Lower Dose of 5 mL of 1% Lidocaine is More Suitable than the Conventional 10 mL for Caudal Block in Transrectal Prostate Biopsy: A Retrospective Cohort Study.

Objectives: In Japan, caudal block with 1% lidocaine is commonly used for transrectal prostate biopsy. Although 10 mL of 1% lidocaine is commonly used, the appropriate dosage of 1% lidocaine has not been studied. Our hospital routinely uses two different doses (5 or 10 mL) of 1% lidocaine for caudal block for transrectal prostate biopsy. Herein, we retrospectively evaluated the efficacy and safety of both doses of 1% lidocaine. Methods: This retrospective study included 869 patients who underwent transrectal prostate biopsy with caudal block at our hospital. The amount of 1% lidocaine was determined by the day of the week on which the biopsy was performed, and the patient voluntarily chose the day of the biopsy, unaware of the dose of 1% lidocaine used on that day. Pain, anal sphincter tonus, cancer diagnosis rate, and early complications were compared. Results: In total, 466 and 403 patients received 5 and 10 mL of 1% lidocaine for a caudal block, respectively. After propensity-score matching for patient characteristics, each group contained 395 patients. The pain score, anal sphincter tonus score, or prostate cancer diagnosis rate were not significantly different between the two groups. However, rectal bleeding was significantly more frequent and severe in the 10-mL than the 5-mL group (p=0.018 and p=0.0036, respectively). The incidence of other complications was not significantly different between the groups. Conclusions: Our results suggest that 5 mL of 1% lidocaine may be more suitable than 10 mL for caudal block during transrectal prostate biopsy.

[A Rare Case of Adrenal Metastasis Diagnosed before Discovery of Invasive Ductal Breast Cancer which was Confirmed to Be the Primary Site].

A 54-year-old female underwent open left adrenalectomy for a left adrenal tumor in 2013. The pathology showed metastatic poorly differentiated adenocarcinoma. Despite a close examination, the primary tumor could not be identified. During the follow-up, a computed tomographic scan showed a hyper vascular tumor in the left breast in2015. A left mastectomy was performed for diagnosis and treatment. The pathology showed invasive ductal carcinoma of the breast. Comparing the histopathology and immunohistochemistry of the breast tumor with the adrenal tumor, the adrenal tumor was finally confirmed as metastatic invasive ductal carcinoma. Adrenal gland metastasis from invasive ductal carcinoma is said to be extremely rare. To our knowledge, there have been no reports of cases in which metastatic invasive ductal carcinoma of the adrenal gland was found before the primary site. We report this case with some literature review.

Assessment of bone health in patients with prostate cancer using cancer staging computed tomography.

PURPOSE: To evaluate the utility of vertebral Hounsfield unit (HU) values from computed tomography (CT) in cancer staging as a supplementary screening tool for bone health among prostate cancer (PCa) patients. METHODS: T-scores of bone mineral density (BMD) in each lumbar vertebra (L1-L4) and hip for newly diagnosed PCa patients (N = 139) were measured using dual-energy X-ray absorptiometry (DXA). The degenerative changes in each lumbar vertebra were assessed, and the HU values of trabecular bone in axial CT images of each vertebral body (vertebral CT-HU value) were measured using staging CT. RESULTS: 556 vertebrae were analyzed. 326 of 556 (59%) lumbar vertebrae had degenerative changes. The vertebral CT-HU value was positively correlated with the lumbar BMD T-score, with higher correlation coefficients observed in vertebrae without degenerative changes (r = 0.655, N = 230) when compared to vertebrae with degenerative changes (r = 0.575, N = 326). The thresholds matching BMD T-scores of - 2.0 and - 1.5 set by cancer treatment-induced bone loss guidelines were 95 HU and 105 HU, respectively. Based on the intervention threshold (lumbar BMD T-score < - 1.5), 15.1% of PCa patients required osteoporosis treatment; and, this value increased to 30.9% when L1-L4 CT-HU thresholds that corresponded to BMD T-score < - 1.5 were used. CONCLUSION: Lumbar BMD values from DXA may not reflect true bone health in PCa patients who often have lumbar degenerative diseases. Thresholds based on the vertebral CT-HU value can be used as a supplementary method to identify PCa patients who need anti-osteoporosis drugs.

Advantage of urological experience with both transperitoneal and retroperitoneal laparoscopy in lymph node biopsy for malignant lymphoma diagnosis.

PURPOSE: Laparoscopic urologists are familiar with both transperitoneal and retroperitoneal approaches. That experience is an advantage when devising a strategy for intra-abdominal lymph node biopsy. We report the feasibility and effectiveness of laparoscopic biopsy using a urological laparoscopic technique for the treatment of patients with clinically suspected intra-abdominal lymphoma. MATERIALS AND METHODS: From October 2010 to April 2015, a total of 22 patients underwent laparoscopic biopsy for suspected intra-abdominal lymphoma. We adopted a retroperitoneal approach for paraaortic or paracaval masses, whereas we used a transperitoneal approach for mesenteric, iliac, or obturator masses. Whenever possible, an entire node was removed; otherwise, the biopsy consisted of wedge resection sized at least 1 cm3. RESULTS: Biopsy specimens were obtained from the following lymph node sites: 10 paraaortic, 5 paracaval, 3 mesenteric, 2 obturator, 1 common iliac, and 1 perinephric fat. Laparoscopic lymph node biopsy was completed in all patients, and there were no conversions to open surgery. The median operating time was 97 minutes (range, 62-167 minutes). The estimated blood loss was <50 mL in all cases. Postoperatively, one patient (4.5%) had symptomatic chylous lymphocele that required surgical intervention. Precise diagnosis was established for all patients: malignant lymphoma in 20 patients and metastatic urothelial carcinoma and squamous cell carcinoma of unknown origin in 1 patient each. All lymphomas could be fully subclassified. CONCLUSIONS: Appropriate use of the transperitoneal or retroperitoneal approach is safe and effective for laparoscopic lymph node biopsy in patients with suspected intra-abdominal lymphoma.

[Urinary Diversion Using an Appendicovesicostomy for Idiopathic Urethral Stricture : A Case Report].

A 55-year-old woman was referred to our hospital with dysuria. We were unable to catheterize her using a nelaton catheter because of a urethral stricture, resulting in a large residual urine volume on ultrasonography. The circumference of the periurethral tissue was also thickened and the entire length of the urethra was stenotic, without apparent cause, on magnetic resonance imaging. Biopsy did not reveal malignancy. The pathological diagnosis of the periurethral tissue was simply fibrosis, and there was no definitive diagnosis. We decided to place a guidewire to attempt transurethral dilation, but it was unsuccessful because of the urethral stricture. The patient then underwent Mitrofanoff appendicovesicostomy. Three years later, there was no difficulty with catheterization through the appendix, despite her suffering from a bladder stone during the interim. We consider the Mitrofanoff appendicovesicostomy a good substitute technique for catheterization in patients with very severe urethral stricture.

[Renal Cell Carcinoma with Metastasis to the Gallbladder : A Case Report].

A 63-year-old male with a past history of left nephrectomy due to clear cell renal cell carcinoma at the age of 57 was admitted for further evaluation. Enhanced abdominal computed tomography revealed that there were several hypervascular tumors in the pancreas and a single hypervascular tumor in the gallbladder. Laparoscopic cholecystectomy was performed to obtain pathological diagnosis. Microscopically, the tumor in the gallbladder was filled with clear cells and was diagnosed as metastatic gallbladder cancer from the previous clear cell renal cell carcinoma. Metastatic renal cell carcinoma to the gallbladder is extremely rare, with reported frequencies of less than 0. 6% in 687 autopsies. We herein report a case in which cholecystectomy enabled a successful diagnosis and review the reported 22 cases in Japanese patients.

[Laparoscopic Radical Cystectomy in the Elderly Patients].

We compared the perioperative and oncological outcomes of laparoscopic radical cystectomy (LRC) between elderly patients over 75 years old and younger patients. Fifty-three patients underwent LRC between 2003 and 2014 at Tenriyorozu Hospital. Eighteen patients were classified as elderly (over 75) and the other 35 patients were considered young. The median operating time (434 vs 465 min, p＝0.35), estimated bloodloss (534 vs 525 g, p＝0.74), time to recommencing foodintake (7 vs 6 days, p＝1.00), and hospital stay (35 vs 32 days, p＝0.81) were not significantly different between the groups. Perioperative pyelonephritis was significantly more frequent in the elderly group (50% vs 20%, p＝0.02), while other complications were not significantly different between the two groups. The perioperative mortality rate was 0% in both groups. There were no significant differences between the elderly and young groups with respect to 2-year overall survival (74. 4% vs 91. 6%), cancer-specific survival (74. 4% vs 91. 6%), and recurrence-free survival (70.2% vs 81. 8%). LRC is a safe andefficient procedure for selected elderly patients.

[Case of juxtaglomerular cell tumor (reninoma) treated with laparoscopic partial nephrectomy].

We report a case of a 22-year-old male with juxtaglomerular cell tumor treated with laparoscopic partial nephrectomy. He was referred to our hospital with hypertension, high concentration of plasma renin activity (PRA) and renal mass. Dynamic enhanced computed tomography showed 17-mm weak contrast-enhancing tumor at the upper pole of the left kidney. Renin suppression and stimulation test revealed autonomous renin secretion although renal venous sampling failed to show significant difference in the PRA between the right and left renal vein. We performed laparoscopic left partial nephrectomy. The histological diagnosis was juxtaglomerular cell tumor. After the operation, his blood pressure and PRA were immediately normalized. Juxtaglomerular cell tumor is an important renal tumor as a curable cause of secondary hypertension.