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UTIs are amongst the most frequent bacterial infections. However, the clinical phenotypes of UTI are heterogeneous and range from rather benign, uncomplicated infections to complicated UTIs (cUTIs), pyelonephritis and severe urosepsis. Stratification of patients with UTIs is, therefore, important. Several classification systems exist for the description and classification of UTIs, with the common rationale that cUTIs have a higher risk of recurrence or chronification, progression or severe outcome than uncomplicated UTIs. The pathophysiology and treatment of cUTIs and pyelonephritis are driven more by host factors than by pathogen attributes. cUTIs and pyelonephritis are associated with high antimicrobial resistance rates among causative pathogens. However, antimicrobial resistance rates can differ substantially, depending on the population being studied and whether the data being analysed are from surveillance studies, registry data or interventional studies, in which specific inclusion and exclusion criteria are used for patient selection. For example, antibiotic resistance rates are higher in patients with urosepsis than in those with less severe infections. Thus, treatment outcomes differ substantially among studies, ranging from 50% to almost 100% clearance of infection, depending on the patient population analysed, the UTI entities included and the primary outcome of the study. Pyelonephritis and cUTIs have emerged as infection models for the study of novel antibiotics, including extensive investigation of novel substances active against Gram-negative bacteria.Complicated UTI (cUTI) incidence and the prevalence of antibiotic resistance among uropathogens are increasing. Here, the authors discuss different cUTI classification systems, describe current understanding of the aetiology of cUTIs and outline clinical studies of novel antibiotics in patients with cUTIs or pyelonephritis and the use of UTI as a model for other infection types in clinical studies.

Key Points Male fertility is controlled by a Zn 2+ -dependent short circuit of the Krebs cycle within prostate epithelial cells Homeostasis of the prostate epithelium is reliant on the intracellular androgen-dependent accumulation of Zn 2+ and citrate Sperm motility requires the coordinated action of the components of the two main fluids in the human seminal plasma: the prostatic fluid, which is enriched with Zn 2+ , citrate and kallikreins, and the semenogelin-enriched seminal vesicle secretion The prostate is the direct target for a number of benign and malignant diseases that are potentially linked to impaired fertility status Prostatitis might be directly linked with changes in fertility The prostate gland is the major male reproductive gland involved in male fertility. In this Review, the authors discuss the reproductive function of the prostate gland, summarizing physiological and molecular mechanisms that connect prostate homeostasis with male fertility and describing how these mechanisms are associated with prostatic diseases. They highlight the central role of Zn 2+ and citrate in regulating activities of the prostate epithelium, discuss the influence of bacteria-related prostate inflammation on male fertility, and note the potential role of prostatic inflammation in the development of prostatic hyperplastic growth and prostate carcinogenesis. Ejaculation is a synchronized cascade of events that has the ultimate goal of activating sperm and enabling them to reach an egg for fertilization. The seminal plasma contains a complex mixture of fluids that is secreted from the testes, epididymis and male accessory glands. The prostate gland has a pivotal role in this process, as prostatic fluid enriched in Zn 2+ , citrate and kallikreins is crucial for the molecular synchronization of the functional cascade triggered by ejaculatory stimuli. The prostate is the target of a number of common diseases that can affect male fertility at different ages. In both young and aged men, prostatic diseases or an unhealthy prostate can affect spermatozoa functioning and, therefore, male fertility. Consideration of prostate physiology emphasizes a number of points: the central role of Zn 2+ and citrate in the regulation of prostate epithelium homeostasis and in ejaculation; the influence of bacteria-related prostatic inflammation on male fertility; and the potential role of prostatic inflammation in promoting the development of prostatic hyperplastic growth and carcinogenesis.

Inflammation is inherent in prostatic diseases and it is now accepted that it may facilitate cellular proliferation in both benign and malignant conditions. The strong relationship between prostatic inflammation and pathogenesis of benign prostatic hyperplasia (BPH) is supported by epidemiologic, histopathologic and molecular evidence. Contrariwise, the role of inflammation in prostate carcinogenesis is still controversial, although current data indicate that the inflammatory microenvironment can regulate prostate cancer (PCa) growth and progression. Knowledge of the complex molecular landscape associated with chronic inflammation in the context of PCa may lead to the introduction and optimization of novel targeted therapies. In this perspective, evaluation of the inflammatory component in prostate specimens could be included in routine pathology reports.

Background Recently, renal angioembolization (RAE) has gained an important role in the non-operative management (NOM) of moderate to high-grade blunt renal injuries (BRI), but its use remains heterogeneous. The aim of this review is to examine the current literature on indications and outcomes of angioembolization in BRI. Methods We conducted a search of MEDLINE, EMBASE, SCOPUS and Web of Science Databases up to February 2021 in accordance with PRISMA guidelines for studies on BRI treated with RAE. The methodological quality of eligible studies and their risk of bias was assessed using the Newcastle–Ottawa scale Results A total of 16 articles that investigated angioembolization of blunt renal injury were included in the study. Overall, 412 patients were included: 8 presented with grade II renal trauma (2%), 97 with grade III renal trauma (23%); 225 with grade IV (55%); and 82 with grade V (20%). RAE was successful in 92% of grade III–IV (294/322) and 76% of grade V (63/82). Regarding haemodynamic status, success rate was achieved in 90% (312/346) of stable patients, but only in 63% (42/66) of unstable patients. The most common indication for RAE was active contrast extravasation in hemodynamic stable patients with grade III or IV BRI. Conclusions This is the first review assessing outcomes and indication of angioembolization in blunt renal injuries. The results suggest that outcomes are excellent in hemodynamic stable, moderate to high-grade renal trauma.

BackgroundA 68-year-old man died of cerebral arterial embolism 6 days after transrectal prostate biopsy with a single p.o. dose of trimethoprim sulfamethoxazole (TMP-SMX) as prophylaxis. The case precipitated analysis of local antibiotic resistance and complication rates.Materials and methodsData on E. coli resistance from Oslo University Hospital and national data on hospitalizations and mortality after biopsy were retrieved from local microbiology files and the Norwegian Patient Registry (NPR) 2011–2017.ResultsUrine E. coli resistance against TMP-SMX increased from 35% in 2013 to more than 60% in 2015. For ciprofloxacin, the resistance increased from 15% in 2013 to about 45% in 2016. The highest annual E. coli resistance in blood cultures for TMP-SMX and ciprofloxacin was 37% and 28%, respectively. 10% of patients were hospitalized with a diagnosis of infection within the first 60 days after biopsy and there was a relative increase in mortality rate of 261% within the first 30 days. Due to the severity of the figures, the story and the NPR data were published in Norway’s leading newspaper and were succeeded by a series of chronicles and commentaries.ConclusionsSeveral critical points of the biopsy procedure were not performed according to current standards. We believe that the patient might have died of septic embolism after biopsy. As a result of the findings and the debate, local practice was changed from transrectal to transperineal prostate biopsies.

Complicated urinary tract infections denote an important research field for new antibiotics against Gram-negative pathogens. There is, however, increasing concern that this disease entity is too vaguely defined, leading to heterogeneous study populations and risk of bias. We analysed researchers’ adherence to the US Food and Drug Administration (FDA) guidance on complicated urinary tract infection and assessed risk of bias using a three-step procedure: literature review of full-text articles on complicated urinary tract infection; assessment of the importance of risk factors for treatment failure, including statistical evaluation of how patients with risk factors might skew treatment effects; and a Delphi consensus process in a multidisciplinary group. Our evaluation showed poor adherence to FDA guidance on complicated urinary tract infection and significant heterogeneity in the reporting of study, patient, and pathogen characteristics, leading to a high risk of bias when interpreting and comparing study findings. We therefore question the concept of complicated urinary tract infection as a meaningful entity with its own study guidance.

Background/Objectives: Small renal masses (SRMs) are being detected more often due to the increasing use of imaging techniques. Many of these lesions are benign or grow slowly, but a small proportion can exhibit aggressive behavior. Several reports have shown that synchronous metastases may occur even in small renal cell carcinomas (RCCs). Our aim is to assess the malignant potential and the metastatic risk of very small RCCs (≤2 cm). Methods: We reviewed consecutive patients who underwent partial nephrectomy for SRMs at our tertiary referral center between 2005 and 2024, focusing on those with a maximum pathologic diameter ≤ 2 cm. Clinical and pathological data were collected, and cases with aggressive features were described. In addition, a literature search on the Medline/PubMed database was performed to identify previously published cases of RCC ≤ 2 cm and to assess their risk of synchronous metastases (SM). Results: Among 578 patients who underwent partial nephrectomy, 116 patients (20%) had tumors ≤ 2 cm, 90 (77.5%) of which were malignant, whereas 22.5% were benign (oncocytoma = 13%; angiomyolipoma = 5%). Median age and tumor size were 51 yrs and 1.7 cm, respectively. Histology showed clear cell (72.2%), papillary (20%), chromophobe (6.6%), and mixed (0.9%). Two patients (2.2%) experienced aggressive disease: one with synchronous metastases and one with recurrence and later progression. From the literature, we identified 16 additional cases of RCC ≤ 2 cm with synchronous metastases and found an important heterogeneity of results regarding the metastatic potential of SRMs. Conclusions: Although uncommon, synchronous metastases can occur in RCCs even smaller than 1–2 cm. Reported rates for SM of SRMs across the literature range between 1% and 13%, with higher risk observed in tumors larger than 3 cm, but without an absolute safe cutoff. Tumor size alone is therefore insufficient to exclude aggressive potential. Clinical decision-making should consider histology, grade, patient age, radiologic features, and emerging molecular markers to guide surveillance and treatment in this growing patient population.

PurposeTo evaluate and report the complications, and to analyse antimicrobial stewardship aspects following prostate biopsies (P-Bx) based on the data from a 9-year global study.MethodsThe primary outcome was to compare complications after P-Bx between patients of two cohorts: 2010–2014 and 2016–2019. Primary outcomes included symptoms of lower and severe/systemic urinary tract infection (LUTIS and SUTIS, respectively), and positive urine culture. Readmission to hospital after P-Bx, need for additional antimicrobial therapy, consumption of different antimicrobial agents for prophylaxis and therapy were evaluated. Students t test and chi-square test were used for comparative analyses. ResultsOutcome data were available for 1615 men. Fluoroquinolones-based prophylaxis rate increased from 72.0% in 2010–2014 to 78.6% in 2015–2019. Overall rates of complications increased from 6 to 11.7% including an increase in symptomatic complications from 4.7 to 10.2%, mainly due to an increase in LUTIS. Rates of patients seeking additional medical help in primary care after P-Bx increased from 7.4 to 14.4%; cases requiring post P-Bx antibiotic treatment increased from 6.1 to 9.7%, most of which received fluoroquinolones. Transperineal P-Bx was significantly associated with LUTIS. Following transrectal P-Bx, 2.8% developed febrile infections and 4.0% required hospitalisation. Two men (0.12%) died after transrectal P-Bx due to sepsis. ConclusionsThe rates of complications after P-Bx tended to increase in time, as well as rates of patients seeking additional medical help in the post-P-Bx period. To reduce the risk of infectious complications and to comply with the principles of antibiotic stewardship, clinicians should switch to the transperineal biopsy route.