The findings arrive at a moment when the clinical rationale for prebiopsy imaging has never been stronger. Multiple randomized trials have demonstrated that imaging the prostate before obtaining tissue, and then using those images to target suspicious lesions, detects more of the clinically significant, aggressive cancers that genuinely threaten a patient’s life, while reducing the detection of indolent tumors that might otherwise trigger unnecessary treatment. This evidence base has prompted professional guidelines to progressively strengthen their endorsement of MRI as a standard step before needles are placed. What had remained unknown until now, however, was whether that accumulating evidence had actually changed what happens in hospitals and clinics across the country.

To answer that question, the research team, including lead clinical research biostatistician Stephen Rhodes of the UH Urology Institute, turned to Epic Cosmos, a large-scale database built from electronic health records spanning many health systems nationwide. Unlike earlier studies that relied on insurance claims data, which often lag behind real-world practice and miss patients whose care crosses different payers, the electronic health record approach captures what actually happened to individual patients at the point of care. The scale of the dataset, encompassing more than half a million biopsies over nearly a decade, allowed the researchers to track utilization trends with unusual granularity, including how patterns differed by whether a man was undergoing his first biopsy or a repeat procedure after a previously negative result.

The trajectory was striking in both groups, but for slightly different reasons. Among men with a prior negative biopsy, where the evidence supporting MRI was established earliest and where the procedure has long been recommended to help explain persistent elevations in prostate-specific antigen, MRI use rose from 38 percent in 2017 to 67 percent by the first half of 2026. Among biopsy-naive men, the increase was even more dramatic in relative terms, nearly a fivefold rise over the study period. Rhodes described the pace of change as genuinely rapid, noting that the timing tracks closely with the publication of the major randomized trials and their successive adoption into clinical guidelines. In an era when many evidence-based practices take fifteen to twenty years to diffuse into routine care, a near-complete transformation of biopsy practice within less than a decade represents an unusually swift example of evidence translation.

Yet the study’s authors are careful to emphasize that the story is one of substantial progress coexisting with persistent gaps. A full third of men undergoing a first prostate biopsy are still not receiving an MRI beforehand, which means the procedure is being performed, in effect, blind. That matters because the decision to image first changes two things simultaneously: whether a biopsy is needed at all, and, if it is, exactly where the needles should go. A man whose MRI shows no suspicious lesions may be spared the procedure entirely, avoiding the discomfort, bleeding risk, infection risk, and potential overdiagnosis that accompany blind sampling. A man whose scan reveals a concerning lesion can undergo targeted biopsies that are far more likely to find an aggressive cancer if one is present. Skipping the scan forfeits both benefits at once.

The senior author of the study, Jonathan Shoag, MD, Chief of the Division of Urologic Oncology and Director of the Prostate Cancer Program at University Hospitals, framed the problem in terms of quality measurement and equity. He noted that the true scope of the shortfall had been difficult to pin down before this analysis, with the best prior data, derived from insurance claims through 2022, suggesting MRI was used in only about 30 percent of biopsies. The motivation for the new study, he explained, was to establish a current, national picture: how many men are getting an MRI before biopsy today, and whether everyone is benefiting equally. Shoag said he still regularly sees patients who were biopsied at other institutions without a preceding MRI, and he attributes part of the persistent gap to access barriers and issues with insurance coverage, a well-recognized national problem that the new data now illuminate more clearly.

The analysis also surfaced patterns that the researchers found worth examining rather than simply accepting. MRI use fell off in two specific groups: men with very high PSA levels and men over the age of 80. In some cases, the authors suggest, this may reflect reasonable clinical judgment, since a markedly elevated PSA in an older patient may prompt an urgent diagnostic pathway in which imaging is perceived as a delay, and life expectancy considerations may alter the calculus for men in their ninth decade. But the researchers caution that these patterns deserve scrutiny rather than assumption. If otherwise appropriate candidates for imaging are being sent directly to biopsy out of habit, expedience, or lack of access, a measurable quality gap exists that health systems can and should audit. The study’s practical message for institutions is direct: track your own MRI rates by patient group, compare them against the evidence, and act on what the audit reveals.

Even where MRI is used, quality is not uniform, and the authors flag this as an ongoing concern for the field. Prostate MRI is a technically demanding examination that depends on scanner capability, protocol design, radiologist expertise, and structured reporting standards. A poor-quality scan can miss a clinically significant lesion, giving false reassurance, or overcall suspicious findings, triggering unnecessary biopsies. Shoag described how University Hospitals has invested in rigorously tracking MRI quality and performance and how it relates to biopsy outcomes, establishing workflows that give patients access to the latest imaging and biopsy techniques, including the transperineal approach, which carries a lower infection risk than the traditional transrectal route. He noted that the institution participated in the clinical trials that established these techniques as standards and has built a program to offer targeted biopsy with sedation to all patients, while also being an early adopter that made MRI accessible across its patient population.

Beyond the numbers, the study highlights how the diagnostic journey itself is being restructured around advanced imaging. Shoag described a coordinated model in which patients with elevated PSA levels are navigated through evaluation and decision-making, supported by a point-of-service scheduling initiative that books imaging and follow-up appointments before patients leave the office. The goal is to compress the interval between an abnormal screening result and a definitive answer, reducing the anxiety and drop-off that can occur when patients must coordinate multiple appointments across weeks. The institution is currently involved in multiple studies testing new tools to further improve prostate cancer diagnosis, suggesting that the rapid diffusion documented in this paper may be followed by another wave of refinements in how men are evaluated for the disease.

For patients, the study’s most actionable conclusion may be the simplest: any man facing a prostate biopsy should be asking whether an MRI beforehand is appropriate for him. For clinicians and health systems, the paper provides both a benchmark and a warning, documenting extraordinary progress in translating randomized trial evidence into practice while quantifying the gap that remains. With two thirds of men now imaged before their first biopsy and more than two thirds before repeat procedures, prebiopsy MRI has decisively entered the mainstream of American prostate cancer care. The remaining task, the authors suggest, is to close the residual gaps in access, coverage, and quality so that the benefits of targeted, image-guided diagnosis extend to every patient who stands to gain from them, rather than to a fortunate majority.

Subject of Research: National trends in prebiopsy MRI utilization for prostate cancer detection in the United States

Article Title: University Hospitals researchers find major increase in the use of MRI before prostate biopsy

Article References: University Hospitals researchers find major increase in the use of MRI before prostate biopsy. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: prostate cancer, prebiopsy MRI, prostate biopsy, JAMA Oncology, University Hospitals, mpMRI imaging, targeted biopsy, transperineal biopsy, PSA screening, clinical guidelines, healthcare quality, Epic Cosmos

The research, led by Belarmino Gonçalves of the Portuguese Oncology Institute of Porto and Thiago Franchi Nunes of Interventix in Campo Grande, Brazil, brought together ten tertiary referral centers across South America and Europe. Between January 2018 and July 2025, the investigators analyzed 68 diagnostic percutaneous transhepatic cholangioscopy, or PTCS, procedures performed in patients whose cross-sectional imaging and prior endoscopic evaluation had been nondiagnostic, or whose anatomy made standard endoscopic access impossible. Crucially, cases performed primarily to treat gallstones were excluded, isolating a cohort in which the sole purpose of the camera voyage into the ducts was to determine whether cancer was present.

The technique itself is a remarkable feat of interventional radiology. Using ultrasound and fluoroscopic guidance, physicians thread a needle through the liver into the bile ducts and establish a percutaneous tract, typically secured with a 10 to 12 French introducer sheath. Through that sheath, flexible cholangioscopes, single-operator platforms, or single-use ultra-slim endoscopes measuring roughly 2.8 to 3.5 millimeters in outer diameter are advanced directly into the biliary tree. Saline irrigation clears the field, allowing the operator to inspect the duct lining in real time — something computed tomography and magnetic resonance cholangiopancreatography fundamentally cannot do, since they offer only indirect views of the biliary mucosa. Some centers perform the cholangioscopic inspection in the same session when tract and sheath conditions permit; others prefer a staged approach roughly 48 to 72 hours later to allow decompression and reduce infection risk in patients with cholangitis or complex anatomy.

During each procedure, operators recorded two kinds of optical judgments before any tissue results were known. The first was a global impression — a binary real-time call of benign versus malignant that integrated everything seen during the examination. The second was a checklist of five predefined visual criteria: tumor vessels appearing as tortuous neovessels, hypervascular mucosa, nodular or polypoid masses, papillary projections, and infiltrative lesions marked by irregular mucosa and loss of normal duct architecture. When recorded images or videos were available, blinded investigators independently reviewed the material against the checklist, with disagreements resolved by consensus, adding a layer of methodological rigor to what has historically been a subjective art.

The results against the gold standard of histopathology were striking. Malignancy was ultimately confirmed in 57 of the 68 procedures, reflecting the referral-enriched, high-risk nature of the population. Against that benchmark, the operator’s global impression achieved 84.2 percent sensitivity, 90.9 percent specificity, and 85.3 percent accuracy. Most notable was the positive predictive value of 98.0 percent: when an experienced operator called a lesion malignant on direct visualization, that call was almost always right. The negative predictive value of 52.6 percent, by contrast, shows that a benign-appearing duct cannot safely rule out cancer — tissue sampling remains essential. The authors caution that these predictive values must be interpreted in light of the unusually high cancer prevalence in this cohort.

Among the individual visual criteria, two emerged as the most trustworthy warning signs. An infiltrative appearance showed 90.9 percent specificity and was strongly associated with malignant histopathology, carrying an odds ratio of 13.75 and a positive predictive value of 97.1 percent. Tumor vessels were also significantly linked to cancer, with an odds ratio of 4.57. Hypervascular mucosa, by comparison, offered little discriminatory power. The researchers then explored combined decision rules: using the permissive rule of tumor vessels or infiltrative appearance raised sensitivity to 84.2 percent at moderate specificity, while the restrictive rule requiring both features achieved 100 percent specificity — a powerful rule-in finding when tissue is scarce — albeit with sensitivity dropping to 36.8 percent. These PTCS-specific heuristics remain hypothesis-generating and await prospective validation.

Safety data were equally informative. Adverse events occurred in 10 of 68 procedures, or 14.7 percent, graded using the modified CIRSE classification system. Two events were grade I, five were grade II, and three were grade IV — the latter all infectious complications requiring intensive care-level support such as vasopressors or ventilation, rather than mechanical injury from the instruments themselves. The predominance of low-grade complications underscores the importance of standardized antibiotic prophylaxis, careful biliary decompression, controlled irrigation strategies, and structured post-procedure monitoring for anyone undergoing antegrade cholangioscopy.

The study’s context matters. In patients with surgically altered anatomy — bilioenteric anastomoses or Roux-en-Y reconstructions accounted for nearly a third of the cohort — conventional endoscopic retrograde cholangiopancreatography is often impossible or has already failed. Traditional blind or fluoroscopy-guided biopsies perform poorly for infiltrative, flat, or submucosal tumors, frequently returning nondiagnostic or discordant samples. Prior meta-analyses have shown that cholangioscopy-guided targeted biopsy outperforms fluoroscopy-guided sampling for indeterminate strictures, and consensus guidelines now frame cholangioscopy as a problem-solving tool. What has been missing, the authors argue, is multicenter real-world evidence about how the percutaneous, antegrade version of the technique performs across diverse devices, operators, and health systems — a gap this Brazil-and-Europe network directly addresses.

The investigators are candid about the limitations. The retrospective design limits control of confounding and standardization, and partial verification bias is possible. The high prevalence of malignancy limits generalizability to lower-risk populations, and procedural heterogeneity — different scopes, sheath sizes, sedation protocols, and timing — reflects the reality of a varied referral network but complicates interpretation. Confidence intervals around some analyses were wide, and inter-observer reproducibility was not formally assessed. Still, the single-session design, which avoided within-patient clustering, and the combination of operator impression with structured criteria strengthen the findings considerably.

Looking ahead, the authors call for prospective validation of PTCS-specific optical reporting frameworks, standardized documentation of procedural variables such as tract maturation and irrigation strategy, and quantification of how cholangioscopic findings actually change patient management. Emerging technologies, including standardized image annotation and artificial intelligence-assisted pattern recognition, could sharpen interobserver agreement and refine the visual criteria tailored to percutaneous referral populations. For now, the message for patients with mysterious bile duct blockages is encouraging: a camera threaded through the liver, guided by a trained eye and a disciplined checklist, can bring clarity where scans and standard endoscopy leave only doubt — with a safety profile that is, in most cases, reassuringly benign.

Subject of Research: Diagnostic performance and safety of percutaneous transhepatic cholangioscopy for complex, indeterminate biliary lesions

Article Title: Percutaneous transhepatic cholangioscopy for complex biliary lesions: multicenter real-world diagnostic performance and safety study

Article References: Percutaneous transhepatic cholangioscopy for complex biliary lesions: multicenter real-world diagnostic performance and safety study. (n.d.). https://doi.org/10.1007/s44343-026-00045-3

Image Credits: AI Generated

DOI: 10.1007/s44343-026-00045-3

Keywords: percutaneous transhepatic cholangioscopy, biliary strictures, cholangiocarcinoma, indeterminate biliary lesions, targeted biopsy, interventional radiology, diagnostic accuracy, adverse events, multicenter study, bile duct cancer, Percutaneous, transhepatic