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Objectives: This study aimed to compare the effectiveness of software-based fusion-targeted biopsies (STBx) versus cognitive fusion-targeted biopsies (CogTBx) in detecting prostate cancer (PCa) and clinically significant PCa.

Materials and methods: Men aged 30-85 were included in a target trial emulation if they had undergone a STBx or CogTBx of Prostate Imaging Reporting and Data System (PI-RADS) 3-5 lesions in 2020-2024. Using log-link binary regression models with inverse probability of treatment weighting to adjust for confounding, we estimated the associations between biopsy technique and detection of PCa and clinically significant PCa (Gleason ≥3 + 4 and Gleason ≥4 + 3) by use of adjusted relative risks (aRR) with 95% confidence intervals (CIs) obtained via bootstrapping.

Results: A total of 2092 men who underwent STBx and 7933 men who underwent CogTBx in 2020-2024 were identified in PCBase Xtend. The overall proportion diagnosed with PCa was 64%. STBx detected PCa with a slightly higher frequency (aRR, 1.05; 95% CI, 1.02-1.09), corresponding to an absolute increase of 3.3 percentage points (95% CI 1.2-5.3). The relative risk for detection of Gleason ≥4 + 3 was somewhat larger (aRR, 1.13; 95% CI, 1.03-1.23). The largest relative difference for detection of PCa was observed in PI-RADS 3 lesions (aRR, 1.12; 95% CI, 1.01-1.24), and this pattern became even more apparent when the outcome was restricted to clinically significant PCa.

Conclusions: Software-based fusion-targeted biopsies detected slightly more PCa and clinically significant PCa compared to cognitive fusion-targeted biopsies, particularly in men with PI-RADS 3 lesions. Prioritizing PI-RADS 3 lesions for software-based targeted fusion biopsy could optimize diagnostic effectiveness.

Background and objective

There are several methods for estimating prostate-specific antigen (PSA) doubling time (DT), and many men exhibit long periods of undetectable PSA below 0.1 ng/ml after radical prostatectomy (RP). We quantified between-method differences in estimated PSA-DT at PSA relapse after RP and evaluated how these differences affect discrimination of prostate cancer (PCa) death.

Methods

Men who underwent RP in 2007–2024 and subsequently developed a PSA relapse, defined as two consecutive values above 0.2 ng/ml, were included. We estimated PSA-DT from the date of the first undetectable PSA after RP until PSA relapse using four methods: (1) all detectable PSAs only, (2) two most recent detectable PSAs, (3) three most recent PSAs (with the third forced to 0.1 ng/ml if ≤0.1 ng/ml), and (4) all PSAs using a missing data approach. Discrimination of 10-yr PCa death was assessed using concordance index (C-index).

Key findings and limitations

A total of 3826 men were included. Median PSA-DT ranged from 4.4 to 8.6 mo, with a wide range in PSA-DT across different estimation methods. All four methods discriminated PCa death to a similar level, with C-index ranging from 0.70 to 0.74, which was slightly lower than the C-index (0.77) for the absolute PSA level at relapse. This study was restricted to men with PSA relapse after RP and may not be generalizable to other patient categories.

Conclusions and clinical implications

PSA-DT after RP was sensitive to the choice of estimation method, and all methods had comparable prognostic value to the last measured PSA level.

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

To estimate risk of prostate-specific antigen (PSA) relapse after radical radiotherapy (RT) for prostate cancer (PCa), and risk of PCa death after relapse according to Gleason score and time to relapse.

Patients and Methods

Men in the National Prostate Cancer Register of Sweden who underwent primary radical RT in 2007–2024 were followed until 31 December 2024. Relapse was defined as a PSA level increase of ≥2 ng/mL above nadir (Phoenix criteria). Competing risk cumulative incidence analyses were used to estimate risk of PSA relapse and risk of PCa death after relapse according to Gleason score and time to relapse.

Results

The 10-year risk of relapse in 26 634 men treated with RT was 25% (95% confidence interval [CI] 24–25%). The 10-year risk of PCa death after relapse was 35% (95% CI 33–37%). In men with relapse after >3 years the risk was 18% for Gleason score 6 and 19% for Gleason score 3 + 4, while in men with a relapse within 18 months the risk was 52% for Gleason score 4 + 3 and 75% for Gleason score 9–10. In men with a relapse at 1 year after RT there was a four-fold higher risk of PCa death for men with Gleason score 9–10 compared to men with Gleason score 6 (86% vs 22%). In contrast, in men with a relapse at 10 years after RT there were little differences in risk of PCa death according to Gleason (14% vs 23%).

Conclusion

In this population-based study of RT for PCa, there was a wide range in the estimates of risk of PCa death after relapse in highly granular groups according to Gleason score and time to relapse. Notably, some estimates did not align with the European Association of Urology relapse risk group classification.

Evidence on long-term outcomes after a negative biopsy, particularly prostate cancer mortality, remains limited, and optimal follow-up strategies are unclear. This nationwide population-based study assessed whether prostate-specific antigen (PSA) decline or stability during 5-a reductase inhibitor (5-ARI) therapy after a negative biopsy identifies men at very low risk of prostate cancer and prostate cancer death. Using Prostate Cancer data Base Sweden (PCBaSe Xtend), we identified men with longitudinal PSA and biopsy data who had at least one negative prostate biopsy between 2007 and 2018 and who initiated 5-ARI therapy with defined exposure and adherence criteria. PSA change during the first 2 yr of treatment was evaluated using PSA velocity and classified as stable or increasing. Follow-up started 2 yr after treatment initiation. Among 1248 men, 901 had stable PSA and 347 had increasing PSA. After 10 yr, the cumulative incidence proportion of prostate cancer was 8.3% (95% confidence interval [CI] = 6.0-12%) in men with stable PSA and 18% (95% CI = 13-24%) in men with increasing PSA; most cancers in men with stable PSA were low grade. Prostate cancer mortality was very low among men with stable PSA (standardized mortality ratio [SMR] = 0.19; 95% CI = 0.04-0.56) and higher in men with increasing PSA (SMR = 1.20; 95% CI = 0.52-2.37. Stable PSA during 5-ARI therapy after a negative biopsy was associated with very low prostate cancer mortality; whether this should influence PSA surveillance intensity requires further study.

(c) 2026 The Author(s).

Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creative

Background and aim: Magnetic resonance imaging (MRI) is crucial for prostate cancer (Pca) diagnosis, risk stratification, and treatment planning. However, large-scale observational studies require structured MRI data, which are often only obtainable from free-text reports. We aimed to extract information from narrative prostate MRI reports and to describe subsequent biopsy outcomes in a nationwide population-based cohort.

Methods: We identified 108,361 prostate MRI examinations in Prostate Cancer database Sweden with extended treatments and endpoints data (PCBase Xtend) performed in 2015-2023. A rule-based text recognition algorithm was created and used to extract Prostate Imaging Reporting and Data System (PI-RADS) score and prostate volume from free-text MRI reports. Extracted data were validated against manually extracted information in the National Prostate Cancer Register (NPCR). We examined biopsy rates and Gleason score according to PI-RADS, Prostate Specific Antigen (PSA) density, and calendar year.

Results: The proportion of reports with identifiable PI-RADS scores increased from 38% in 2015-2016 to 83% in 2022-2023, with excellent agreement with NPCR data (correlation coefficient r = 0.94). Extracted prostate volumes correlated well with those in NPCR (r = 0.88). Biopsy rates decreased for PI-RADS 3 lesions over time, particularly in men with PSA density < 0.15 ng/ml/ml, while the proportion of men with PI-RADS 5 lesions who underwent biopsy increased. Almost all prostate cancers in men with PI-RADS 3 lesions were Gleason 6 or 7 (3+4). Gleason 9-10 was almost exclusively found in PI-RADS 5 lesions.

Conclusions: Automated extraction of information from unstructured MRI reports is feasible and accurate. The observed temporal trends reflecting increasing quality and standardization of prostate MRI support its use in large-scale epidemiological research.

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 ofa urinary tract antibiotic and secondary outcome was inpatient care for infection both within 30 days. Riskfactors 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).

A family history of prostate cancer in first-degree relatives is an established risk factor for prostate cancer, but the specific associations between prostate cancer characteristics in fathers and the risk of high-risk prostate cancer in their sons remain unclear. We identified men in Prostate Cancer data Base Sweden whose fathers had been diagnosed with prostate cancer in 1998-2005. We compared the observed number of prostate cancer diagnoses in these men with the expected number in the Swedish male population, estimating standardized incidence ratios (SIR). The median age of the 25,287 included sons of men with prostate cancer was 52 years (interquartile range 47-57 years) at end of follow-up. Their overall risk of a prostate cancer diagnosis was higher if the father had been diagnosed at less than 65 years old (SIR, 4.3, 95% confidence interval [CI], 3.8-5.0), compared with having a father diagnosed when 70 years old or older (SIR, 2.3; 95% CI 1.9-2.8). Sons of fathers diagnosed at less than 65 had a higher risk of Gleason score >= 8 cancers (SIR, 2.3; 95% CI 1.1-4.1) than sons of fathers diagnosed at 70 years old or older (SIR, 1.2; 95% CI 0.4-2.6). Having a father with a Gleason >= 8 cancer was associated with an increased risk for a Gleason >= 8 cancer (SIR, 2.6; 95% CI 1.1-5.1). These population-based results suggest that the father's prostate cancer characteristics should be considered when counseling men on prostate-specific antigen testing and diagnostic strategies.

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, afterTR 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) afterTP biopsy and 6.9% (n = 1,883) afterTR 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.