Background: Multi-parametric magnetic resonance imaging (mpMRI) is validated for the diagnosis of clinically significant prostate cancer (csPCa). ⁶⁸Ga-PSMA -11 PET/CT (PSMA-PET/CT) combined with mpMRI has improved negative predictive value over mpMRI alone for csPCa. The aim of this post-hoc analysis of the PRIMARY study was to evaluate the clinical significance of patterns of intra-prostatic PSMA activity, proposing a 5- point PRIMARY score to optimise accuracy of PSMA-PET/CT for csPCa in a low prevalence population. Methods: The PRIMARY trial is a prospective multi-centre phase II imaging trial that enrolled biopsy-naïve men with suspected PCa, no prior biopsy, recent mpMRI (6 months) and planned for prostate biopsy. 291 men underwent mpMRI, PSMA-PET/CT and systematic +/- targeted biopsy. The mpMRI was read separately using PI-RADS (V2). PSMA-PET/CT (pelvic only) was acquired a minimum 60 minutes post injection. PSMA-PET/CT was centrally read for pattern (diffuse transition zone (TZ), symmetrical central zone (CZ), focal TZ or peripheral zone (PZ), and intensity (SUV_max). In this post-hoc analysis, a 5-level PRIMARY score was assigned based on analysis of the central read: 1. No pattern, 2. Diffuse TZ or CZ (no focal), 3. Focal TZ, 4. Focal PZ or 5. SUV_max ≥ 12. Two further readers independently assigned a PRIMARY score to 118 scans for inter-rater agreement. Associations between PRIMARY score and csPCa (ISUP≥2) were evaluated. Results: Of 291 men enrolled, 162 (56%) had csPCa. PRIMARY score-1 was present in 16% (47), score-2 in 19% (55), score-3 in 10% (29), score-4 in 40% (117) and score-5 in 15% (43). The proportion of patients with csPCa and PRIMARY score 1 to 5 was 8.5% (4/47), 27% (15/55), 38% (11/29), 76% (89/117) and 100% (43/43) respectively. Sensitivity, specificity, PPV and NPV for PRIMARY score 1,2 (low-risk patterns) vs PRIMARY score 3-5 (high-risk patterns) was 88%, 64%, 76% and 81%, compared to 83%, 53%, 69% and 72% for PI-RADS (2 vs 3-5) on mpMRI. The inter-rater agreements for PRIMARY score 1,2 vs. PRIMARY score 3-5 was 0.76 (CI: 0.64-0.88) and 0.64 (CI: 0.49-0.78). Conclusion: A PRIMARY score incorporating intra-prostatic pattern and intensity on PSMA-PET/CT shows potential with high diagnostic accuracy for csPCa. Further validation is warranted prior to implementation.

Objective: To compare recurrent urinary tract infection (rUTI) guidelines from major urological and non‐urological organisations internationally and identify areas of consensus and discrepancy. Methods: PubMed, Google Scholar and the official webpages of major urological, gynaecological, infectious diseases and general practice organisations were searched for rUTI guidelines in March 2022. Nine guidelines were included for review: European Association of Urology, National Institute for Health and Care Excellence (NICE), Society of Obstetricians and Gynaecologists of Canada, American Academy of Family Physicians, Mexican College of Gynaecology and Obstetrics Specialists, Swiss Society of Gynaecology and Obstetrics, Spanish Society of Infectious Diseases and Clinical Microbiology, German Association of Scientific Medical Societies, and the combined American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. Results: The definition and evaluation of rUTIs, and antibiotic prophylaxis strategies, were mostly consistent across guidelines, and emphasised the importance of obtaining urine cultures and limiting cystoscopy and upper tract imaging in women without risk factors. Variable recommendations were noted for symptomatic treatment, self‐initiated antibiotics, and antibiotic‐sparing preventative strategies such as cranberry, vaginal oestrogen, immunoactive prophylaxis with OM‐89, intravesical glycosaminoglycan instillation, and phytotherapeutics. Recent randomised evidence supports the use of methenamine hippurate. Either continuous or post‐coital prophylactic antibiotics were supported by all guidelines. None of the guidelines were tailored to the management recurrent complicated UTI. Conclusion: Multiple rUTI guidelines were identified and mostly limited their recommendations to otherwise healthy non‐pregnant women with uncomplicated cystitis. Variation was noted, particularly in antibiotic‐sparing preventative strategies. Some conflicting recommendations are due to more recent guidelines including updated evidence. Future guidelines should consider recommendations to assist management of complex patient groups, such as recurrent complicated UTI.

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