Magnetic Resonance Imaging-Based Artificial Intelligence in Predicting Prostate Cancer Biochemical Recurrence: Systematic Review and Meta-Analysis.

Background: Artificial intelligence (AI) has emerged as a promising tool for prostate cancer (PCa) risk stratification and outcome prediction. However, current studies often lack multicenter external validation, have limited sample sizes, present significant intermodel variability, and face overfitting concerns. Objective: This study aimed to comprehensively evaluate the diagnostic performance of magnetic resonance imaging (MRI)-based AI models in predicting biochemical recurrence (BCR) of PCa. Methods: Systematic searches were conducted in the PubMed, Embase, Web of Science, and Cochrane Library databases up to January 13, 2026. Studies were included that involved participants diagnosed with PCa, used MRI-based AI for predicting BCR, and had clearly defined reference standards. The quality of the included studies was assessed using the PROBAST+AI tool. A bivariate random effects model was used to pool sensitivity, specificity, and area under the curve (AUC) statistics. Results: A total of 28 studies were included, with 2623 patients in internal validation and 1134 patients in external validation. Diagnostic contingency tables were reconstructed from published performance metrics for most studies, while others were extracted from receiver operating characteristic curves due to the lack of direct reporting. In the internal validation set, pooled sensitivity was 0.80 (95% CI 0.73-0.86; prediction interval [PI] 0.48-0.99), specificity was 0.83 (95% CI 0.77-0.89; PI 0.49-1.00), and AUC was 0.86 (95% CI 0.83-0.89; PI 0.74-0.99). In the external validation set, pooled sensitivity was 0.82 (95% CI 0.72-0.91; PI 0.54-0.99), specificity was 0.83 (95% CI 0.71-0.92; PI 0.49-1.00), and AUC was 0.84 (95% CI 0.79-0.90; PI 0.70-0.98). No statistically significant differences were observed between internal and external validation in sensitivity (P=.73), specificity (P>.99), AUC (P=.53), or diagnostic odds ratio (P=.98). Medical Net and Extreme Gradient Boosting achieved the highest sensitivity and AUC, whereas multiple kernel learning and support vector machine had the highest specificity. Subgroup and meta-regression analyses suggested that AI method, model type, timing of MRI acquisition, and treatment modality may contribute to heterogeneity. Conclusions: This meta-analysis innovatively realizes the quantitative direct comparison of MRI-based AI model performance between internal and external validation cohorts for PCa BCR prediction. It comprehensively evaluates AI performance across diverse PCa treatment modalities and integrates machine learning and deep learning approaches. For the field, it identifies key sources of performance heterogeneity (eg, MRI acquisition timing and treatment modality) and quantifies the sensitivity-specificity trade-off in integrated radiomic-clinical models, advancing the systematic understanding of MRI-based AI for BCR prediction. In real-world practice, it provides actionable guidance to prioritize pretreatment MRI for AI model development and clinical BCR assessment and underscores the urgent need for standardized imaging protocols and prospective multicenter studies, laying a foundation for the safe clinical translation of these AI tools as adjunctive decision support instruments.