Injectable Penile Enhancement Procedures: A Review of Agents, Risks, and Complications.

Penile dysmorphophobic disorder describes men who feel their normal penile size is inadequate. Penile fillers have been used to address penile size dissatisfaction. However, unpredictability of these procedures can yield unfavorable outcomes. Reactions to these foreign bodies are inherently uncertain, owing to an array of materials, concentrations, and biocompatibility. Management of complications also varies. As fillers are more commonly used in cosmetic procedures to augment facial features, most genitourinary surgeons are unfamiliar with these therapies. This review seeks to describe the available materials, techniques, and risk profiles of the various types of fillers used for penile augmentation.

Procedural Intervention for Benign Prostatic Hyperplasia in Men ≥ Age 70 Years - A Review of Published Literature.

Objective: We set out to review studies reporting on the use of surgical intervention to treat Benign Prostatic Hyperplasia in elderly men ≥70 years of age. Methods: A systematic literature search was conducted using Scopus, PubMed-MEDLINE, Cochrane, and Wiley Online Library databases including studies published between January 2012 through December 2022. This 10-year interval was chosen given the recent plethora of new modalities that have entered the BPH armamentarium, many of which have been marketed as appropriate for older and high-risk patients. The following database search words were used either individually or in conjunction: "BPH", "elderly", "surgical", "ablation", "resection", "embolization", and "aging". Results: We identified 28 studies for inclusion in this review. The pros and cons of these modalities are presented, specifically as applicable to an older and higher risk population. Conclusion: There are a wide variety of surgical procedures available for surgically treating BPH in elderly men with varying states of health. Each of these comes with different risks and benefits, supporting that individualized approaches are important. Long-term data and further studies comparing modalities, specifically as regards the elderly and frail, would enhance our approaches to BPH treatment in this patient population.

A scoping review of office-based prostatic stents: past, present, and future of true minimally invasive treatment of benign prostatic hyperplasia.

PURPOSE: To conduct a scoping review of the existing literature and recent developments on prostatic stents for the treatment of benign prostatic hyperplasia (BPH). METHODS: A comprehensive search was performed on Embase, MEDLINE, and Web of Science to identify English literature on prostatic stents for the treatment of BPH. Additional studies and upcoming devices were identified through grey literature search and expert consultation. Study characteristics and stent information were extracted and tabulated narratively. RESULTS: Of the 1171 search results, 64 studies were included in this review. iTiND was the prostatic stent with the most long-term evidence. iTiND is a safe and effective minimally invasive treatment for BPH that preserves sexual function. Adverse events are mild and transitory. Emerging stents (e.g. Zenflow, Butterfly, Urocross, and Exime) had 7/64 eligible studies, where no studies had long-term follow-up. These newer stents show promising results for quality of life and BPH symptom management; however, long-term monitoring and head-to-head comparisons are needed. CONCLUSION: Over the last 50 years, prostatic stents have evolved and demonstrated improved clinical efficacy. iTiND provides a safe and effective outpatient treatment of LUTS secondary to BPH preserving erectile and ejaculatory function. Emerging prostatic stents are a promising, effective, and safe intervention in well-selected patients interested in its benefits.

Enterococcal Urinary Tract Infections: A Review of the Pathogenicity, Epidemiology, and Treatment.

Urinary tract infections (UTIs) are among the most common causes of infections worldwide and can be caused by numerous uropathogens. Enterococci are Gram-positive, facultative anaerobic commensal organisms of the gastrointestinal tract that are known uropathogens. Enterococcus spp. has become a leading cause of healthcare associated infections, ranging from endocarditis to UTIs. In recent years, there has been an increase in multidrug resistance due to antibiotic misuse, especially in enterococci. Additionally, infections due to enterococci pose a unique challenge due to their ability to survive in extreme environments, intrinsic antimicrobial resistance, and genomic malleability. Overall, this review aims to highlight the pathogenicity, epidemiology, and treatment recommendations (according to the most recent guidelines) of enterococci.

Ejaculatory Preserving Holmium Laser Enucleation of the Median Lobe: Preserving Sexual Function While Improving Urinary Outcomes.

OBJECTIVE: To evaluate perioperative outcomes related to sexual and urinary function in patients who underwent a holmium laser enucleation of the prostate (HoLEP) with selective laser enucleation of the median lobe. MATERIALS AND METHODS: We retrospectively reviewed the first 450 HoLEP cases by a single surgeon from April 2019 to March 2022. Fifty-five patients with intravesical-prostatic protrusion or high bladder neck without obstructing lateral lobes underwent selective enucleation of the median lobe of the prostate. Patients were asked to comment on whether they had retrograde ejaculation during their follow-up appointment. Urinary function was assessed using the American Urological Association Symptom Score and subjective evaluation of urinary incontinence. RESULTS: Median age of the cohort was 65 years (range: 44-91). Compared to preoperative, there was significant improvement in mean postoperative American Urological Association Symptom Score (22.5 vs 6.9, P < .001), mean postoperative quality of life scores (4 vs 1.2, P < .001), and mean postoperative post void residual volumes (244.1 vs 69.3 cc, P < .001). No patients reported stress urinary incontinence. Of the 55 patients who underwent selective enucleation of the median lobe, 40 were sexually active. Of those men, 35 reported normal ejaculation, 3 had retrograde ejaculation that was unchanged from pre-op, and 2 had new ejaculatory dysfunction. CONCLUSION: In this case series of selective laser enucleation of the median lobe, urinary function significantly improved in short-term follow-up with preservation of ejaculation in approximately 90% of men.

Development of a North American coordinated registry network for surgical treatment of benign prostatic hyperplasia.

PURPOSE: To create a prospective, multicenter coordinated registry network (CRN) of robust "real world" data for benign prostatic hyperplasia (BPH) that links surgical practices to objective and subjective outcomes of patients who undergo surgery for the improvement in lower urinary tract symptoms (LUTS) secondary to BPH. METHODS: We gathered a group of BPH experts from various institutions to identify the minimum core data elements needed to assess BPH procedures. To achieve consensus on the data elements, we used a Delphi method adaptation, in which a series of surveys were answered by the expert panel individually and anonymously. Survey results were collected and analyzed. Questions for the following round were based on response analysis from the prior survey. This process was repeated until consensus was achieved. RESULTS: Participation rates in the first and second rounds were 100% and 90%, respectively. The expert panel reached consensus on 148 data elements out of the 182 proposed, capturing patient medical and surgical history, procedure, discharge, short- and long-term follow-up, device factors, surgery, and surgeon factors. CONCLUSION: We have successfully developed a set of core data elements to support the study of BPH surgical therapies by gathering an expert panel on BPH and using the Delphi method. These data elements influence provider decisions about treatment and include important outcomes related to efficacy and safety.

Aquablation Treatment for Benign Prostate Hyperplasia: Current Standardized Procedure.

The following video Atlas summary reviews all technical elements of the standardized setup, robotic execution, aquablation procedure, and hemostasis for efficient rapid benign prostate hyperplasia treatment.

What we know about intra-operative radiation exposure and hazards to operating theatre staff: A systematic review.

BACKGROUND: The widespread adoption of minimally invasive surgery and increased use of intra-operative fluoroscopy places surgeons and trainees at risk of cumulative occupational radiation exposure. Unfortunately, there is limited published data specific to surgeons on the potential health implications. This study aims to review current literature regarding the hazards of cumulative radiation exposure among operating theatre staff. METHODS: A systematic review was conducted of four databases for studies reporting on cumulative intra-operative radiation exposure for operating theatre staff and the hazards associated with prolonged and frequent use. References from relevant studies were screened for additional texts. English language studies, controlled trials and cross-sectional studies were included. Abstracts and full-text studies were assessed for relevance and eligibility independently by two authors using Covidence. RESULTS: Six studies were included, with cancer being the most commonly reported long-term health hazard possibly associated with cumulative radiation exposure. A 1.85 fold greater prevalence of all cancers and 2.9 fold greater prevalence of breast cancer was reported amongst female orthopaedic surgeons compared to a sex- and age-adjusted population, but the results were not replicated amongst other surgical specialties. Multiple limitations of quantifying health risks of intra-operative radiation exposure were identified, including identifying a dose-effect relationship and confounders such as nulliparity and maternal age. CONCLUSION: This article highlights the lack of robust evidence regarding the potential hazards of cumulative occupational intra-operative radiation exposure. This study demonstrates the importance of developing standardised national radiation safety protocols for surgical colleges and subspecialties to minimise risks to operating theatre staff.

Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment.

PURPOSE: Surgical therapies for symptomatic bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH) are many, and vary from minimally invasive office based to high-cost operative approaches. This Guideline presents effective evidence-based surgical management of male lower urinary tract symptoms secondary/attributed to BPH (LUTS/BPH). See accompanying algorithm for a detailed summary of procedures (figure[Figure: see text]). MATERIALS/METHODS: The Minnesota Evidence Review Team searched Ovid MEDLINE, Embase, Cochrane Library, and AHRQ databases to identify eligible studies published between January 2007 and September 2020, which includes the initial publication (2018) and amendments (2019, 2020). The Team also reviewed articles identified by Guideline Panel Members. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, information is provided as Clinical Principles and Expert Opinions (table[Table: see text]). RESULTS: Twenty-four guideline statements pertinent to pre-operative and surgical management were developed. Appropriate levels of evidence and supporting text were created to direct urologic providers towards suitable and safe operative interventions for individual patient characteristics. A re-treatment section was created to direct attention to longevity and outcomes with individual approaches to help guide patient counselling and therapeutic decisions. CONCLUSION: Pre-operative and surgical management of BPH requires attention to individual patient characteristics and procedural risk. Clinicians should adhere to recommendations and familiarize themselves with criteria that yields the highest likelihood of surgical success when choosing a particular approach for a particular patient.

Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART I-Initial Work-up and Medical Management.

PURPOSE: Benign prostatic hyperplasia (BPH) is a histologic diagnosis describing proliferation of smooth muscle and epithelial cells within the prostatic transition zone. The prevalence and severity of lower urinary tract symptoms (LUTS) in aging men are progressive and impact the health and welfare of society. This revised Guideline provides a useful reference on effective evidence-based management of male LUTS/BPH. See the accompanying algorithm for a summary of the procedures detailed in the Guideline (figures 1 and 2[Figure: see text][Figure: see text]). MATERIALS AND METHODS: The Minnesota Evidence Review Team searched Ovid MEDLINE, Embase, Cochrane Library, and AHRQ databases to identify eligible English language studies published between January 2008 and April 2019, then updated through December 2020. Search terms included Medical Subject Headings (MeSH) and keywords for pharmacological therapies, drug classes, and terms related to LUTS or BPH. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, information is provided as Clinical Principles and Expert Opinions (table 1[Table: see text]). RESULTS: Nineteen guideline statements pertinent to evaluation, work-up, and medical management were developed. Appropriate levels of evidence and supporting text were created to direct both primary care and urologic providers towards streamlined and suitable practices. CONCLUSIONS: The work up and medical management of BPH requires attention to individual patient characteristics, while also respecting common principles. Clinicians should adhere to recommendations and familiarize themselves with standards of BPH management.

Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2020.

PURPOSE: The AUA Guideline panel provides evidence-based recommendations for the surgical management of male lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: The Panel amended the Guideline in 2020 to reflect additional literature published through September 2019. When sufficient evidence existed, the Panel assigned the body of evidence a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, the Panel provided additional information as Clinical Principles and Expert Opinions (See table 1[Table: see text]). RESULTS: Amendments to these Guidelines include: 1) an amended statement (Guideline 1) to include conducting a physical examination; 2) a new statement (Guideline 6) discussing concepts of treatment failure and retreatment; 3) an amended statement (Guideline 15) with updated supporting text for prostatic urethral lift (PUL); 4) an amended statement (Guideline 16) for PUL; 5) an amended statement (Guideline 17) with updated supporting text for transurethral microwave therapy (TUMT); 6) an amended statement (Guideline 18) with updated supporting text for water vapor thermal therapy; 7) updated supporting text for water vapor thermal therapy (Guideline 19); 8) an amended statement (Guideline 21) with updated supporting text for laser enucleation; 9) an amended statement (Guideline 22) with updated supporting text for Aquablation; and 10) an amended statement (Guideline 23) with updated supporting text for Prostate Artery Embolization (PAE). CONCLUSIONS: These evidence-based updates to the AUA Guidelines further inform the surgical management of LUTS/BPH.

Re-evaluation of birth trends and pregnancy complications among female urologists: Have we made any progress?

AIMS: Females are becoming surgeons at ever-increasing rates and doing so while many have or wish to have children. This study follows up on a 2007 effort to study the problems and conditions such women faced. We ask here if these challenges are different after a decade that included changes in working rules. METHODS: A survey was sent to all female American Board of Urology diplomates. Birth trends, pregnancy complications, infertility service requirements, and satisfaction were evaluated in respondents (n = 183) and compared to the previous survey of female urologists who completed residency before August 2007 as well as Center for Disease Control data. RESULTS: Seventy-six physicians completed the survey who were residents before 2007, while 107 replied who experienced residency after. The first group's average age was 50.2 and the second's 38.3. Overall, these women gave birth 6 to 7 years later than the US mean. Complications did not decrease, infertility occurred at similar levels, and both were higher than US norms. Length of maternity leave correlated with respondents' level of overall satisfaction. The most positive responses came from those with more than 8 weeks off (P = .002). CONCLUSIONS: Women practicing in urology gave birth later, had greater fertility issues, used assisted reproductive technology (ART) more and reported a higher level of at least one complication during pregnancy than American women overall. Changes in hours and awareness of this issue have not made giving birth a healthier event for these physicians. Further investigation into factors other than work hours is needed.

Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2019.

PURPOSE: Male lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is common in men and can have negative effects on quality of life (QoL). It is the hope that this Guideline becomes a reference for effective evidence-based surgical management of LUTS/BPH. MATERIALS AND METHODS: The evidence team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality database to identify studies indexed between January 2007-September 2017. Following initial publication, this guideline was amended in 2019 and reflects relevant literature published through January 2019. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1 in supplementary unabridged guideline, https://www.jurology.com). RESULTS: This Guideline provides evidence-based recommendations regarding management of LUTS/BPH utilizing surgery and minimally invasive surgical therapies (MIST). Additional statements are made regarding diagnostic and pre-operative tests. Clinical statements are made in comparison to what is generally accepted as the gold standard (i.e. transurethral resection of the prostate [TURP] monopolar and/or bipolar). This guideline is designed to be used in conjunction with the associated treatment algorithm (see figure).[Figure: see text]Conclusions:The prevalence and the severity of LUTS increases as men age and is an important diagnosis in the healthcare of patients and the welfare of society. This document will undergo updating as knowledge regarding treatments and future surgical options continues to expand.

Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline.

PURPOSE: Male lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is common in men and can have negative effects on quality of life (QoL). It is the hope that this Guideline becomes a reference on the effective evidence-based surgical management of LUTS/BPH. MATERIALS AND METHODS: The evidence team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality (AHRQ) database to identify studies indexed between January 2007 and September 2017. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1 in supplementary unabridged guideline, http://jurology.com/). RESULTS: This Guideline provides updated, evidence-based recommendations regarding management of LUTS/BPH utilizing surgery and minimally invasive surgical therapies; additional statements are made regarding diagnostic and pre-operative tests. Clinical statements are made in comparison to what is generally accepted as the gold standard (i.e. transurethral resection of the prostate [TURP]-monopolar and/or bipolar). This guideline is designed to be used in conjunction with the associated treatment algorithm. CONCLUSIONS: The prevalence and the severity of LUTS increases as men age and is an important diagnosis in the healthcare of patients and the welfare of society. This document will undergo additional literature reviews and updating as the knowledge regarding current treatments and future surgical options continues to expand.

Laser prostate ablation and enucleation: Analysis of a national cohort.

OBJECTIVE: To compare characteristics and outcomes of benign prostatic hyperplasia patients undergoing prostate laser ablation with those undergoing laser enucleation using a nationwide cohort. METHODS: Men who underwent prostate laser ablation (n=10054) or laser enucleation (n=1705) between 2011 and 2015 were identified by the common procedural terminology code as recorded in the National Surgical Quality Improvement Program database. Preoperative, intraoperative and postoperative parameters were compared between the groups using univariate and multivariate analysis. RESULTS: Prostate laser ablation patients were older, had more comorbidities and were more likely to have abnormal laboratory values. Enucleations were significantly longer and more likely to result in a hospital stay >1day. Enucleation patients were also more likely to require a blood transfusion postoperatively, but less likely to experience urinary tract infection and sepsis on both univariate and multivariate analysis adjusted for preoperative and intraoperative factors. CONCLUSIONS: Although laser enucleation and prostate laser ablation are both considered minimally invasive techniques, significant differences in patient selection, intraoperative factors and postoperative complications are identified in this national cohort. The present study shows that despite similar outcomes in prospective single-center studies, prostate laser ablation and laser enucleation have distinct practice patterns in a broader national context.

Perioperative antithrombotic therapy in patients undergoing endoscopic urologic surgery: where do we stand with current literature?

The number of patients on chronic anticoagulant or antiplatelet therapy requiring endoscopic urological surgery is increasing worldwide. Therefore, there is a strong demand to standardize the perioperative treatment of this cohort of patients, both from a surgical and cardiological point of view, balancing the risks of bleeding versus thrombosis, and the important possible clinical and medical legal repercussions therein. Although literature is scarce and the quality of evidence quite low, in line with other surgical specialties, guidelines and recommendations for the management of urological patients have begun to emerge. The aim of this review is to analyze current available literature and evidence on the most common endoscopic procedures performed in this high-risk group of patients, focusing on the perioperative management. In particular, to analyze the most frequently performed endoscopic procedures for the treatment of benign prostate enlargement (transurethral resection of the prostate, Thulium, Holmium and greenlight laser prostatectomy), bladder cancer (transurethral resection of the bladder), upper urinary tract urothelial cancer, and nephrolithiasis. Despite the lack of randomized studies, regardless of individual patient considerations, studies would support continuation of acetylsalicylic acid, which is recommended by cardiologists, in patients with intermediate/high risk of coronary thrombosis. In contrast, multiple studies found that bridging with light weight molecular weight heparin can potentially lead to more bleeding than continuation of the anticoagulant(s) and antiplatelet therapy, and caution with bridging is advised. All urologists should familiarize themselves with emerging guidelines and recommendations, and always be prepared to discuss specific cases or scenarios in a dedicated multidisciplinary team.

Holmium laser for the surgical treatment of benign prostatic hyperplasia.

INTRODUCTION: Holmium laser ablation of the prostate (HoLAP) is a surgical approach for treatment of benign prostatic hyperplasia (BPH). Limited evidence suggests laser ablation/vaporization is inferior to enucleation with respect to reoperation rates. Our objective was to determine if properly performed laser ablation results in outcomes similar to enucleation. MATERIALS AND METHODS: A total of 198 patients with moderate to severe lower urinary tract symptoms and/or acute urinary retention had holmium laser enucleation of the prostate (HoLEP) or HoLAP between 2008 and 2014. Patients with metastatic prostate cancer, prior pelvic radiation, or bladder cancer involving the bladder neck or prostatic urethra were excluded. All procedures involved residents and were supervised by one experienced surgeon. The decision to perform HoLAP versus HoLEP was made intraoperatively. Demographics, pre, peri and postoperative data were collected. RESULTS: A total of 169 men were analyzed: 54 had HoLAP and 115 had HoLEP. Mean follow up was 27.16 months for HoLAP, and 38.18 months for HoLEP. As expected, the HoLEP group had larger prostates, longer mean operative times, and greater reduction in total PSA. There was no difference in the net change of flow rate between groups. CONCLUSION: Both HoLEP and HoLAP are appropriate surgical interventions for the management of BPH, when properly performed. Our findings suggest that adequate ablation of prostatic adenoma results in similar 2 year outcomes as enucleation.

Laser prostate enucleation techniques.

INTRODUCTION: Laser treatment of benign prostatic hyperplasia (BPH) through enucleation techniques has become increasingly more utilized in the field of urology. Laser enucleation of the prostate (LEP) is a transurethral procedure that employs several different types of lasers to dissect the adenoma from the surgical capsule in a retrograde fashion. MATERIALS AND METHODS: We review basic laser physics and current laser prostate enucleation techniques. Holmium-LEP (HoLEP), Thulium-LEP (ThuLEP), Greenlight-LEP (GreenLEP) and Diode-LEP (DiLEP) applications are discussed. We summarize the current literature with respect to functional outcomes and complications. RESULTS: Although each laser device used for prostate enucleation has the same goal of removal of the adenoma from the surgical capsule, each has unique characteristics (i.e. wavelength, absorption rates) that must be understood by the practicing surgeon. Mastery of one LEP technique does not necessarily translate into facile use of an alternative enucleation energy source and/or approach. The various LEP techniques have demonstrated similar, if not superior, postoperative results to transurethral resection of the prostate (TURP), the current gold standard in the treatment of BPH. CONCLUSIONS: This article outlines the current LEP techniques and should serve as a quick reference for the practicing urologist.

Comparative Effectiveness of Single versus Combination Antibiotic Prophylaxis for Infections after Transrectal Prostate Biopsy.

An increase in fluoroquinolone resistance and transrectal ultrasound-guided prostate (TRUS) biopsy infections has prompted the need for alternative effective antibiotic prophylaxis. We aimed to compare ciprofloxacin and other single-agent therapies to combination therapy for efficacy and adverse effects. Men who underwent a TRUS biopsy within the VA Boston health care system with documented receipt of prophylactic antibiotics periprocedure were eligible for inclusion. Postprocedure infections within 30 days were ascertained by chart review from electronic records, including any inpatient, outpatient, or urgent-care visits. Among 455 evaluable men over a 3-year period, there were 25 infections (5.49%), with sepsis occurring in 2.4%, urinary tract infections (UTI) in 1.54%, and bacteremia in 0.44% of patients. Escherichia coli was the most common urine (89%) and blood (92%) pathogen, with fluoroquinolone resistance rates of 88% and 91%, respectively. Ciprofloxacin alone was associated with significantly more infections than ciprofloxacin plus an additional agent (P = 0.014). Intramuscular gentamicin alone was also significantly associated with a higher infection rate obtained with all other regimens (P = 0.004). Any single-agent regimen, including ciprofloxacin, ceftriaxone, or gentamicin, was associated with significantly higher infection rates than any combination regimen (odds ratio [OR], 4; 95% confidence interval [CI], 1.47, 10.85; P = 0.004). Diabetes, immunosuppressive condition or medication, hospitalization within the previous year, and UTI within the previous 6 months were not associated with infection risk. Clostridium difficile infections were similar. These findings suggest that ciprofloxacin, ceftriaxone, and gentamicin alone are inferior to a combination regimen. Institutions with high failure rates of prophylaxis for TRUS biopsies should consider combination regimens derived from their local data.