Comparative diagnostic accuracy of PSMA-PET versus conventional imaging for Initial T/N/M staging of intermediate- to high-risk prostate cancer: a patient-level paired bivariate meta-analysis

To compare the patient-level diagnostic accuracy of PSMA-PET with multiparametric magnetic resonance imaging (mpMRI), computed tomography (CT), and bone scintigraphy (BS) for initial T, N, and M staging of newly diagnosed intermediate- to high-risk prostate cancer using paired studies. We searched PubMed, Embase, Web of Science, and Scopus from inception to December 1, 2025, for paired studies in which the same patients underwent PSMA-PET and conventional imaging, with histopathology or predefined composite criteria as the reference standard. Risk of bias was assessed with QUADAS-2 and QUADAS-C. Pooled sensitivity and specificity with 95% confidence intervals (CIs) were estimated using bivariate composite-likelihood models. Modality effects were tested by meta-regression and likelihood ratio tests, and absolute between-modality differences with 95% CIs were estimated using the delta method. Forty-three studies including 4,023 patients were analyzed. For local T staging, PSMA-PET did not show uniform superiority over mpMRI. For extraprostatic extension, PSMA-PET/CT did not differ significantly from mpMRI in sensitivity (absolute difference, -7.6 percentage points; 95% CI, -16.1 to 0.9; p = 0.08) or specificity (-7.0 percentage points; 95% CI, -14.7 to 0.8; p = 0.08); no significant differences were observed for seminal vesicle invasion. In an exploratory six-study comparison, PSMA-PET/MRI had higher sensitivity than mpMRI for extraprostatic extension (+ 12.1 percentage points; 95% CI, 1.9 to 22.2; p = 0.02). For regional lymph node staging, PSMA-PET/CT sensitivity was 69.3% (95% CI, 56.6–79.7) versus 45.3% (95% CI, 33.0–58.3) for mpMRI (difference, + 24.1 percentage points; 95% CI, 6.0–40.3; p = 0.009), whereas specificity did not differ (difference, + 3.2 percentage points; 95% CI, -4.6 to 11.8; p = 0.41). For bone metastasis staging, PSMA-PET had greater sensitivity than BS (95.8% [95% CI, 92.8–98.7] versus 76.2% [95% CI, 68.7–83.8]) and greater specificity (92.8% [95% CI, 89.9–95.7] versus 77.4% [95% CI, 71.3–83.5]; both p < 0.001). PSMA-PET/CT was more sensitive than mpMRI for regional lymph node staging, while specificity was comparable. PSMA-PET had greater sensitivity and specificity than bone scintigraphy for bone metastasis staging. For local T staging, PSMA-PET did not show uniform superiority over mpMRI.