Pitfalls and Limitations of the Vesical Imaging-Reporting and Data System (VI-RADS): Challenges in the Multiparametric Magnetic Resonance Imaging (mpMRI) Assessment of Bladder Cancer

The Vesical Imaging-Reporting and Data System (VI-RADS) has emerged as a standardised scoring system for assessing detrusor muscle invasion in patients with urothelial bladder cancer using multiparametric magnetic resonance imaging (mpMRI). Accurate staging is critical for guiding treatment decisions, including bladder-sparing strategies and radical cystectomy. We performed a comprehensive literature review, complemented by illustrative images from real cases at our institution, to highlight potential pitfalls, limitations, and technical challenges in VI-RADS interpretation. Post-transurethral resection of bladder tumour (post-TURBT) changes, intravesical therapy, and neoadjuvant chemotherapy may mimic residual tumour, affecting both diffusion-weighted imaging and dynamic contrast-enhanced sequences. Specific tumour locations, such as the ureteric orifices, trigone, or bladder neck, as well as flat or small lesions, may complicate accurate staging. Non-urothelial histologies, extravesical tumours, and bladder diverticula can also lead to misinterpretation, while technical factors such as bladder distension, motion artefacts, and slice thickness can impact image quality and scoring accuracy. VI-RADS remains a valuable tool for the non-invasive staging of bladder cancer, but recognition of its limitations and potential pitfalls is essential to prevent misdiagnosis and inappropriate management. Careful integration of clinical history, cystoscopy, histopathology, and meticulous mpMRI technique improves diagnostic confidence and guides optimal patient care.