignancy in men, yet the majority of prostate cancers detected on systematic biopsy are either clinically insignificant (Gleason Grade Group 1, GGG1) or low-grade (GGG2) and do not require immediate treatment. The fundamental value of prostate MRI is its ability to identify clinically significant prostate cancer (csPCa — defined as GGG ≥ 2, Gleason score ≥ 3+4=7) within the heterogeneous prostate glandular tissue, enabling targeted biopsy, informed active surveillance decisions, and pre-surgical staging — while simultaneously reducing unnecessary biopsies of clinically insignificant disease.
1.1 Core Strengths
Detection of clinically significant prostate cancer: mpMRI achieves pooled sensitivity for csPCa of approximately 0.89 (95% CI 0.87–0.91) and specificity of 0.73 (95% CI 0.69–0.76) across meta-analytic studies [4], substantially outperforming systematic biopsy in identifying index lesions. The landmark PRECISION trial demonstrated that an MRI-targeted biopsy pathway detected more csPCa and less clinically insignificant cancer than standard systematic biopsy [5].
Zonal anatomy characterisation: T2-weighted imaging provides exquisite soft tissue contrast for the prostate zonal anatomy — peripheral zone (PZ), transition zone (TZ), central zone (CZ), and anterior fibromuscular stroma (AFMS) — at a level of detail unachievable by any other modality.
Local staging: extracapsular extension (ECE), seminal vesicle invasion (SVI), and neurovascular bundle involvement are assessed on MRI and directly influence surgical approach (nerve-sparing decisions, surgical margins).
Active surveillance guidance: MRI guides re-biopsy decisions and monitors lesion stability in patients on active surveillance for low-grade prostate cancer.
Superiority over CT: CT cannot differentiate intraprostatic anatomy or small intraglandular lesions; it is used for pelvic lymph node assessment only. For the prostate itself, MRI is definitively superior.
Superiority over TRUS: transrectal ultrasound has low sensitivity and specificity for prostate cancer detection without MRI guidance; it is primarily used for systematic biopsy guidance and gland volume measurement.
1.2 Intrinsic Limitations of the Generic Protocol
The multiparametric prostate MRI protocol is among the most technically demanding clinical MRI examinations. Its limitations are not incidental but are structurally embedded in the current evidence base.
Reader dependence: prostate MRI interpretation has high inter-reader variability even among experienced radiologists. The same PI-RADS v2.1 criteria applied to identical images produce different scores across readers, particularly for PI-RADS 3 lesions (the most clinically relevant zone of uncertainty). The ESUR recommendations explicitly state that prostate MRI should be performed and interpreted by radiologists with specific training and minimum volume requirements [1].
biparametric vs. multiparametric debate: the role of dynamic contrast-enhanced (DCE) imaging — the "third parameter" — is under active reassessment. Recent high-quality evidence demonstrates that biparametric MRI (bpMRI: T2 + DWI without DCE) is non-inferior to mpMRI for csPCa detection in treatment-naïve patients [6, 7]. The practical and financial implications are significant, but current PI-RADS v2.1 maintains DCE as the standard protocol. For sequence-level protocol optimisation, vendor terminology and artefact management, see the dedicated MRIninja page Diffusion-Weighted Imaging (DWI) Sequence.
Field strength and coil dependence: 3T is preferred over 1.5T for prostate MRI [1]. The endorectal coil, once standard at 1.5T, is not recommended for routine use at 3T due to added patient discomfort, geometric distortion, and evidence that external multi-element phased array coils at 3T provide equivalent or superior image quality in most clinical scenarios.
Active surveillance limitation: MRI cannot reliably detect Gleason 3+3=6 (GGG1) disease, which is intentionally designed into the PI-RADS framework. This is a clinical feature, not a diagnostic failure — it reflects the deliberate focus on csPCa. However, it means that a negative MRI does not exclude all prostate cancer.
When dedicated child protocols are required: post-prostatectomy PSA recurrence assessment; radiation-treated or focal therapy-treated prostate; staging lymph node assessment; MR spectroscopy; recurrent disease workup. These require modifications beyond the scope of the generic protocol.
2. Main Clinical Indications
2.1 Standard Indications
Primary prostate cancer detection in biopsy-naïve patients with elevated PSA or abnormal DRE is the dominant indication for prostate MRI. The EAU Guidelines (2024) [2] and ESUR/ACR PI-RADS guidance [1] recommend MRI before any prostate biopsy. The PRECISION (2018) [5] and MRI-FIRST (2019) trials established that an MRI-first strategy detects more csPCa and fewer clinically insignificant cancers than systematic biopsy alone.
Active surveillance guidance for men with known GGG1 or GGG2 prostate cancer. MRI documents baseline lesion characteristics, detects index lesions for targeted re-biopsy, and monitors disease stability over time. The generic protocol is usually sufficient; follow-up imaging requires adherence to reproducible protocol parameters.
Pre-biopsy staging and lesion localisation when MRI-targeted biopsy is planned. MRI identifies the index lesion location within the 39-sector PI-RADS anatomical map, enabling cognitive fusion, ultrasound fusion, or in-bore MRI-guided biopsy. Localisation is a primary reporting requirement.
Local staging of known or suspected prostate cancer before radical prostatectomy or radiation therapy. The primary staging questions are extracapsular extension (ECE), seminal vesicle invasion (SVI), neurovascular bundle involvement, and bladder neck involvement. These determine surgical approach and eligibility for nerve-sparing procedures.
Biochemical recurrence after treatment — post-prostatectomy, post-radiation, post-focal therapy — is an indication where the generic protocol requires modification (see Section 3.3). The anatomy and expected findings differ substantially from the treatment-naïve prostate.
Evaluation of patients with prior negative systematic biopsy despite persistent elevated PSA or high clinical suspicion. MRI identifies lesions that systematic biopsy may have missed, particularly in the anterior transition zone.
2.2 Urgent Red Flags Requiring Expedited or Emergency Imaging
The prostate is not an organ where emergency MRI is commonly required. However, the following scenarios require clinical escalation:
| Red flag scenario | Recommended action |
|---|---|
| Rapidly rising PSA with new bone pain or neurological deficit | CT/bone scan or PSMA-PET for metastatic staging; MRI supplements but does not replace staging workup |
| Suspected cord compression from spinal metastatic disease | Urgent spine MRI; prostate MRI is not the priority |
| Acute urinary retention with suspected large obstructive transition zone mass | Ultrasound first for acute management; prostate MRI for planning when patient is stabilised |
| Post-biopsy infection with abscess formation | CT or ultrasound for acute abscess assessment; prostate MRI has a role in defining extent if clinically stable |
3. Preparation Reference
Universal MRI safety screening, contraindication assessment, and IV access documentation are covered in the general MRI preparation page and are not repeated here.
3.1 Anatomy-Specific Preparation Items
Bowel preparation is a specific requirement for prostate MRI, directly affecting image quality. Rectal gas and faecal material produce susceptibility artefacts on DWI and T2 images that degrade both the left and right peripheral zones adjacent to the rectal wall. PI-RADS v2.1 [1] and the ESUR prostate MRI guidelines recommend:
- Cleansing micro-enema 1–2 hours before the examination (approximately 60 mL rectal cleansing preparation)
- Alternatively, fleet enema the evening before and morning of the examination
- The specific preparation regimen is not mandated (no consensus on optimal agent) but rectal evacuation is strongly recommended
Failure to perform rectal preparation is one of the most common causes of degraded prostate DWI quality in routine clinical practice. The technologist should verify preparation before starting.
Antiperistaltic agents: intramuscular or intravenous antispasmodic agents (hyoscine butylbromide, glucagon) are widely used to reduce bowel motion artefacts, particularly on DWI and DCE sequences. Their use is associated with improved image quality, particularly for the peripheral zone. However, their routine use is centre-dependent and not mandated by PI-RADS v2.1. Contraindications (glaucoma, prostatic hypertrophy, cardiac arrhythmia for glucagon) must be assessed before administration.
Bladder filling: a partially filled bladder (not overdistended, not empty) provides a useful anatomical landmark for the bladder neck and base of the seminal vesicles. Overdistention causes patient discomfort and involuntary motion; complete emptying removes anatomical landmarks for the bladder neck interface. Instruct the patient to void 30–60 minutes before the examination and not to void again immediately before.
Ejaculation abstinence: 3–7 days of sexual abstinence before the examination is recommended by PI-RADS v2.1 [1] to optimise seminal vesicle fluid volume, which provides natural T2 contrast for seminal vesicle assessment. Ejaculation within 24–48 hours before imaging produces seminal vesicle depletion that can simulate seminal vesicle invasion by appearing as T2 hypointensity.
Prior therapy documentation: prior TRUS-guided biopsy produces haemorrhage in the peripheral zone (T1 hyperintensity, T2/DWI signal distortion) that can persist for 4–8 weeks and confound lesion detection. PI-RADS v2.1 recommends a minimum interval of 6 weeks between prostate biopsy and MRI. Post-radiation changes and post-focal therapy changes require the radiologist to be explicitly informed of prior treatment type, dose, and date.
Metallic implants: hip arthroplasty produces susceptibility artefacts that are more severe at 3T than 1.5T. For patients with hip prostheses, 1.5T imaging may provide better image quality for the peripheral zone adjacent to the prosthesis side. Metal artefact reduction sequences (MARS) can partially mitigate this.
3.2 Patient Positioning on the MRI System
Standard position: supine, feet-first entry. This is the universal standard for pelvic MRI. Head-first entry is used only for prostate in-bore MRI biopsy, where procedure guidance requires different gantry access.
Coil selection: a phased-array external surface coil (pelvic or cardiac coil; typically 8–32 channel) is the standard at 3T. The endorectal coil (ERC) was historically used at 1.5T to compensate for reduced SNR; at 3T with modern multi-element coils, the ERC is not recommended for routine clinical imaging because: (i) it produces geometric distortion of the peripheral zone adjacent to the rectal wall; (ii) it degrades DWI quality due to T2* effects; (iii) the additional discomfort reduces patient tolerance. PI-RADS v2.1 does not recommend ERC at 3T for routine mpMRI.
At 1.5T, an ERC combined with a pelvic phased-array coil may still be used to achieve adequate SNR when surface coil alone is insufficient, particularly for assessment of the posterior peripheral zone.
Centering: isocentre at the level of the prostate — approximated by the level of the superior pubic symphysis (visible on palpation) or at a point 2–3 cm superior to the pubic symphysis. Verify on the three-plane localiser that the entire prostate, seminal vesicles, and neurovascular bundle region are within the FOV.
FOV planning: the FOV for prostate sequences must include:
- Entire prostate gland (craniocaudal extent: from the bladder neck to the prostatic apex)
- Both seminal vesicles entirely (for SVI assessment)
- Neurovascular bundle regions bilaterally
- For staging sequences: pelvic lymph node regions (obturator fossa, external iliac chain)
Immobilisation: no specific immobilisation beyond standard comfort padding. Respiratory motion is not a significant issue for the prostate (pelvic location, relatively fixed position). However, bowel peristalsis and patient discomfort from a distended bladder or rectal preparation discomfort are the primary motion sources.
Common positioning errors:
- FOV too small: seminal vesicles not fully included; SVI cannot be assessed
- FOV centred too cranially: the prostatic apex (most common site of positive surgical margins) is excluded
- FOV centred too caudally: the bladder neck and base of seminal vesicles are excluded
4. Standard Protocol Design
The PI-RADS v2.1 standard mpMRI protocol specifies a minimum of four sequences: T1-weighted, T2-weighted (multiplanar), DWI with ADC map, and DCE [1]. The biparametric protocol (bpMRI) omits DCE and uses T2 + DWI only.
4.1 Mandatory Core Sequences
| # | Sequence | Plane | Status |
|---|---|---|---|
| 1 | T2-weighted TSE (high resolution) | Axial | Mandatory |
| 2 | T2-weighted TSE (high resolution) | Sagittal | Mandatory |
| 3 | T2-weighted TSE (high resolution) | Coronal | Mandatory |
| 4 | DWI (multiple b-values including b ≥ 1400 s/mm²) | Axial | Mandatory |
| 5 | ADC map (calculated from DWI) | Axial | Mandatory |
| 6 | T1-weighted (without fat suppression) | Axial (large FOV) | Mandatory |
| 7 | DCE (dynamic T1-FS post-contrast) | Axial | Mandatory in mpMRI; conditional in bpMRI |
4.2 Conditional Sequences
| Sequence | Indication | Plane |
|---|---|---|
| High-b-value DWI (b = 1400–2000, acquired) | Standard at 3T; complementary to calculated high-b | Axial |
| Calculated high-b DWI (b = 1500–2000) | Alternative when acquired high-b is not available; acceptable per PI-RADS v2.1 | Axial |
| Large FOV T2 coronal | Pelvic lymph node staging; pelvic bones | Coronal |
| T2 axial (large FOV) | Pelvic lymph nodes; bladder | Axial |
| Post-contrast T1-FS (late phase) | Staging; suspected extraprostatic extension enhancement; recurrent disease | Axial |
| PSMA-PET/MRI correlation | Metastatic staging; recurrence localisation — specialist setting only | Whole body |
4.3 Rationale Summary Per Sequence
Axial T2-weighted TSE is the anatomical cornerstone of prostate MRI and the dominant sequence for the transition zone under PI-RADS v2.1. It provides the zonal anatomy of the prostate, the critical landmarks of the prostate capsule, neurovascular bundles, seminal vesicles, and the bladder neck. In the peripheral zone, T2 is the background reference against which DWI-identified lesions are cross-referenced. In the transition zone, T2 is the dominant sequence: the PI-RADS TZ score is primarily T2-based, because DWI has lower specificity in the TZ (BPH nodules frequently show restricted diffusion).
The tissue contrast logic: the normal peripheral zone is T2-hyperintense (high free water content in glandular tissue). Prostate cancer in the PZ appears as a T2-hypointense lesion — because cancer replaces the normal glandular architecture with solid, cellular tissue of lower T2 signal. BPH nodules in the TZ appear as heterogeneous T2 signal (mixed glandular and stromal nodules). The anterior fibromuscular stroma (AFMS) and the central zone (CZ) are normally T2-hypointense.
Fat suppression is not applied to T2 sequences in the prostate because the periprostate fat is an important anatomical landmark for capsular assessment and ECE detection. Fat suppression would reduce the contrast between the capsule and the periprostate fat that is needed for ECE grading.
Sagittal and Coronal T2-weighted TSE: the sagittal plane is essential for visualising the apex-to-base extent of the prostate and the relationship of the seminal vesicles to the posterior prostate. The coronal plane provides the widest-field view of both seminal vesicles simultaneously, the NVBs, and the relationship of the prostate to the levator ani. PI-RADS v2.1 mandates axial T2 as the primary sequence and requires at least one additional orthogonal plane; both sagittal and coronal are recommended [1].
DWI / ADC map is the dominant sequence for the peripheral zone under PI-RADS v2.1. The DWI sequence samples the restriction of water molecular diffusion within tissue. Prostate cancer — particularly higher-grade cancer — shows markedly restricted diffusion due to high cellularity, high nuclear-to-cytoplasm ratio, and disrupted cell membrane integrity. This produces high signal on high-b-value images and low signal (reduced ADC values) on ADC maps.
The PI-RADS DWI protocol specification [1] requires:
- Minimum b-values: b=0 + b=800–1000 s/mm² (minimum for ADC calculation)
- Preferably: b=50–100 (for T2-shine-through separation) + b=800–1000 + b≥1400 s/mm²
- High-b-value DWI (b ≥ 1400): may be acquired or calculated from lower b-values; both are acceptable
The ADC map is the primary DWI-derived image for PI-RADS scoring. The qualitative ADC signal (markedly hypointense vs. moderately hypointense vs. non-hypointense) defines the PI-RADS DWI score 1–5 for the peripheral zone. Quantitative ADC values are not required by PI-RADS but are increasingly used as adjunctive metrics.
T1-weighted (large FOV, no fat suppression): the T1 sequence at prostate MRI has a specific and limited but essential role: detection of post-biopsy haemorrhage. Blood in the peripheral zone from prior TRUS-guided biopsy appears as T1 hyperintensity. If the T1 shows diffuse T1 hyperintensity in the peripheral zone, DWI and T2 findings must be interpreted with caution — haemorrhage produces T2 shortening (T2 hypointensity) and variable DWI signal that can simulate cancer. The T1 sequence allows the radiologist to identify haemorrhagic zones and document this as a confounding factor. The T1 sequence also detects T1-bright lesions (haemorrhagic cysts, calcifications which are T1-bright in some cases) that might otherwise confuse T2 and DWI interpretation.
DCE (Dynamic Contrast-Enhanced MRI): DCE uses a rapid intravenous gadolinium injection followed by a time-series T1-FS acquisition with temporal resolution ≤ 15 seconds per volume. Prostate cancer induces angiogenesis that produces early, rapid enhancement; the cancer-specific pattern is focal, early enhancement that appears at the same time as or earlier than adjacent normal prostatic tissue. Under PI-RADS v2.1, DCE has a minor role: it does not contribute to the overall PI-RADS score when DWI and T2 findings already assign a clear PI-RADS 1–2 or 4–5 category. However, when DWI is PI-RADS 3 in the peripheral zone, a positive DCE finding upgrades the lesion to PI-RADS 4 [1].
The clinical evidence for routine DCE in biopsy-naïve patients is being actively reassessed. Large-scale multicentre studies including the international observer study by Hamid et al. (2025) [6] have demonstrated that bpMRI (T2 + DWI without DCE) is non-inferior to mpMRI for csPCa detection, with AUROC 0.853 vs 0.859 respectively. This has renewed the debate about whether DCE adds sufficient value to justify the additional cost, time, and contrast administration.
4.4 Sequence Matching and Cross-Sequence Consistency
All prostate MRI sequences must use the same slice prescription: identical slice position, identical angulation, and identical slice thickness for all axial sequences. This is explicitly required by PI-RADS v2.1 [1] and is the single most common technical violation in real-world practice. If the DWI, T2, and DCE acquisitions use different slice locations, cross-referencing a lesion across sequences becomes unreliable, particularly for small (< 5 mm) lesions.
The slice angulation must be prescribed perpendicular to the prostate's rectoprostatic angle — typically a small axial obliquity of 5–15° from the true axial plane, aligned to the posterior surface of the prostate as seen on the sagittal localiser.
For serial follow-up studies (active surveillance), identical geometric parameters at each examination are required for reliable lesion size comparison and PI-RADS score comparison. The slice prescription angle must be documented and reproduced.
Post-contrast T1-FS subtraction (post minus pre) is not part of standard prostate DCE interpretation — the DCE assessment uses the time-series directly to identify early focal enhancement. However, in cases where T1-bright haemorrhage is present and post-contrast images are obtained, subtraction can help confirm genuine gadolinium enhancement.
4.5 Fat Suppression — Region-Specific Technical Considerations
Fat suppression strategy for prostate MRI is sequence-dependent and deliberately asymmetric:
T2-weighted sequences: fat suppression is not applied in prostate T2 imaging. The periprostate fat provides the T1/T2 contrast reference for capsular assessment and ECE grading. The thin capsular margin is identified precisely at the fat-prostate interface; fat suppression would eliminate this diagnostic landmark.
DWI: fat suppression is mandatory for EPI-based DWI to eliminate the fat signal that would be displaced by the chemical shift in the phase direction. Dixon fat suppression or spectral CHESS/SPAIR is applied to DWI at the prostate. This is standard for all EPI-DWI acquisition and does not require specific protocol notation. For sequence-level protocol optimisation, vendor terminology and artefact management, see the dedicated MRIninja page Echo Planar DWI (EPI-DWI / SE-EPI DWI) Sequence.
DCE (post-contrast T1): fat suppression is mandatory for DCE — identical principle to all other post-contrast T1 sequences. The enhancing prostate tissue must be distinguishable from adjacent fat. SPAIR or Dixon-based fat suppression is used for DCE. Standard axial T1-FS post-contrast.
T1 non-fat-suppressed (pre-contrast): fat is not suppressed on the T1 survey sequence because its purpose is to identify T1-bright haemorrhage against the background of normal prostatic tissue (T1 intermediate), not against fat.
4.6 Slice
Positioning — Complete Technical Reference
Technical reference — click to expand / collapse
Why Slice Positioning Matters in Prostate MRI
Prostate MRI slice positioning determines whether the prostate apex is included (the most common site of positive surgical margins), whether the seminal vesicles are fully covered (for SVI assessment), and whether all axial sequences are perfectly co-registered. PI-RADS v2.1 is explicit: all sequences must use the same angulation, location, and slice thickness [1]. Any deviation between sequences degrades the cross-sequence concordance that is the basis of multi-parametric PI-RADS scoring.
Anatomical Landmarks
Prostatic apex: the inferior termination of the prostate, adjacent to the external urethral sphincter. On the sagittal localiser, the apex is identified as the inferior tip of the glandular tissue below the verumontanum. The apex must be included in all sequences, as apical tumours are both common and frequently missed when the inferior coverage is insufficient.
Bladder neck: the superior margin of the prostate, where the urethral lumen transitions from the bladder to the prostatic urethra. Visible on sagittal T2 as the funnel-shaped superior prostatic opening.
Seminal vesicles: paired superior-posterior structures that are joined to the prostate at the base. The seminal vesicle tips must be included in the superior extent of coverage.
Rectoprostatic angle: the angle between the posterior prostate surface and the anterior rectal wall. The axial slices should be aligned parallel to the posterior prostatic surface rather than the true transverse body plane, to ensure symmetric visualisation of both neurovascular bundles.
Axial Slice Prescription
Reference: the sagittal T2-weighted image (from the localiser or from the first sagittal T2 acquisition).
Alignment: draw the prescription line perpendicular to the rectoprostatic angle — that is, parallel to the posterior surface of the prostate on the sagittal view. This typically requires a 5–15° tilt from the true axial. In a truly anatomical position this small obliquity ensures symmetric bilateral NVB assessment.
Coverage: from the prostatic apex (below the verumontanum on sagittal view) to 1–2 cm above the seminal vesicle tips. For a typical adult prostate, this is approximately 4–5 cm craniocaudal extent.
Phase encoding direction: for axial prostate sequences, A-P (anterior-posterior) is the standard phase direction. This displaces any motion artefacts from the anterior abdominal wall and bowel loops in the AP direction, away from the left and right peripheral zones. R-L phase encoding in the axial plane would propagate rectal gas and bowel motion artefacts directly through the peripheral zone.
A posterior saturation band should be placed over the rectum on axial DWI to suppress rectal gas and wall pulsation artefacts that propagate in the AP direction into the peripheral zone.
Sagittal Slice Prescription
Alignment: true sagittal, with the prescription line parallel to the midline of the prostate on the coronal or axial localiser. Coverage must include both seminal vesicles fully.
Phase encoding direction: S-I (superior-inferior) for sagittal prostate sequences.
Coronal Slice Prescription
Alignment: perpendicular to the sagittal plane; true coronal. Coverage must include both NVBs laterally and the full craniocaudal extent of the seminal vesicles superiorly.
Phase encoding direction: R-L for coronal prostate sequences.
Verification Before Scanning
On the three-plane localiser, confirm:
- Prostate apex included in inferior extent of axial coverage (below verumontanum on sagittal)
- Seminal vesicle tips included in superior extent (1–2 cm above tips)
- Bladder neck visible in superior coronal/sagittal images
- Both NVBs symmetrically visible on the axial images at mid-gland level
- Identical slice positions for T2 axial, DWI axial, and DCE axial (same scan plan)
ACR-ESUR-AdMeTech. PI-RADS Prostate Imaging — Reporting and Data System, Version 2.1. American College of Radiology; 2019. Available at acr.org/pirads. (High — Primary guideline) Specifies identical slice position/angulation/thickness requirement for all prostate MRI sequences; documents the phase encoding and antiperistaltic agent considerations.
Padhani AR, Barentsz J, Villeirs G, et al. PI-RADS Steering Committee: The PI-RADS Multiparametric MRI and MRI-directed Biopsy Pathway. Radiology. 2019;292(2):464–474. PMID: 31209175. DOI: 10.1148/radiol.2019190011. (High — Guideline companion paper) Documents the slice prescription methodology for prostate mpMRI within the PI-RADS v2.1 framework; the positioning figures in this paper define the rectoprostatic angle alignment.
5. Optimisation Strategy
5.1 Artifact Reduction by Source
Rectal gas and peristalsis artefacts are the dominant DWI artefact source in prostate MRI. Rectal gas produces susceptibility effects that distort the posterior peripheral zone (closest to the rectum) on EPI-based DWI and reduces ADC accuracy in the posterior PZ. These artefacts directly simulate or obscure lesions. Mitigation: bowel preparation (enema); posterior rectal saturation band on DWI; antiperistaltic agents; repeat DWI if artefact is visible over the posterior peripheral zone.
Patient motion: bladder filling changes and bowel peristalsis cause subtle position shifts between T2, DWI, and DCE acquisitions. Even 2–3 mm displacement reduces cross-sequence co-registration reliability. Mitigation: antiperistaltic agents; consistent bladder preparation; patient instruction.
EPI distortion on DWI: the echo-planar readout for DWI produces geometric distortion from B0 inhomogeneity, particularly near air-tissue interfaces (rectum-prostate posterior wall). The posterior peripheral zone is the region most affected. Modern distortion correction algorithms (based on B0 field maps or reverse-phase encoding) substantially reduce this distortion. The distortion correction should be applied as part of the standard DWI post-processing.
T2 shine-through on DWI high-b images: some benign prostatic structures with high T2 signal (normal PZ, seminal vesicles, urine in the urethra) maintain high signal on high-b DWI due to T2 shine-through rather than restricted diffusion. These structures appear bright on high-b DWI but should show high ADC (not restricted). Misinterpreting T2 shine-through as diffusion restriction is a common source of false-positive DWI scoring.
Susceptibility artefacts from hip prostheses: metallic hip prostheses produce T2* signal loss and geometric distortion that can extend into the peripheral zone, particularly ipsilateral. Mitigation: 1.5T field strength; MARS sequences (STIR, wide bandwidth); awareness that the affected peripheral zone cannot be reliably assessed. For sequence-level protocol optimisation, vendor terminology and artefact management, see the dedicated MRIninja page STIR Sequence.
Bowel motion artefacts on DCE: the time-series nature of DCE makes it particularly vulnerable to bowel motion — a single bowel movement during the 5-minute DCE acquisition produces misregistration between timepoints that makes focal enhancement assessment impossible in adjacent voxels. Antiperistaltic agents are most valuable for DCE quality.
5.2 Protocol Efficiency and Throughput
A full mpMRI protocol at 3T with DCE can be completed in 30–45 minutes total table time. A bpMRI protocol (T2 + DWI without DCE) reduces table time to approximately 20–30 minutes.
The efficiency argument for bpMRI — combined with the non-inferiority evidence [6, 7] — makes it the preferred approach in high-volume diagnostic prostate MRI settings, active surveillance programmes, and settings where contrast administration is not clinically justified.
mpMRI with DCE is retained as the standard when: (i) local staging with assessment of vascular invasion is required; (ii) post-treatment evaluation is the question; (iii) atypical or indeterminate DCE contribution to PI-RADS 3 lesion reclassification is clinically relevant; (iv) the patient has had prior negative biopsy in the setting of PI-RADS 3 DWI where DCE reclassification would change management.
5.3 Field Strength Considerations
3T is preferred for prostate MRI and is the standard at which PI-RADS v2.1 parameters are defined [1]. The SNR advantage at 3T translates directly into higher spatial resolution achievable within clinical acquisition times — critical for the sub-centimetre lesions that represent the most diagnostically challenging csPCa.
3T advantages: higher SNR for T2 and ADC; higher resolution achievable; better DWI performance for high-b-value imaging; faster DCE temporal resolution.
3T disadvantages: greater susceptibility artefacts in DWI from rectal gas; greater distortion in EPI sequences; higher SAR — limits flip angle for TSE sequences; more B1 inhomogeneity in the pelvis (B1+ field heterogeneity produces signal variation across the prostate cross-section).
1.5T: clinically adequate for prostate MRI with optimised parameters and is acceptable per PI-RADS v2.1 [1]. The key adaptation at 1.5T is that the lower SNR requires: (i) longer acquisition times for equivalent T2 resolution; (ii) potentially using ERC to boost SNR at the expense of geometric distortion (centre-dependent decision); (iii) slightly longer TE for T2 to maintain tissue contrast. Diagnostic accuracy at 1.5T with optimised protocol is similar to 3T in meta-analytic data, but 3T is preferred whenever available.
When 1.5T is preferred: patients with bilateral hip prostheses (less susceptibility at 1.5T); patients with MR-conditional implants rated at 1.5T only.
6. Contrast Use Principles Specific to Prostate MRI
6.1 Non-Contrast Standard Protocol — Sufficient For
The biparametric protocol (T2-weighted + DWI, no contrast) is sufficient for:
- Primary prostate cancer detection in biopsy-naïve patients — supported by high-quality non-inferiority evidence [6, 7]
- Active surveillance monitoring in patients with established GGG1 or GGG2 prostate cancer
- Serial follow-up where the question is lesion stability
- Patients with contraindications to gadolinium-based contrast agents (renal impairment, allergy)
- Paediatric prostate assessment (rare)
6.2 Gadolinium Indicated — Region-Specific Contexts
DCE as part of mpMRI is recommended or preferred for:
- PI-RADS 3 peripheral zone lesions on DWI — DCE positive finding upgrades to PI-RADS 4 [1]
- Pre-surgical local staging where vascular and capsular enhancement assessment is needed
- Post-treatment prostate assessment (post-prostatectomy bed, post-radiation, post-focal therapy) where DCE characterises residual or recurrent enhancing tissue
- Suspected inflammatory/infectious lesion (prostatitis, abscess) where enhancement pattern is diagnostically relevant
- Staging with concern for seminal vesicle invasion, where DCE provides additional enhancement characterisation
6.3 Post-Contrast Acquisition Timing
DCE temporal resolution must be ≤ 15 seconds per volume (PI-RADS v2.1 requirement [1]). This is essential for detecting the early focal enhancement that characterises cancer — enhancement occurring at the same time as or before adjacent normal prostatic tissue.
A total DCE acquisition duration of 2–5 minutes is standard, covering the arterial, portal, and early equilibrium phases. The early phase (0–60 seconds post-injection) is the most diagnostically relevant for cancer identification. The delayed phases (2–5 minutes) help characterise washout patterns.
Injection should be performed via power injector at 2–3 mL/s (standard dose 0.1 mmol/kg macrocyclic agent) followed by 20 mL saline flush. Pre-contrast T1-FS and the DCE time series must use identical sequence parameters and prescription for potential subtraction.
7. Reporting Essentials
7.1 Interpretation Framework
Prostate MRI interpretation follows the PI-RADS v2.1 framework [1], which is not simply a reporting system but the primary interpretive structure for the entire examination. The reporting radiologist must understand PI-RADS as an integrated multi-sequence algorithm, not a sequence-by-sequence scoring exercise.
Zonal anatomy first: assess the glandular zones systematically — PZ (both sides, apex to base), TZ (both sides, anterior TZ where cancer is uncommon but can occur), CZ (bilaterally symmetric T2 hypointense tissue), AFMS.
Dominant sequence by zone:
- Peripheral zone: DWI is dominant; T2 provides anatomical context
- Transition zone: T2 is dominant; DWI provides supplementary information
- DCE contributes only when PZ DWI is PI-RADS 3
Lesion identification and scoring: for each lesion detected, assign a PI-RADS category (1–5) based on the dominant sequence for the relevant zone, modified by DCE in the specific scenario where DWI-PZ is 3.
Staging assessment: after lesion scoring, systematically assess all staging elements: capsular integrity (smooth vs. irregular vs. bulging vs. definite ECE), NVB status, seminal vesicle involvement (unilateral vs. bilateral), bladder neck, and lymph nodes if within field of view.
PI-RADS sector map: all lesions must be localised to the 39-sector anatomical map for precise biopsy targeting. The standardised map divides the prostate into anterior-posterior, left-right, and base-mid-apex zones for each of the major anatomical compartments.
7.2 Mandatory Reporting Checklist
Overall examination quality:
- State field strength (3T or 1.5T)
- State protocol type (mpMRI or bpMRI)
- Document bowel preparation status
- Note any artefacts that limit assessment (rectal gas, hip prosthesis, motion)
Lesion inventory (repeat for each lesion, up to 4 per PI-RADS standard):
- Location (PI-RADS sector, zone, laterality, apex/mid/base level)
- Size (longest dimension)
- PI-RADS assessment category (1–5)
- Dominant sequence and score
- T2 findings
- DWI/ADC findings
- DCE findings (if performed)
Staging elements (for each positive lesion or when requested):
- Extracapsular extension: absent / equivocal (PI-RADS ECE score 0/1/2) / definite (PI-RADS ECE score 3)
- Seminal vesicle invasion: absent / unilateral / bilateral
- Neurovascular bundle status: preserved / contacted / invaded
- Bladder neck involvement: absent / present
Background prostate:
- Overall gland volume (mL), estimated from T2 axial
- BPH: absent / mild / moderate / severe
- Prostatitis changes if present
Pelvic nodes if in FOV: normal / suspicious
Prior biopsy changes: haemorrhage present/absent, extent, confounding effect
7.3 Structured Reporting
Reports must include: Indication (PSA value, DRE findings, prior biopsy history, clinical question); Technique (field strength, coil, sequences, contrast use and timing, bowel preparation); Comparison (prior MRI date, protocol, significant findings); Findings (per systematic checklist above); Impression (PI-RADS categories with sector locations, staging, and biopsy recommendation); Limitations (technical limitations, haemorrhage confound, unassessable regions).
The impression must explicitly state the PI-RADS category for each lesion and its anatomical location in PI-RADS sector terminology — not just qualitative descriptions.
7.4 Incidental Findings — Clinical Decision Framework
Usually benign: benign prostatic hyperplasia (BPH) nodules — document size and impact on urethra; simple prostatic cysts (midline/utricle cysts, ejaculatory duct cysts); seminal vesicle cysts; benign phleboliths.
May require clinical correlation: moderate-to-severe BPH with significant urethral deviation and suspected outlet obstruction — urology referral; incidental seminal vesicle signal abnormality in the absence of adjacent prostate lesion — document; incidental enlarged pelvic lymph nodes in a patient imaged for staging.
Require explicit communication: unexpected large lesion with features suggesting high PI-RADS category in a patient referred for a different question; unexpected seminal vesicle invasion in a patient thought to have localised disease; unexpected pelvic bone lesion suggesting metastasis.
8. MRI Technologist Pearls
8.1 Sequence Order Logic
Recommended acquisition order for standard prostate mpMRI:
- Three-plane localiser
- Sagittal T2 ← used for axial prescription planning; must be acquired first
- Axial T2 (high resolution) ← primary T2 sequence; patient is freshest; most diagnostically critical
- Coronal T2 ← after axial for bilateral SV assessment
- T1 axial large FOV ← pre-contrast; haemorrhage detection; no motion sensitivity concern
- DWI ← after T1; critical sequence; place before DCE to use remaining patient attention window
- DCE ← last; requires IV contrast; motion-sensitive time series
If bpMRI protocol (no DCE): omit step 7.
The sagittal T2 must always be first to enable correct axial prescription. The DWI should precede DCE because DWI is more motion-sensitive and benefits from being acquired when the patient is less fatigued.
8.2 Positioning Tricks
- After bowel preparation, give the patient 10 minutes to acclimatise before scanning — immediate post-enema imaging produces bowel spasm and motion.
- If antiperistaltic injection is given, begin DCE approximately 5 minutes after injection for maximum effect (onset time varies by agent: Buscopan 3–5 min IV; glucagon 1 min IV).
- For the posterior saturation band on DWI: position the saturation slab over the rectum only, not over the prostate — the saturation slab should be tight and posterior to the prostate posterior wall.
- For patients with hip prostheses: centre the FOV slightly anterior if the prosthesis side is producing susceptibility artefact; acquire DWI with wider bandwidth and shorter TE if artefact reaches the PZ.
8.3 Fast Salvage Protocol
| Priority | Sequence | Approx. time (3T) | What it covers |
|---|---|---|---|
| 1 | Axial T2 high-resolution | 4–5 min | Prostate anatomy, TZ lesions, staging |
| 2 | DWI (b = 0, 800, ≥ 1400) + ADC | 4–6 min | PZ lesion detection and PI-RADS scoring |
| 3 | Sagittal T2 | 3–4 min | Apex-to-base coverage, SV extent |
A bpMRI-equivalent protocol in approximately 12–15 minutes. T1 (for haemorrhage) and coronal T2 (for bilateral SV) are deferred. DCE is omitted.
8.4 Common Avoidable Errors
| Error | Consequence | Prevention |
|---|---|---|
| Different slice positions for T2 and DWI | Cross-sequence PI-RADS scoring unreliable; lesion cannot be confirmed on both sequences | Copy slice plan from T2 axial to DWI and DCE before scanning |
| Insufficient inferior coverage (apex excluded) | Apical cancer missed; most common site of positive margin in surgery | Extend inferior coverage 5 mm below the visible apex on sagittal localiser |
| Insufficient superior coverage (SV tips excluded) | SVI cannot be assessed; T staging incomplete | Include 1–2 cm above seminal vesicle tips in superior extent |
| DWI without posterior saturation band | Rectal gas artefact over posterior PZ | Always apply posterior rectal saturation band |
| Ejaculation within 48 hours not identified | Seminal vesicle T2 hypointensity simulates SVI | Confirm ejaculation abstinence at patient preparation; document in report if violated |
| Bowel preparation not performed | Rectal gas artefact degrades DWI over posterior PZ | Verify enema performed; reschedule if not |
| B0 distortion correction not applied to DWI | Geometric distortion of posterior PZ; ADC values inaccurate | Apply distortion correction in DWI post-processing |
9. Quality Control Checklist
10. Advanced Technical
Parameters
Technical supplement — click to expand / collapse
This section is intended for MRI technologists, protocol optimisation specialists, and advanced technical review.
10.1 T2-Weighted TSE (Axial High-Resolution)
Tissue Contrast Logic
T2-weighted TSE provides the highest soft tissue contrast for prostate zonal anatomy. Long TE (80–120 ms) produces T2 contrast: the peripheral zone (high free water content, glandular architecture) is T2-hyperintense. Prostate cancer replaces the glandular architecture with cellular infiltrate, reducing T2 signal — the fundamental contrast mechanism. BPH in the TZ produces heterogeneous signal (mixed glandular and stromal nodules with different T2 characteristics). The capsule, NVB fat, and seminal vesicle wall are all distinguishable based on T2 signal.
Key Parameters
| Parameter | 1.5T | 3T | Rationale |
|---|---|---|---|
| Sequence type | 2D TSE T2 | 2D TSE T2 | Standard |
| TR | 3000–5000 ms | 2500–5000 ms | Long TR for T2 weighting |
| TE | 100–120 ms | 80–120 ms | T2-dominant; longer TE at 1.5T compensates for lower T2 effect |
| ETL | 12–20 | 10–16 | |
| Slice thickness | 3 mm | 3 mm | No gap |
| Gap | 0 mm | 0 mm | |
| FOV | 160–200 mm | 150–180 mm | |
| Target in-plane resolution | ≤ 0.6 × 0.6 mm | ≤ 0.4 × 0.4 mm | PI-RADS minimum: ≤ 0.7 mm phase, ≤ 0.4 mm frequency |
| Fat suppression | None | None | Periprostate fat is a diagnostic landmark for ECE |
| Phase encoding | A-P | A-P | Bowel and motion artefacts displaced anteriorly |
PI-RADS v2.1 minimum resolution requirements [1]: frequency ≤ 0.4 mm, phase ≤ 0.7 mm, slice thickness 3 mm. These are minimums — not targets. At 3T, 0.3–0.4 mm isotropic in-plane at 3 mm is achievable and preferred.
Vendor equivalents: Siemens TSE T2; GE FSE T2; Philips TSE T2; Canon Fast SE T2.
Diagnostic Advantages
TZ lesion characterisation (dominant T2 role in PI-RADS); capsular integrity (ECE grading); SV morphology; gland volume; BPH nodule characterisation; NVB fat visualisation.
Limitations
PZ lesions without structural distortion (DWI is the dominant sequence for PZ); post-biopsy haemorrhage T2 hypointensity confounds PZ assessment; post-radiation T2 signal changes are non-specific.
10.2 DWI (Diffusion-Weighted Imaging)
Tissue Contrast Logic
DWI in the prostate exploits the restriction of water molecular diffusion within cellular cancer tissue. High-grade prostate cancer (high Gleason score) shows marked restriction — high signal on b ≥ 1400 images, low ADC values — because of high cellularity, disrupted gland architecture, and increased cell membrane density. The peripheral zone provides the optimal background for DWI because its normal high T2 signal (glandular water) produces high baseline DWI signal, against which cancer-related restriction stands out.
Key Parameters
| Parameter | 1.5T | 3T | Rationale |
|---|---|---|---|
| Sequence type | EPI-SE DWI | EPI-SE DWI | Standard EPI for prostate |
| b-values | 0, 800–1000, ≥ 1400 | 0, 50–100, 800–1000, ≥ 1400 | PI-RADS v2.1 minimum: b=0 + b=800/1000 + b≥1400 |
| High b-value | ≥ 1400 acquired or calculated | ≥ 1400 acquired or calculated | Suppresses T2 shine-through; improves cancer conspicuity |
| Slice thickness | 3–4 mm | 3 mm | Match T2 axial |
| Gap | 0 mm | 0 mm | Match T2 axial |
| FOV | 180–220 mm | 160–200 mm | |
| Target in-plane resolution | ≤ 2.5 × 2.5 mm | ≤ 2.0 × 2.0 mm | EPI SNR constraint; PI-RADS minimum FOV 120–220 mm |
| Fat suppression | CHESS/SPAIR/Dixon | CHESS/SPAIR/Dixon | Mandatory for EPI; fat chemical shift displacement in phase direction |
| Distortion correction | Apply | Apply | B0 field map-based correction |
| ADC calculation | From b=0 + b=800/1000 | From b=0 + b=800/1000 | Standard mono-exponential model |
Acquired vs. calculated high-b DWI: PI-RADS v2.1 states that high-b-value images may be acquired directly (at b ≥ 1400) or calculated by extrapolation from lower b-values. Acquired high-b provides the most reliable signal; calculated images may overestimate restriction in some scenarios. Both are acceptable; acquired high-b is preferred.
Vendor equivalents: Siemens ep2d_diff; GE DWI (GRE EPI); Philips EPI DWI; Canon EPI DWI.
Diagnostic Advantages
Dominant sequence for peripheral zone PI-RADS scoring; detects csPCa with high sensitivity at high b-values; ADC values provide quantitative correlation with Gleason grade (lower ADC → higher grade).
Limitations
EPI geometric distortion at the posterior PZ (rectum-prostate interface); T2 shine-through mimicking restricted diffusion; limited specificity in the transition zone (BPH shows restriction).
10.3 DCE (Dynamic Contrast-Enhanced MRI)
Tissue Contrast Logic
DCE exploits gadolinium-induced T1 shortening in tissues with increased vascular permeability. Prostate cancer induces angiogenesis — new, leaky vessels that allow rapid gadolinium extravasation. This produces early, focal enhancement that can be visualised as a time-intensity curve: rapid early rise (within 60 seconds of injection) followed by plateau or washout. The PI-RADS DCE "positive" criterion is qualitative: focal enhancement occurring earlier or contemporaneously with adjacent normal tissue, with defined T2 or DWI correlate [1].
| Parameter | 1.5T | 3T | Rationale |
|---|---|---|---|
| Sequence type | 3D T1-GRE FS | 3D T1-GRE FS | Fast spoiled GRE for temporal resolution |
| Temporal resolution | ≤ 15 s per volume | ≤ 15 s per volume | PI-RADS v2.1 mandatory requirement |
| TE/TR | TE < 5 ms / TR < 10 ms | TE < 5 ms / TR < 10 ms | Minimise TR for temporal resolution |
| Flip angle | 15–25° | 10–20° | T1-dominant; lower at 3T due to shorter T1 tissues |
| Slice thickness | 3–4 mm | 3 mm | Match T2 axial |
| Gap | 0 mm | 0 mm | |
| FOV | 160–200 mm | 150–180 mm | |
| Target in-plane resolution | ≤ 1.5 × 1.5 mm | ≤ 1.5 × 1.5 mm | Temporal resolution is the priority; spatial resolution is secondary |
| Fat suppression | SPAIR or Dixon | SPAIR or Dixon | Mandatory; prostate tissue vs. periprostate fat |
| Total duration | ≥ 2 min post-injection | ≥ 2 min post-injection | Captures early and plateau phases |
Vendor equivalents: Siemens VIBE; GE LAVA; Philips THRIVE; Canon 3D T1W.
[1] ACR-ESUR-AdMeTech Foundation. PI-RADS Prostate Imaging — Reporting and Data System, Version 2.1. American College of Radiology; 2019. Available at acr.org/pirads. (High — Primary protocol guideline) Defines all sequence minimum technical requirements for prostate mpMRI including T2, DWI, DCE parameters; the foundational protocol reference.
[8] Padhani AR, Barentsz J, Villeirs G, et al. PI-RADS Steering Committee: The PI-RADS Multiparametric MRI and MRI-directed Biopsy Pathway. Radiology. 2019;292(2):464–474. PMID: 31209175. DOI: 10.1148/radiol.2019190011. (High — Guideline companion) Documents acquisition parameter rationale and workflow context for PI-RADS v2.1 mpMRI.
[9] Tamada T, Kido A, Yamamoto A, et al. Comparison of Biparametric and Multiparametric MRI for Clinically Significant Prostate Cancer Detection with PI-RADS Version 2.1. J Magn Reson Imaging. 2021;53(1):283–291. PMID: 32939906. DOI: 10.1002/jmri.27317. (Moderate — Prospective study) Documents equivalent bpMRI vs mpMRI performance; provides parameter baseline comparison at 3T.
[10] Esses SJ, Taneja SS, Babb JS, et al. Imaging Facilities' Adherence to PI-RADS v2 Acquisition and Interpretation Guidelines: A Multicenter Study. Acad Radiol. 2018;25(5):594–601. PMID: 29153972. DOI: 10.1016/j.acra.2017.10.010. (Moderate — Multicentre survey) Documents real-world PI-RADS v2 compliance failure rates; identifies slice thickness, phase resolution, and DCE temporal resolution as most commonly violated parameters.
11. Evidence Gaps and Ongoing Debate
biparametric vs. multiparametric MRI: the non-inferiority of bpMRI (T2 + DWI) relative to mpMRI (T2 + DWI + DCE) for csPCa detection in biopsy-naïve patients has been established in large prospective international studies [6]. However, the subset of patients where DCE provides decisive additional information (PI-RADS 3 PZ lesions) and the role of DCE in post-treatment assessment remain incompletely characterised. Whether the current PI-RADS v2.1 standard should formally adopt bpMRI as the default primary protocol in treatment-naïve patients is actively debated.
Quantitative ADC thresholds: multiple studies have proposed quantitative ADC cutoffs for csPCa (commonly 0.90–1.0 × 10⁻³ mm²/s), but these values are scanner- and protocol-dependent and have not been validated across centres with sufficient consistency to be incorporated into PI-RADS. Standardisation of ADC measurement (including b-value choice, mono-exponential model, and reference region) is an active harmonisation effort.
AI-assisted PI-RADS scoring: deep learning models for automated lesion detection and PI-RADS classification have been developed and show AUC values approaching or matching experienced readers in controlled studies. Their clinical deployment — including regulatory approval, workflow integration, and performance in diverse patient populations — is at an early stage.
Endorectal coil at 1.5T: whether the ERC provides meaningful diagnostic benefit over external coils at optimised 1.5T remains debated. Most expert centres have moved away from ERC even at 1.5T.
Abbreviated protocol for active surveillance: the optimal MRI protocol for serial active surveillance monitoring (minimising contrast use, minimising acquisition time, maintaining diagnostic adequacy) has not been formally standardised.
MR spectroscopy: removed from PI-RADS v2 onward. The evidence that MRS adds diagnostic value over T2 + DWI + DCE is insufficient to justify its inclusion in the standard protocol. It remains a research tool.
12. Evidence-Based References
### A. Guidelines / Consensus / Society Recommendations
B. Systematic Reviews / Meta-analyses
C. Important Prospective / Original Studies
D. Technical MRI Papers
E. Landmark Historical References
End of document — MRI Prostate Generic Standard Protocol — MRIninja v1.0 — May 2026 This master page is the reference for all future prostate MRI child pages including: prostate cancer detection and PI-RADS scoring deep dive; local staging and ECE assessment; active surveillance protocol; post-prostatectomy assessment; post-radiation and post-focal therapy assessment; MRI-guided biopsy protocol.
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