Scandinavian Journal of Urology最新文献

Objective: To investigate histopathological assessment practices following medical circumcision, analyse the prevalence of lichen sclerosus (LS) and assess the management of circumcised LS patients.

Material and methods: This retrospective study was conducted at Umeå University Hospital. A total of 416 patients aged ≥18 years who underwent medical circumcision between 2016 and 2023 were included. The variables investigated were the frequency of histopathological diagnosis of preputial tissue, pre- and post-surgery treatment, further management and the prevalence of LS.

Results: The mean (standard deviation [SD]) age of included patients was 47 (21) years. Before circumcision, 34% (141/416) of the study population had received treatment with potent or ultrapotent topical corticosteroids. A pre-operative diagnosis of LS was set in 4.8% (20/416) of the patients. Histopathological analysis of circumcised material was performed in 44% (183/416) of cases. Amongst these, LS was confirmed in 60% (110/183). Amongst the patients with histologically confirmed LS, 13% (14/110) received a recorded diagnosis of LS. A total of 15% (16/110) of the patients with LS were either referred to a dermatovenereologist and/or received treatment with an ultrapotent topical corticosteroid.

Conclusions: LS appears to be both underdiagnosed and not adequately treated in patients undergoing medical circumcision. Less than half of the circumcised specimens were analysed, which means a risk of missing LS and potential dysplastic changes. Most patients with LS did not receive adequate diagnosis and treatment after surgery. Failure to diagnose LS limits patient awareness, follow-up and appropriate care, factors that may contribute to disease progression and increased cancer risk.

Objective: To determine whether asymptomatic bacteriuria (ABU) prior to Bacillus Calmette-Guérin (BCG) immunotherapy has an impact on the oncological results and overall tolerability of BCG treatment in patients with non-muscle-invasive bladder cancer (NMIBC).

Materials and methods: We analyzed retrospectively all patients who received ≥ 1 BCG instillations as treatment of NMIBC in Helsinki University Hospital and Turku University Hospital during 2009-2018. Patients submitted urine specimen 1-7 days prior to the initiation of BCG therapy. ABU was classified as having any positive urine culture but no dysuria or fever. Our primary endpoints were 5-yr recurrence-free survival and progression-free survival. Discontinuation rate of BCG therapy was a secondary endpoint.

Results: We identified 795 patients, of whom 154 (19%) had ABU prior to the first BCG instillation. The 5-yr recurrence-free survival rates in the uninfected and bacteriuric groups were 63% (95% confidence interval [CI]: 59-67%) vs. 69% (95% CI: 62-78%), respectively (hazard ratio [HR] 0.83, 95% CI 0.60-1.14). The 5-yr progression-free survival rates were 88% (95% CI: 86-90%) vs. 89% (95% CI: 84-94%), respectively (HR 0.86, 95% CI 0.50-1.49). The 3-yr discontinuation-free survival rates were 51% (95% CI: 47-54%) vs. 51% (95% CI: 44-60%), respectively (HR 0.98, 95% CI 0.75-1.28).

Conclusion: ABU did not significantly affect BCG immunotherapy outcomes. Intravesical BCG during ABU is safe, with similar discontinuation rates, indicating very similar treatment tolerability.

Objective: This article presents a summary of the 2025 Swedish prostate cancer guidelines, focusing on recurrence after local treatment, metastatic disease, and castration-resistant prostate cancer.

Results: The 2025 Swedish guidelines introduce several important updates. Prostate specific membrane antigen (PSMA)-PET/CT is recommended only when PSA exceeds 0.2 µg/L, and reporting should follow the defined PSMA-RADS-scale. PSMA-PET/CT is preferred over lymph-node dissection for staging. A strong recommendation is issued for radiotherapy to the primary tumour in all oligometastatic men with a life expectancy > 5 years, whereas metastasis-directed therapy is restricted to clinical trials. Systemic treatment pathways now prioritise androgen receptor pathway inhibitors (ARPI) plus androgen deprivation therapy (ADT), with triple therapy (including docetaxel) used more selectively. Pathway-specific staging algorithms have been revised. The oly (ADP-ribose) polymerase inhibitor (PARPi) section has expanded, with broader genomic-based selection and integration into treatment sequencing. Two new chapters and an appendix address cardiovascular risk assessment before ARPI or chemotherapy. Supportive care is substantially strengthened. Compared with the EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer 2025, the Swedish guidelines 2025 applies PSMA-PET/CT more conservatively, restricts PSMA-guided nodal salvage therapy, and issues a more universal recommendation for local radiotherapy in oligometastatic disease. The Swedish guidelines 2025 prioritise ARPI + ADT and limit triple therapy and PARPi combinations due to regulatory and reimbursement constraints. PARPi are largely reserved for BRCA1/2-mutated disease. The Swedish guidelines 2025 provide a more comprehensive framework for rehabilitation and survivorship.

Conclusions: The 2025 Swedish prostate cancer guidelines introduce multiple new recommendations and differ in several aspects from the European guidelines.

The International Bladder Cancer Group (IBCG) has proposed a prognostic model for intermediate risk (IR) non-muscle invasive bladder cancer (NMIBC) for clinical decision-making. We applied the IBCG IR model in a population-based Swedish setting in patients with primary IR NMIBC diagnosed 2013-2014 in BladderBaSe 2.0. Patients were stratified into low-risk (unifocal and tumour size < 3 cm) and intermediate-risk (multiple and/or tumour size ≥ 3 cm) for estimation of 1- and 3-year recurrence-free survival (RFS). Among 710 patients with IR NMIBC, 329 (46%) and 381 (54%) were categorized as low- and intermediate-risk, respectively. Probabilities of disease recurrence or death at 1 and 3 years in low-risk patients were 19% (95% confidence interval [CI]: 15-23) and 41% (95% CI: 35-46), versus 27% (95% CI: 22-31) and 45% (95% CI: 40-50) in the intermediate-risk group. In a sensitivity analysis including only patients receiving serial adjuvant instillations (n = 152) the corresponding probabilities at 1 and 3 years were 19% (95% CI: 10-28) and 33% (95% CI: 22-43) versus 15% (95% CI: 7-23) and 31% (95% CI: 20-41), respectively. Thus, no clinically meaningful difference in recurrence-free survival was observed between International Bladder Cancer Group low- and intermediate-risk groups in this population-based primary non-muscle invasive bladder cancer setting.

Introduction: Transurethral resection of bladder tumor (TURBT) is the standard treatment for non-muscle-invasive bladder cancer (NMIBC), but early recurrences remain frequent. The objective of this study was to standardize TURBT management at our institution through the implementation of a treatment protocol designed to reduce early recurrence after primary TURBT.

Material and methods: All patients with newly diagnosed NMIBC who underwent primary TURBT at Landspítali University Hospital between 2013-2015 (control) and 2017-2019 (intervention) were included. The treatment protocol restricted procedures to four surgeons, mandated blue-light cystoscopy, routine postoperative bladder irrigation, and guideline-based instillation therapy. The primary endpoint was recurrence rate at first follow-up cystoscopy; secondary endpoints included adherence to protocol measures and recurrence-free survival.

Results: A total of 133 control and 138 intervention patients were included. Baseline characteristics were comparable. After implementation, bladder irrigation increased from 46 to 90%, blue-light cystoscopy was used in 59% of intervention cases, and instillation therapy rates rose (Mitomycin-C: 0-49% in intermediate-risk; Bacillus Calmette-Guérin (BCG):35-63% in high-risk patients). Early recurrence rates remained comparable (15% vs. 16%). Early recurrence varied markedly between surgeons (11-40%) and correlated strongly with detrusor muscle presence. No significant difference in recurrence-free survival was observed, though a trend toward lower recurrence was seen in the intervention group after adjusting for risk factors.

Conclusion: Implementation of a standardized TURBT protocol improved adherence to recommended measures but did not reduce early recurrence. Marked inter-surgeon variability highlights surgical quality as the key determinant of early recurrence in non-muscle-invasive bladder cancer.

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: Retroperitoneal lymph node dissection (RPLND) for testicular germ cell cancer is a complex procedure associated with postoperative complications and long-term morbidity, best performed by experienced surgeons at high-volume centers. This study evaluates surgical outcomes of RPLND in a centralized population-based cohort.

Methods: This is a retrospective analysis of a prospective multicenter cohort of all RPLNDs in Sweden between 2018 and 2022. 217 patients (175 nonseminomas and 42 seminomas) underwent unilateral or bilateral primary RPLND or post-chemotherapy RPLND. Primary outcomes were complications, loss of ejaculation, and histopathology.

Results: Intraoperative complications occurred in 8% of unilateral and 0% of bilateral templates in primary RPLND, and in 0 and 8% in post-chemotherapy RPLND, most commonly renal injury. Postoperative complications rate was significantly higher with bilateral templates in post-chemotherapy RPLND (49% vs 18%, p < 0.01). Clavien-Dindo ≥ IIIb complications occurred in 2 (primary) and 3% (post-chemotherapy), respectively. Loss of ejaculation was numerically more common after bilateral templates (primary: 60% vs 31%, p = 0.07; post-chemotherapy: 53% vs 38%, p = 0.09). Viable cancer was found in 95% of seminomas and 52% of nonseminomas for primary RPLND and in nonseminoma post-chemotherapy RPLND, 11% viable cancer, 50% teratoma, and 39% benign nodes. Robotic surgery did not increase complications or loss of ejaculation.

Conclusions: RPLND demonstrated low complication rates and rare serious events. Bilateral templates were associated with increased loss of ejaculation. Robotic surgery was safe, and prior chemotherapy did not preclude laparoscopy. Post-chemotherapy RPLND showed more teratoma and viable cancer, and fewer benign findings than previously reported.

Background: We aimed to evaluate the safety and efficacy of transurethral resection/electrocautery for the treatment of urethral hemangiomas.

Methods: A retrospective analysis was conducted on clinical data from patients who underwent transurethral resection/electrocautery for urethral hemangiomas at two medical institutions between August 2018 and July 2025. Perioperative data, short-term and long-term complications, and tumor recurrence were assessed.

Results: In total, 42 patients were included in this study. All patients successfully underwent surgical treatment without any intraoperative complications and residual tumor. The procedures were completed in a median operative length of 10 min (interquartile range [IQR]: 10-15 min) and a median blood loss volume of 20 mL (IQR: 10-20 mL). Most patients (n = 39, 92%) presented multiple lesions, with a median size of 4 mm (IQR: 3-4 mm). The lesion range of the 31 patients (74%) was more than one-half of the circumferential diameter in cystourethroscopy. Postoperative complications occurred in five patients (12%), primarily consisting of difficult urination (n = 4, 10%) and gross hematuria (n = 1, 2%). The median follow-up times were 12.0 months (IQR: 8.0-38.5 months), and one patient developed recurrence 4 months after surgery. Long-term complications, such as urethral stricture, urinary incontinence, and retrograde ejaculation, were observed.

Conclusion: Transurethral resection/electrocautery provides a safe, effective, and feasible treatment for urethral hemangiomas, delivering swift hemostasis with very low rates of complications and recurrence. Although this study included the largest sample size currently available worldwide, the findings still need additional validation.

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).