Comprehensive Imaging in Prostate Cancer: A Focus on MRI and Micro-Ultrasound

Background: The diagnostic approach to prostate cancer (PCa) has evolved from sys-tematic biopsies to imaging-guided strategies that improve detection of clinically sig-nificant PCa (csPCa) while reducing overdiagnosis. Multiparametric MRI (mpMRI) has emerged as the gold standard for pre-biopsy evaluation, while micro-ultrasound (Mi-croUS) offers a promising alternative with real-time imaging capabilities. Objective: This review summarizes the evidence supporting mpMRI and MicroUS for PCa diagnosis, highlighting their respective advantages, limitations, and roles in optimizing diagnostic pathways. Methods: We examined the principles, image interpretation frameworks (PI-RADS and PRI-MUS), and clinical applications of mpMRI and MicroUS, comparing their diagnostic accuracy in biopsy-naïve patients, repeat biopsy scenarios, active sur-veillance, and staging. Results: mpMRI improves csPCa detection, reduces unnecessary biopsies, and enhances risk stratification. Landmark studies such as PRECISION and PRIME confirm its superiority over systematic biopsy. However, mpMRI remains re-source-intensive, with limitations in accessibility and interpretation variability. Con-versely, MicroUS, with its high-resolution real-time imaging, shows non-inferiority to mpMRI and potential advantages in MRI-ineligible patients. It improves lesion visual-ization and biopsy targeting, with ongoing trials such as OPTIMUM evaluating its standalone efficacy. Conclusions: mpMRI and MicroUS are complementary modalities in PCa diagnosis. While mpMRI remains the preferred imaging standard, MicroUS offers an alternative, particularly in patients with MRI contraindications. Combining these tech-niques could enhance diagnostic accuracy, reduce unnecessary interventions, and refine active surveillance strategies. Future research should focus on integrating both modalities into standardized diagnostic pathways for a more individualized approach.