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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

OBJECTIVE: It is unknown how risk factors for infection after transrectal prostate biopsy interact. We designed a study to evaluate this.

METHODS: We identified biopsy procedures from 2006 to 2020 in the Swedish nationwide database PCBaSe. Primary outcome was post-biopsy infection, defined as a dispensed prescription of a urinary tract antibiotic and secondary outcome was inpatient care for infection both within 30 days. Risk factors were age, diabetes, medical treatment of lower urinary tract symptoms (LUTSs), prostate enlargement, immunosuppressives, corticosteroids, and defined antibiotic exposure during the past 1-12 months. When analysing risk in men with several risk factors clinically related factors were grouped as urinary tract infection (UTI)-antibiotics, treatment of LUTS, immunosuppressives including corticosteroids, and diabetes. Logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CI).

RESULTS: A total of 139,056 transrectal prostate biopsy procedures were analysed. The grouped risk factors were significantly associated with post-biopsy infection (multivariable ORs: 1.22-1.72). Infection increased with number of risk factors; none: 4.0% (95% CI: 3.8-4.1), one: 6% (95% CI: 5.9-6.4), two: 10% (95% CI: 9.3-11), and three or four: 12% (95% CI: 9.8-14); inpatient care increased from 2.0% (95% CI: 1.9-2.1) to 3.1% (95% CI: 2.2-4.4).

CONCLUSION: Infection risk after transrectal prostate biopsy incrementally increases with the number of risk factors.

CLINICAL IMPLICATIONS: The transrectal biopsy route should be used with caution for patients with several risk factors for post-biopsy infections.

PATIENT SUMMARY: Diabetes, urinary symptoms, previous urinary infection, and immune suppressing medication increase the risk of infection after a prostate biopsy through the rectum. Patients with many of these conditions have a particularly high risk.

What does the study add? We used nationwide register data to estimate the infection risk after transrectal prostate biopsy by the number of these risk factors: diabetes, medical treatment of lower urinary tract symptoms, immunosuppressives including corticosteroids, and use of urinary tract antibiotics the past year. The risk incrementally increased from 4.0% in men with no risk factor to 12% in those with 3 or 4.

TAKE HOME MESSAGE: Infection after transrectal prostate biopsy increases with number of risk factors: diabetes, medical treatment of lower urinary tract symptoms, immunosuppressives including corticosteroids, and use of urinary tract antibiotics the past year, from 4.0% (none) to 12% (3 or 4).

Background: High recurrence rates for non-muscle-invasive bladder cancer (NMIBC) remain a clinical challenge. Recommended post-operative treatments are underutilized, highlighting the need for alternative strategies. Given the variability in bladder cancer prognosis, personalized treatment approaches are highly relevant. In this study, we evaluated post-operative two-hour continuous sterile water bladder irrigation (CSWBI) regarding recurrence and safety, as a potential addition to the treatment arsenal for bladder cancer.

Method: In 2018, two-hour CSWBI was implemented as routine treatment after all transurethral resection procedures of the bladder (TURB), at the urology department of Sundsvall Hospital. All patients who underwent TURBs four years prior (control group) and four years after the implementation of CSWBI (intervention group) were analyzed. Primary NMIBC were included, MIBC and CIS were excluded. Data were collected retrospectively from patient records, including baseline characteristics, adverse events, and recurrence rates within 12 months follow-up. Statistical analyses included Chi-squared test, Wilcoxon rank-sum test, univariate and multivariate logistic regression analyses, Kaplan–Meier curves and log-rank test.

Results: A total of 168 patients were included (control group n = 90, irrigation group n = 78). Median age was 73 years, 23% were female, 77% were male, and 74% were active or previous smokers. The recurrence rate within twelve months for the intervention group vs. the control group was: 27% vs. 21% (p = 0.4) respectively. CSWBI had no statistically significant impact on recurrence (OR 1.25, 95% CI 0.58–2.68, p = 0.6). Adverse effects were limited and equal between groups. Conclusions: Post-operative two-hour CSWBI did not significantly reduce NMIBC recurrence within twelve months in this cohort.

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.

This nationwide register-based cohort study examined the association between castration status and postoperative survival in men who had undergone surgery for spinal metastases from prostate cancer. Bone metastases are common in prostate cancer, with the spine being the most frequent site. Using data from the Swedish Spine Register (Swespine) and Prostate Cancer Database Sweden (PCBaSe), 306 men with prostate cancer who underwent spinal surgery were identified. In total, 81 were categorized as castration-sensitive and 225 as castration-resistant disease at the time of spinal surgery. Postoperative survival was estimated using Kaplan-Meier analysis and compared with the log-rank test. Multivariable Cox regression was used to adjust for potential confounders. Median survival after surgery was significantly longer in men with castration-sensitive prostate cancer (33 months, IQR 15-55) compared to those with castration-resistant disease (8 months, IQR 5-31; p < 0.001). Castration-sensitive status was independently associated with a lower risk of death (hazard ratio 0.29, 95% CI: 0.20-0.41). These findings indicate that castration sensitivity is a strong prognostic factor for survival after surgery for spinal metastases from prostate cancer and should be considered in surgical decision-making.

Background and purpose: The metastatic castration-sensitive prostate cancer (mCSPC) treatment landscape in Sweden has evolved in recent years. The purpose of this study is to provide contemporary registry data on outcomes and treatment patterns in a nationwide cohort of Swedish patients with de novo mCSPC.

Patient/material and methods: This retrospective cohort study included patients in Sweden with a clinical diagnosis of de novo mCSPC registered between January 1, 2017 and December 31, 2023. The primary outcome was time from de novo mCSPC diagnosis to mCRPC or death (2017-2023). Secondary outcomes included overall survival (OS), comorbidities, co-medication use, and treatment sequencing. OS, time to progression or death, and treatment sequencing for the 2017-2020 and 2021-2023 time periods were also analyzed.

Results: A total of 2421 patients with de novo mCSPC were included in the primary analysis (mean age: 72.8 years). The median time to progression or death was 22.7 months (95% CI: 21.2-24.1), and the median OS was 49.8 months (95% CI: 47.0-52.6). Median time to progression or death increased from 19.9 months (95% CI: 18.6-21.2) in 2017-2020 to 30.0 months (95% CI: 26.6-33.3) in 2021-2023, while the proportion of patients receiving initial doublet or triplet therapy rose from 42.5 to 68.8%. No differences in OS were observed between different time periods.

Interpretation: In Sweden (2017-2023), increased time to progression or death was observed in patients with de novo mCSPC.

Urine is an attractive biospecimen for noninvasive tests to facilitate bladder tumor diagnostics. Three different point-of-care (POC) tests based on lateral flow immunoassays (LFAs) are currently commercially available: UBC® Rapid Test, BTA stat®, and NMP22^TM BladderChek. The present review discusses these different tests based on their performance, clinical utility and the nature of the respective analytes. The level of sensitivities of UBC Rapid Test® and BTA stat® for detection of high-grade nonmuscle invasive bladder cancer using urine is in the order of 80%. Estimations of performance are highly dependent on patient selection criteria. UBC® Rapid Test shows a sensitivity of approximately 85% in patients presenting with macrohematuria which is the most common initial clinical symptom. Estimations of specificity are complicated by differences in how control groups are selected in different studies and are therefore more difficult to compare between published reports. Different POC tests differ with regard to the source of the analytes that are measured. The BTA Stat® test is based on detection of plasma proteins (Factor H/Factor H-related proteins), potentially leading to a lack of specificity during conditions of renal dysfunction. A large number of analytes to be used for urine-based bladder cancer tests have been described in the literature, including cytokines and proteases implicated in tumor invasion. These proteins, although biologically relevant, are often present at very low levels in urine that may be unsuitable for development of LFAs. Release of abundant intracellular structural proteins from cells such as cytokeratins (UBC® Rapid Test) and nuclear matrix proteins (NMP22^TM) may therefore be advantageous. We conclude that available data support the use of urine-based POC tests as adjuncts during the clinical work up of suspected bladder cancer.

BACKGROUND: Swedish national guidelines provide evidence-based recommendations for standard of care; however, little is known about adherence to them. The aim of this study was to assess adherence to management guidelines for prostate cancer (PCa).

MATERIALS AND METHODS: Data in the National Prostate Cancer Register (NPCR), that includes 98% of all incident PCa cases in Sweden, were used to analyse adherence to national PCa guidelines for men diagnosed between 2010 and 2023. A selection of quality indicators displayed on the public web page of NPCR were assessed.

RESULTS: Active surveillance in men with low-risk PCa and an estimated life expectancy >10 years increased from 44% in 2010 to 88% in 2023. Radical treatment for men with localised high-risk PCa and life expectancy >10 years increased from 60% in 2010 to 86% in 2023 and for men with locally advanced PCa and life expectancy >5 years from 37% in 2010 to 64% in 2023. The proportion of radical prostatectomies for low- or intermediate-risk PCa performed with nerve-sparing technique increased from 61% in 2015 to 87% in 2023. Use of adjuvant androgen deprivation therapy after radiotherapy for men with high-risk or locally advanced PCa increased five-fold from 14% in 2010 to 73% in 2022.

CONCLUSION: Adherence to recommendations in national guidelines improved in Sweden between 2010 and 2023. Public, open reporting of NPCR data on adherence to guidelines down to department level is likely to have contributed to these improvements.