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Objective: Antibiotic prophylaxis reduces infection risk following transrectal prostate biopsy. Studies in countries with high antibiotic resistance show that fosfomycin, given an hour or more before biopsy, has equal or better outcomes than ciprofloxacin. This study aimed to evaluate if fosfomycin, administered immediately before biopsy, is as effective as ciprofloxacin in Sweden, where antibiotic resistance is low.

Material and Methods: A randomised, non-inferiority study of different antibiotic prophylactic regimes, including men undergoing transrectal prostate biopsy, was conducted. A total of 3448 patients were planned to be included. Primary outcome was hospitalisation due to urinary tract infection (UTI) within 14 days. Men without risk factors for infection received either fosfomycin or ciprofloxacin immediately before biopsy. Patients with risk factors received additional doses post-biopsy.

Results: The study was stopped by the safety board after enrolment of 42 men. Four of 20 men (25%) in the fosfomycin group were hospitalised due to UTI, including two with positive blood cultures for Pseudomonas, whereas no hospitalisations (0%) occurred in the ciprofloxacin group. The main limitation was the small sample size.

Conclusion: Fosfomycin administered immediately before biopsy was not supported by this study. The results may be skewed by the high incidence of Pseudomonas infections.

Level of evidence: 2

PURPOSE: To assess the risk of Achilles tendon rupture (ATR) following single-dose ciprofloxacin prophylaxis for transrectal prostate biopsy. METHODS: Using the Prostate Cancer data Base Sweden (PCBaSe 5.0), we analysed 44,959 prostate biopsy exposures versus 662,520 non-exposures to assess the risk of ATR. Prostate biopsy served as a proxy for quinolone use, with single-dose ciprofloxacin being the recommended and most extensively documented prophylaxis in Sweden for this procedure. The outcome was ATR in men who underwent a biopsy compared to those who did not. RESULTS: The incidence rate of ATR was 60.46 per 100,000 person-years in the no-biopsy group, compared to 62,77 per 100,000 person-years in the biopsy group. The multivariable analysis yielded a hazard ratio of 0.98 (95% confidence interval [CI]: 0.83-1.15). CONCLUSIONS: Transrectal prostate biopsy was not associated with an elevated risk of Achilles tendon rupture. This provides some evidence against single-dose ciprofloxacin being a relevant risk factor for this outcome, but there is remaining uncertainty related to study limitations.

OBJECTIVE: Prostate biopsy is associated with a risk of significant infectious complications including sepsis. We investigated the risk of infections after transrectal (TR) biopsy compared to transperineal (TP) biopsy.

MATERIALS AND METHODS: Men who had undergone prostate biopsy and diagnosed with prostate cancer were identified in the National Prostate Cancer Register (NPCR) of Sweden. Linkage with Swedish health care registers provided information on hospitalization, antibiotic prescriptions and comorbidities. Rate ratios for hospitalization, for infections, after TR and TP biopsies over day 1-7, 1-14, and 1-30 were estimated with Poisson regression. Filled prescriptions for urinary tract related antibiotics were also assessed.

RESULTS: Thirty-one thousand two hundred twenty-two men underwent biopsy between 1 January 2020 and 31 December 2023. 87% underwent TR and 13% TP biopsy. Hospitalization occurred in 0.6% of men (n = 24) after TP biopsy and 2.0% (n = 548) after TR biopsy. Rate ratios for hospitalization in the TR group compared to TP were 8.0 (95% confidence interval [CI]: 4.0-16.2) for day 1-7, 6.2 (3.2-11.9) for day 1-14, and 4.1 (2.4-6.8) for day 1-30. Filled antibiotic prescriptions were found for 4.5% of men (n = 187) after TP biopsy and 6.9% (n = 1,883) after TR biopsy. For antibiotic prescriptions, the rate ratios were 2.3 (1.8-2.9) for day 1-7 as well as day 1-14, and 1.6 (1.3-1.9) for day 1-30.

CONCLUSIONS: A transrectal prostate biopsy was associated with a significantly higher risk of post-biopsy infectious complications compared to transperineal biopsy. These findings support the use of transperineal biopsy.

Objective: The aim of this study was to evaluate the utilization and impact of emergency computed tomography (CT) on the management of renal colic, focusing on treatment decisions, time to treatment and the subsequent need for additional emergency department (ED) visits.

Materials and methods: Retrospective analysis of patient visits to the ED in Helsingborg with a diagnosis of urolithiasis (ICD codes N20-23) between July 1, 2019 and June 30, 2020.

Results: Out of 64,263 visits, 1.4% (880) visits were related to urolithiasis, involving 612 patients. Emergency CT (within 24 h) was performed in 43% of the cases, with an additional 9% undergoing CT at a subsequent emergency visit. Radiological confirmation of kidney or ureteral stone was found in 324 patients, of which 63% (204) required no treatment. Comparison between patients who underwent emergency CT and those who did not, revealed a significantly shorter time to treatment and closure in the emergency CT group. The median time to treatment was 28 days for those with an emergency CT and 59 days for those without (P < 0.001), acute surgery excluded. The median time to closure was 31 days for emergency CT compared to 37 days without emergency CT (P < 0.010), acute surgery excluded.

Conclusion: In this study, the use of emergency CT shortened the time to treatment and rendered the patient stone free earlier compared to deferred diagnostics, with a note of caution that emergency CT may have led to increased surgical treatments for stones that might otherwise have passed spontaneously.

ClinicalTrials.gov Identifier: NCT06535711.

OBJECTIVE: To investigate the dose-dependent safety and efficacy of using Ethanol 99.5% as a sclerosing agent when treating hydro- and spermatoceles.

MATERIALS AND METHODS: This study (EUDRA-CT 2020-004630-38) was conducted as an open randomised multicentre study where symptomatic hydro- or spermatocele patients were randomised to sclerotherapy with 25- or 50-mL Ethanol 99.5%. The procedure was carried out at four Swedish outpatient clinics. An 8 F pigtail catheter was inserted after local anaesthetics of the skin, the fluid was drained and the randomised dose of Ethanol was instilled. After 30 min, the Ethanol was evacuated. Absorption was measured before and after instillation with a breathalyser and with a blood alcohol test before evacuation. Patients were followed-up by phone on days 1, 2, 3, 4, 30 and 90 after the procedure to capture any complications.

RESULTS: A total of 64 patients were included in this study. None had a significant absorption of alcohol (≥ 0.2‰). The rate of complications was 18%. The number of serious complications needing intervention was 5%. The overall success rate, defined as light or no remaining discomfort, of the treatment regardless of dose was 79%. There was no difference between the different regimens with regards to complications and the success rate, but this study is underpowered in regard to those analysis.

CONCLUSIONS: No systemic absorption of Ethanol 99.5% occurred regardless of dose, when used as a sclerosing agent for hydro- and spermatoceles with a 79% cure rate. The efficacy and risks of complications are comparable to other sclerosants.

Background: There is limited information on the distribution of retroperitoneal lymph node metastases (LNMs) in upper tract urothelial carcinoma (UTUC).

Objective: To investigate the location of LNMs in UTUC of the renal pelvis or proximal ureter and short-term complications after radical nephroureterectomy (RNU) with lymph node dissection (LND).

Design, setting, and participants: This was a prospective Nordic multicenter study (four university hospitals, two county hospitals). Patients with clinically suspected locally advanced UTUC (stage >T1) and/or clinical lymph node–positive (cN+) disease were invited to participate. Participants underwent RNU and fractionated retroperitoneal LND using predefined side-specific templates.

Outcome measurements and statistical analysis: The location of LNMs in the LND specimen and retroperitoneal lymph node recurrences during follow-up was recorded. Postoperative complications within 90 d of surgery were ascertained from patient charts. Descriptive statistics were used.

Results and limitations: LNMs were present in the LND specimen in 23/100 patients, and nine of 100 patients experienced a retroperitoneal recurrence. Distribution per side revealed LNMs in the LND specimen in 11/38 (29%) patients with right-sided tumors, for whom the anatomically larger, right-sided template was used, in comparison to 12/62 (19%) patients with left-sided tumors, for whom a more limited template was used. High-grade complications (Clavien grade ≥3) within 90 d of surgery were registered for 13/100 patients. The study is limited in size and not powered to assess survival estimates.

Conclusions: The suggested templates that we prospectively applied for right-sided and left-sided LND in patients with advanced UTUC included the majority of LNMs. High-grade complications directly related to the LND part of the surgery were limited.

Patient summary: This study describes the location of lymph node metastases in patients with cancer in the upper urinary tract who underwent surgery to remove the affected kidney and ureter. The results show that most metastases occur within the template maps for lymph node surgery that we investigated, and that this surgery can be performed with few severe complications.

Objective:The aim of this study was to evaluate chronic pain 1 year after surgery, and risk factors for chronic pain after groin hernia repair in women.Background:Groin hernia surgery in women is less frequently studied than in men. Chronic pain is common after groin hernia surgery and remains an important area with room for improvement. Previous studies are small or inconclusive. Guidelines recommend timely repair of all female groin hernias.

Methods:From the Swedish Hernia Register 4021 female and 37,542 male patients operated between September 1, 2012 and August 30, 2017 responded to a patient-reported outcome questionnaire (response rate 70.0%) 1 year after primary groin hernia surgery. Multivariable analysis was performed to compare chronic postoperative pain in women with men as a control group, and to evaluate risk factors for chronic pain in women.

Results:Among women operated for groin hernia, 18% suffered chronic postoperative pain. The risk for chronic pain was significantly higher for women [odds ratio 1.3 (95% confidence interval 1.16-1.46). Three risk factors for chronic pain in women were found: High body mass index, high American Society of Anesthesiologists classification, and femoral hernia. No differences in chronic pain in women were seen when comparing surgical methods or emergency versus elective surgery.

Conclusions:Almost one-fifth of women suffered of chronic pain affecting daily activity after groin hernia repair. Chronic pain was more common for women than men. In view of the high-rate chronic postoperative pain, further research on management strategies in female groin hernia is warranted.

Objective: To evaluate the success rate of Extracorporeal Shock Wave Lithotripsy (ESWL) therapy and identify relevant treatment-specific factors affecting stone-free rate (SFR) after ESWL.

Materials and methods: All ESWL treatments in the years 2016–2019, in Ängelholm Hospital, Skåne, Sweden were analysed retrospectively. Primary outcome was stone-free rate (SFR) at 3 months. Univariate logistic regression was used followed by multivariable regression. Lasso analysis was made to adjust for treatment-specific factors such as age, stone size, skin-to-stone distance (SSD), stone attenuation, number of treatments, stone location and presence of a urinary stent.

Results: Factors affecting successful ESWL treatment were lower age (p < 0.001), smaller stone size and volume (both p = 0.001). SSD, stone attenuation, sex, laterality and drainage did not have an effect on SFR in this study. After the first ESWL treatment session, 46.7% of the patients were stone-free.

Conclusion: Results indicate that stone size and age are the most predictive factors for ESWL outcome. Based on this, we present a simple model for prediction of SFR after ESWL, to be used when counseling patients before ESWL treatment.

Objectives: The aim was to describe the patients' experience of undergoing prostatic artery embolization.

Methods: A retrospective qualitative interview study was undertaken with 15 patients of mean age 73 years who had undergone prostatic artery embolization with a median duration of 210 min at two medium sized hospitals in Sweden. The reasons for conducting prostatic artery embolization were clean intermittent catheterization (n = 4), lower urinary tract symptoms (n = 10) or haematuria (n = 1). Data were collected through individual, semi-structured telephone interviews 1-12 months after treatment and analysed using qualitative content analysis.

Results: Four categories with sub-categories were formulated to describe the results: a diverse experience; ability to control the situation; resumption of everyday activities and range of opinions regarding efficacy of outcomes. Overall, the patients described the procedure as painless, easy and interesting and reported that while the procedure can be stressful, a calm atmosphere contributed to achieving a good experience. Limitations on access to reliable information before, during and after the procedure were highlighted as a major issue. Practical ideas for improving patient comfort during the procedure were suggested. Improved communications between treatment staff and patients were also highlighted. Most patients could resume everyday activities, some felt tired and bruising caused unnecessary worry for a few. Regarding functional outcome, some patients described substantial improvement in urine flow while others were satisfied with regaining undisturbed night sleep. Those with less effect were considering transurethral resection of the prostate as a future option. Self-enrolment to the treatment and long median operation time may have influenced the results.

Conclusions: From the patients' perspective, prostatic artery embolization is a well-tolerated method for treating benign prostate hyperplacia.

Introduction: The use of quinolones has recently been questioned due to reports on side effects including an increased risk of aortic aneurysm. The aim of the study was to examine the risk of aortic aneurysm (AA) after short-term ciprofloxacin as prophylaxis for prostate biopsy.

Materials and Methods: We used the Prostate Cancer data Base Sweden and investigated 192,024 prostate biopsy exposures vs. 554,974 non-exposures for risk of AA. Prostate biopsy was used as a proxy for quinolone use as short-term ciprofloxacin is the recommended and documented prophylaxis in Sweden for this procedure. The outcome was the hazard ratio (HR) of AA in men who underwent a biopsy vs. those that did not.

Results: The absolute risk of AA was small, 39/10,000 person years for all AÁs and for ruptured AÁs 3.5/10,000 person years. In multivariate analyses, there were small, non-significant increases in risk of all AA’s (adjusted HR = 1.13, 95% CI: 0.91 to 1.39) and ruptured AÁs (adjusted HR = 1.05, 95% CI: 0.52 to 2.15) in men who underwent biopsy. A significantly increased risk of AA was observed in men diagnosed with high-risk prostate cancer on biopsy (HR = 1.50, 95% CI: 1.15–2.21). The use of prostate biopsy as a proxy for exposure to ciprofloxacin was a limitation of the study.

Conclusions: Short-term ciprofloxacin was not associated with an increased risk of aortic aneurysm and the increased risk in men with high-risk prostate cancer was likely due detection bias caused by imaging more commonly performed in these men.