Abstract
Prostate MRI has transformed lesion detection and risk stratification in prostate cancer, but its impact is constrained by the high cost of the exam, variability in interpretation, and limited scalability. False negatives, false positives, and moderate inter-reader agreement undermine reliability, while long acquisition times restrict throughput. Artificial intelligence (AI) offers potential solutions to address many of the limitations of prostate MRI in the clinical management pathway. Machine learning-based triage can refine patient selection to optimize resources. Deep learning reconstruction enables accelerated acquisition while preserving diagnostic quality, with multiple FDA-cleared products now in clinical use. Ongoing development of automated quality assessment and artifact correction aims to improve reliability by reducing nondiagnostic exams. In image interpretation, AI models for lesion detection and clinically significant prostate cancer prediction achieve performance comparable to radiologists, and the PI-CAI international reader study has provided the strongest evidence to date of non-inferiority at scale. More recent work extends MRI-derived features into prognostic modeling of recurrence, metastasis, and functional outcomes. This review synthesizes progress across five domains-triage, accelerated acquisition and reconstruction, image quality assurance, diagnosis, and prognosis-highlighting the level of evidence, validation status, and barriers to adoption. While acquisition and reconstruction are furthest along, with FDA-cleared tools and prospective evaluations, triage, quality control, and prognosis remain earlier in development. Ensuring equitable performance across populations, incorporating uncertainty estimation, and conducting prospective workflow trials will be essential to move from promising prototypes to routine practice. Ultimately, AI could accelerate the adoption of prostate MRI toward a scalable platform for earlier detection and population-level prostate cancer management. EVIDENCE LEVEL: N/A TECHNICAL EFFICACY: 3.