A Prospective Randomized Trial Comparing a Combined Regimen of Amikacin and Levofloxacin to Levofloxacin Alone as Prophylaxis in Transrectal Prostate Needle Biopsy.

PURPOSE: We investigated whether addition of amikacin to levofloxacin-based antimicrobial prophylaxis reduces febrile urinary tract infections after transrectal ultrasound-guided prostate needle biopsy (TRUSB). MATERIALS AND METHODS: A total of 447 patients undergoing TRUSB were prospectively randomized into two groups. The 230 patients in Group A were given one oral dose of levofloxacin 400 mg prior to TRUSB; the 217 patients in Group B each received the same dose of levofloxacin and one 200 mg intravenous dose of amikacin. Patients' characteristics were assessed prior to TRUSB and their symptoms were checked after the TRUSB. RESULTS: Both regimens were well tolerated with no side effects. No statistically significant difference in patients' characteristics, or in incidence of inflammation- or infection-related symptoms was seen between the two groups; nor any significant difference among those who developed fever and those who did not. Two Group A patients and one Group B patient developed febrile urinary tract infections. Accountable pathogens determined by urine and blood cultures were fluoroquinolone-resistant E.coli and extended-spectrum ß-lactamase-producing E.coli. All pathogens isolated were levofloxacin-resistant, amikacin-susceptible species. CONCLUSION: Although the present study was under-powered by unexpectedly low overall incidence of febrile urinary tract infections, addition of one intravenous administration of amikacin to one oral administration of levofloxacin showed no advantage compared with levofloxacin alone as antimicrobial prophylaxis in TRUSB. Strikingly, all pathogens isolated from febrile patients were sensitive to amikacin in vitro. Therefore, further understanding of amikacin's drug kinetics in the prostate is necessary to develop a more efficient drug delivery system for amikacin.

[A case of percutaneous nephrolithotripsy for pediatric renal stone].

Urolithiasis in pediatric patients is relatively rare. Extracorporeal shock wave lithotripsy and endoscopic procedures play a major role in treating pediatric urolithiasis. A 3-year-old girl presented with macroscopic hematuria and right back pain and was diagnosed with a right renal stone (15 mm). Obstruction of ureteropelvic junction was suspected on computed tomography-urography and therefore the patient underwent percutaneous nephrolithotripsy (PNL). The operation was performed using a 12 Fr miniature nephroscope and Ho : YAG laser without any complications. This patient achieved a stone-free status. The stone analysis revealed a mixture of calcium oxalate and ammonium acid urate. PNL with a miniature nephroscope is safe and effective treatment for pediatric urolithiasis.

[Antimicrobial prophylaxis in radical prostatectomy : single dose versus 1-day treatment].

An adequate protocol for antimicrobial prophylaxis (AMP) in radical prostatectomy (RP) has not been established. We retrospectively compared the occurrence of perioperative infection following RP between two different AMP protocols. This study included 340 cases with prostate cancer who underwent RP at our institution between January 2005 and December 2008. The 1-day group consisting of 93 cases received a second generation cephem, cefotiam, intravenously during and after the operation on the operative day. The single dose group consisting of 247 cases received cefotiam during the operation only. The incidence of surgical site infection (SSI) and remote infection (RI) was retrospectively investigated. There was no significant difference in the rate of SSI and RI occurrence between the 1-day group (2.2, 0%) and single dose group (3.6, 0.4%) (p = 0.52). The single dose protocol of AMP seems sufficient for prevention of perioperative infection in RP.

Severe gastrointestinal hemorrhage due to metastatic renal cell carcinoma to the pancreas successfully controlled by transarterial embolization and adjuvant administration of Sunitinib Malate.

Metastatic renal cell carcinoma to the pancreas rarely causes massive gastrointestinal hemorrhage. Management of patients who cannot undergo pancreaticoduodenectomy is difficult. Here, we report a case of severe gastrointestinal hemorrhage that was successfully controlled by combination therapy of transarterial embolization and Sunitinib Malate administration. Transarterial embolization was effective in controlling the acute phase of hemorrhage, and Sunitinib Malate effectively achieved long term control. We propose that such combination therapy is useful for hemorrhagic events due to renal cell carcinoma.

[Experience on the use of extra slim gastrointestinal endoscopes in ileal conduit endoscopy].

Using extra slim gastrointestinal endoscopes, we have examined ileal conduits in two patients. This endoscope has almost the same caliber as a flexible cystoscope and has multiple manipulation levers and channels as ordinal gastrointestinal endoscopes. It is often difficult to examine ileal conduits with flexible cystoscopes because ileal conduits lack continent mechanisms and cannot be dilated adequately with water irrigation. With air insufflations, extra slim gastrointestinal endoscopes could adequately distend ileal conduits, and with multiple levers, they provided much more freedom of manipulation than flexible cystoscopes. Visualization of ureterointestinal anastomosis sites and biopsy of tumors could be performed very easily. We strongly recommend the use of extra slim gastrointestinal endoscopes than flexible cystoscopes when retrograde examinations and procedures are necessary in patients with ileal conduits.

Clinical outcome of conservative therapy with transurethral resection for patients with invasive bladder cancer who cannot tolerate cystectomy.

Among patients with invasive bladder cancer, there are patients who cannot tolerate cystectomy due to high age or comorbidities. We retrospectively reviewed 27 patients who were treated conservatively with transurethral resection (TUR). All patients had undergone TUR and 5 patients had received subsequent pelvic radiation therapy. The survival and control of local symptoms were analyzed statistically. Sixteen patients died of bladder cancer and 4 died of other causes with a median survival of 10 months. Seven patients were alive at a median follow up of 36 months. Tumor stage, grade and hydronephrosis at diagnosis were related with survival. Hematuria, bladder tamponade, and lower urinary tract obstruction could be controlled with TUR. However, those patients who complained of bladder irritative symptoms at diagnosis were likely to develop uncontrollable bladder irritability. Conservative treatment with TUR alone was an acceptable option in terms of survival for stage II patients with a short life expectancy. Even at more advanced stages, most of the local symptoms could be controlled with TUR. However, in patients with bladder irritability at diagnosis, the merit of cystectomy may outweigh its risk even among high age patients or those with severe comorbidities.

Ectopic adrenocorticotropic hormone syndrome in a case of small cell carcinoma of the bladder manifesting as severe muscle weakness.

Ectopic adrenocorticotropic hormone syndrome is a paraneoplastic syndrome associated with small cell carcinoma. However, ectopic adrenocorticotropic hormone syndrome is rare in association with small cell carcinoma of the bladder. We report what we believe to be the first case of ectopic adrenocorticotropic hormone syndrome associated with small cell carcinoma of the bladder that manifested as severe muscle weakness due to hypokalemia. An early diagnosis and aggressive potassium replacement is essential for retaining muscle strength. The patient died of pneumonia less than 2 months after the diagnosis. Severe immunosuppression by excess cortisol production was suspected. Control of cortisol levels before chemotherapy might be beneficial in preventing infective complications.

Immune thrombocytopenia during interferon-alfa therapy for renal cell carcinoma.

Immune thrombocytopenia is a rare complication of interferon-alfa (IFN-alpha). A patient with renal cell carcinoma developed severe thrombocytopenia during therapy with purified IFN-alpha. The patient's exposure to IFN, exclusion of other causes, and bone marrow biopsy were consistent with drug-induced immune thrombocytopenia. Cessation of IFN and corticosteroid administration resulted in the prompt recovery of platelets. The patient was re-challenged with recombinant IFN-alpha-2b under careful observation; there was no occurrence of severe thrombocytopenia. It was suggested that the difference of the subtypes composing IFN-alpha resulted in the lack of cross reactivity.