Unmet needs and emerging solutions in MRI-guided prostate cancer care

Despite the advantages of MRI in prostate cancer diagnosis and intervention, access remains a key challenge in clinical practice. Recent data has suggested that fewer than half of men in the US receive an MRI prior to biopsy,¹ a gap that carries consequences for cancer detection rates, diagnostic timelines, and patient anxiety.

Against this backdrop, a new generation of technologies is working to close that divide. Advances in biparametric MRI are compressing scan times and reducing the need for IV contrast, and AI-assisted reading platforms are helping radiologists work faster and with greater consistency. Now, robotic systems like Glenn, an investigational MRI robotics platform designed to bring intuitive, precise needle guidance directly into the MRI suite, are pointing toward a future where in-bore procedures become more accessible, efficient, and clinician-friendly. Glenn is designed to overcome some of the challenges with traditional ultrasound guidance, offering potential advantages in both biopsy procedures and focal therapy.

To understand what these shifts mean in practice, Urology Times^® spoke with Preston C. Sprenkle, MD, urologic oncologist at Yale Cancer Center and associate professor at Yale University School of Medicine, about the unmet needs, emerging solutions, and longer-term vision shaping the field.

Urology Times: What are some of the most significant unmet needs in MRI-guided prostate cancer diagnosis and intervention today?

Sprenkle: I think the biggest barrier right now to MRI-guided interventions is access. Geoffrey Sonn[, MD,] and his group published a paper that showed that by 2022, only 35% of men in the US were getting an MRI prior to biopsy.¹ We're lagging behind other countries. In the UK, only 17% of institutions were not doing MRI before biopsy. So, the brief answer is access, which I think is the biggest challenge to MRI-guided diagnostics.

Urology Times: How do barriers such as MRI availability affect patient care and decision-making in prostate cancer management?

Sprenkle: It leads to a lot of men having a delay in getting an MRI, which is anxiety provoking. There are also many men who are getting an ultrasound-guided biopsy only, which we know is inferior in terms of cancer detection rate. We may miss cancer in some of these men, or some may require multiple biopsies to adequately detect their cancer. Even if cancer is detected on subsequent targeted biopsy or repeat biopsy, there can be a lot of upgrading. Overall, it adds to a lot of anxiety for men going through the process. It ends up being a longer diagnostic pathway, and men are having to have multiple biopsies sometimes unnecessarily.

It's been around for a while, but biparametric MRI is a potential solution. There was a randomized trial called PRIME [(NCT04571840)] that looked at biparametric MRI vs multiparametric MRI. With expert readers, there was a very similar clinically significant cancer detection rate.² The benefit of using a biparametric MRI is that the diagnostic scans can be done in 15 or 20 minutes vs 45 minutes to an hour [with multiparametric MRI]. It does not require IV contrast administration, so a radiologist does not need to be immediately present. This may mean that MRI could be done in ancillary centers. They do seem to have very similar, if not equivalent, diagnostic capability.

The other advance that is exciting is that there's a growing number of AI-based platforms to assist the radiologist in reading MRIs. These tools can enable the radiologist to read more quickly and detect lesions. Those are 2 things that are here and are being implemented to try to make it easier and faster for men to get MRI of the prostate.

Urology Times: Another challenge may be visualization. How much variability do you think fusion introduces into biopsy results, and how does that affect your downstream treatment decisions?

Sprenkle: That's a good question. We have some idea, but not a great idea about that. There is clearly some variability; most of the fusion biopsy devices will say there's a 1- to 4-mm variance in their targeting accuracy. Some of the lesions we biopsy now are pretty small—they're 4 or 5 mm—so if you have that much of a miss with your targeting, that can obviously be a problem. In clinical studies, we have not seen a statistically significant difference between, for example, an in-bore MRI-guided biopsy vs computer fusion system. The differences have not been statistically significant, but no one would argue that anything is more accurate than in-bore. The in-bore biopsies do have a higher accuracy per biopsy. We can't say that it clinically compromises cancer detection by doing fusion biopsy, but I think there is room for improvement.

We presented a [study on] inter-urologist variability at [the 2026 American Urological Association Annual Meeting]. We know that there is variability between radiologists in how they identify PIRADS 4 or 5 lesions, but we looked at variability among urologists who have the same radiologists. It's not statistically significant, but there is variability in how often cancers are detected in different PIRADS lesions based on user experience, etc.³

Right now, in-bore biopsy has been done primarily by interventional radiologists. There are not a lot of urologists doing in-bore biopsies. I think we may see a difference, potentially, if we're having people who do a lot of prostate biopsies start using enhanced imaging to do those biopsies. There's always the caveat that targeted biopsy alone, especially in the US, is not accepted as the standard of care. We are still relying heavily on a full template biopsy, a 12-core biopsy or 10-core, depending on if you're doing transperineal or transrectal, in addition to targeted biopsies, because about 10% of the time, there is outside of the lesion cancer detected. For that reason, I think we still have some room to grow with MRI imaging. We're still not detecting all the clinically significant cancer.

This gets into a whole other discussion about, is MRI invisible cancer clinically relevant? There are more studies looking at MRI visible disease vs MRI invisible, and it appears that some of the driver mutations and genomic and cellular characteristics of MRI visible disease are different and more aggressive than MRI invisible. Some people are starting to make the argument that even though we're detecting some technically clinically significant cancer out of field, away from where the visible lesions are, that cancer may not be bad cancer, and it may not matter if we detect that or not. That would be the argument of many of the Europeans who have only been doing targeted biopsies for about a decade now. They have stopped doing the 10-core or 12-core template biopsies.

Urology Times: Emerging platforms like Glenn aim to bring precision and improve visualization in the MRI suite. How does this technology work, and what clinical problems do you think this approach is best suited to solve?

Sprenkle: Glenn is a robotic platform that allows for targeting within the MRI for needle placement. This is helping to address or facilitate in-bore procedures for the prostate. Right now, as I mentioned, most prostate procedures in an MRI are done by interventional radiologists. Even though we're in the MRI, most patients are prone, and biopsies are done using general anesthesia. It's not comfortable, it's lengthy, and it's expensive in terms of time and cost for the patient and the physicians.

Having Glenn automate the needle positioning does a few different things. One, it makes the procedure significantly faster. It could also allow for transperineal biopsy vs transrectal, which is a major push around the world due to an apparent decreased risk of infection.

On the procedure side, needle placement for procedures in real-time could be a possibility. We do some in-bore therapies right now. These are primarily whole prostate therapies with ultrasound, but if we have a needle positioning system, that could allow for some of our other ablation technologies, such as laser, cryoablation, etc. with more precise needle positioning for treatments in MRI, with the advantage of MRI in-bore thermometry for thermal therapies and monitoring of treatment zone. That could be done with a 360 degree [range], which is new and different from how we do things with transrectal ultrasound guidance currently. We have increased fidelity and monitoring of our treatments with that type of approach.

Urology Times: How important is robotic assistance for improving trajectory alignment and targeting accuracy during prostate biopsy or focal therapy?

Sprenkle: For biopsy, it's very important. Needle location, trajectory, and tracking are key. We need to be very precise when we are doing our diagnosis. One of the benefits of MRI in-bore biopsy is being able to precisely adjust and monitor that trajectory and put our needle directly into where we want to go. Even when we're doing ultrasound fusion, we still are looking for the lesion on ultrasound to confirm that the fusion is correct. In this case, the fusion is not necessary, because you're looking at the lesion, so you know if your needle is there. That precision is very important for adequately and accurately determining what the cancer is that you're dealing with.

For ablation therapies, the accuracy is honestly not quite as important, because we are trying to treat with a margin. There is a benefit to knowing where you're putting your needle, but the benefits are more with the ability to track the lesions. Primarily that will be with software, but MRI gives us much more ability to monitor treatment than we have with ultrasound. I think there's a more dramatic future there, more so than just precision.

Urology Times: Looking ahead, what is your broader vision for MRI in prostate cancer care?

Sprenkle: The main limitation to MRI right now is access. Fusion is great, but if you don't need to do fusion, why add an extra step? If those things are relatively the same in terms of ease, it makes sense to remove a middleman. Microultrasound is trying to get rid of MRI and do everything with ultrasound, because it's so much easier to do the diagnosis and potentially do an intervention at the same time. However, MRI gives us a 360-degree full volume assessment of the entire prostate, which is something that no other imaging technology can do in the same way. If we can get better access to MRI, that then facilitates a higher throughput in diagnosis.

Screening [is also an important consideration]. The ReIMAGINE trial (NCT04063566) was an interesting glimpse at using biparametric MRI as a screening tool. This was done in the UK, and Caroline M. Moore, [MD, FRCS (Urol)], was the senior author. Men didn't have to have an elevated [prostate-specific antigen] PSA level. PSA is a great screening tool, but one of the reasons that PSA has been frowned upon is because of the false positives. If there was a confirmatory tool that was easy and cheap, like MRI or bioparametric MRI, we could rule out a lot of those false positives quickly and reduce some of the burden of overdetection associated with screening. The study demonstrated that there are a significant number of men who have prostate cancer with a "normal PSA." They had clinically significant cancer visualized and detected with MRI and then targeted biopsy.⁴

There are also some interesting interventional MRIs being developed. Siemens has the Freemax and now a Max XL, which are wide-bore MRI with a very low field strength. They don't require the same housing. They're cheaper, and they have things like MRI fluoroscopy, where you can do interventional procedures with real-time MRI guidance.

This is potentially a new wave. We’re not trying to replace radiologists. They still have their role, but I do think that urologists can be involved. We do a lot of ultrasound-guided therapies, and some urologists do CT-guided biopsies. With evolving MRI technology, there is a role for urologists to be doing diagnostic and therapeutic procedures under MRI guidance. As the technology evolves, I think we're going to see a lot more of that.

Urology Times: Is there anything else that you’d like to add?

Sprenkle: I'm also a pragmatist. I recognize that this is forward thinking and is not going to be available to everyone. As we get cheaper, more readily available MRI, we'll see much greater usage. It's taking some of the procedures out of the urology clinic, but it's more infrastructure related. We want the most accurate diagnostic tool, and right now MRI gives us functional and anatomic information, which is more than what we get from a bunch of other technologies individually.

REFERENCES
1. Soerensen SJC, Li S, Langston ME, et al. Trends in pre-biopsy MRI usage for prostate cancer detection, 2007-2022. Prostate Cancer Prostatic Dis. 2025;28(2):519-522.doi: 10.1038/s41391-024-00896-y

2. Ng ABCD, Asif A, Agarwal R, et al. Biparametric vs Multiparametric MRI for Prostate Cancer Diagnosis: The PRIME Diagnostic Clinical Trial. JAMA. 2025;334(13):1170-1179. doi:10.1001/jama.2025.13722

3. Barreto A, Zhang A, Sprenkle P. Variation in cancer detection across urologists performing MRI-targeted prostate biopsies using exactvu micro-ultrasound. J Urol. 2026;215(5S):e894. doi:10.1097/01.JU.0001191540.85098.f9.22

4. Thorley N, Parry T, Giganti F, et al. Diagnostic accuracy of abbreviated biparametric MRI for prostate cancer screening: a prospective feasibility study (ReIMAGINE study). Eur Radiol. 2026;36(3):1959-1970. doi:10.1007/s00330-025-11837-1