[A CASE OF TESTICULAR TUMOR DIAGNOSED DUE TO ACUTE SCROTUM].

A 32-year-old man visited the emergency department complaining of the right scrotal pain, which occurred suddenly during sexual intercourse. Palpation revealed induration and tenderness on the caudal side of the right testis. Ultrasonography revealed a mosaic-like mass on the caudal side of the testis and no difference in blood flow between the right and left testes. The patient underwent a thorough examination the next day. Although the blood test did not show elevated tumor marker levels, testicular MRI revealed a mass with heterogeneous signal in the right scrotum. Subsequently, the patient was referred to another hospital for surgery. The pathological examination revealed a mixed germ cell tumor: seminoma (60%), teratoma (20%), and embryonal carcinoma (20%). One year postoperatively, the patient has had no recurrence. Testicular tumors are rarely discovered in acute scrotum, and few such cases have been reported. Torsion of the tumor, hemorrhage, necrosis, rupture, and infection have been reported as mechanisms of occurrence. When acute scrotum is diagnosed, testicular tumor should be considered as a differential diagnosis.

How does pre-operative antimicrobial treatment influence the intra-operative culture results and infectious complications in patients with positive baseline bladder urine culture undergoing ureteroscopic lithotripsy?

We investigated how pre-operative antimicrobial treatment influenced intra-operative culture (IC) results and infectious complications in patients with positive pre-operative bladder urine culture (PBUC) undergoing ureteroscopic lithotripsy. We assessed 162 patients undergoing ureteroscopic lithotripsy from April 2019 to March 2020. Based on PBUC findings, they were divided into positive and negative PBUC groups. We administered pre-operative antimicrobial treatment to the positive PBUC group and only peri-operative antimicrobial prophylaxis to the negative PBUC group. We examined intra-operative cultures (ICs), including bladder urine culture, renal pelvic urine culture and stone culture, in all cases. We studied the association between the results of PBUC, ICs and infectious complications in both groups. A total of 67 and 95 patients had positive and negative PBUC, respectively. In the positive PBUC group, 19 (28.4%) patients still had positive bladder urine culture after the antibiotic treatment. Positive ICs (43.3% vs. 3.2%, p < 0.001) and post-operative fever (16.4% vs. 2.0%, p = 0.001) were more common in the positive PBUC group than in the negative PBUC group. In the positive PBUC group, 11 patients had a post-operative fever, regardless of the ICs results (6 positive ICs and 5 negative ICs). Furthermore, antimicrobial-resistant bacteria were detected from ICs in 5 patients with positive PBUC, including 4 suffering from a post-operative fever. Although the effect of pre-operative antimicrobial treatment is not definitive, to avoid serious infectious complications, we should recognize high-risk patients and perform more careful infection control based on the pre- and intra-operative culture results.

Chronic Unilateral Hematuria: Compound Papillae Are Likely to Bleed.

Objectives: The present study investigated the recent outcomes of chronic unilateral hematuria (CUH), focusing on the detailed distribution of bleeding points based on the anatomical classification of the pelvicaliceal system. Materials and Methods: We evaluated 75 CUH patients treated in the past decade. Bleeding points were recorded separately as five levels of minor calices (Top, Upper, Middle, Lower, and Bottom). Bleeding point detection, immediate success, and recurrence-free rates were assessed. Results: The median age was 47 (range: 13-81) years. Bleeding points were detected in 62 patients (83%), including at the Top calix in 24 patients (32%), the mid-calices (Upper, Middle, and Lower) in 20 patients (27%), and the Bottom calix in 18 patients (24%). As there are typically six total calices in the mid calices, the probability of bleeding per renal papilla was higher in the compound papillae at the Top and Bottom calices than in the simple papilla at the mid calices. The bleeding point detection rate was significantly higher in the 65 patients with confirmed unilateral gross hematuria than in the 10 patients without confirmation (88% vs 50%, p < 0.01). The immediate success rate was 97% (73/75), and only two patients (3%) needed a second ureteroscopy. Ultimately, all patients achieved the disappearance of gross hematuria, including 13 patients (17%) whose bleeding points were not identified by ureteroscopy. The recurrence-free rate was 100% at a median follow-up of 42 (3-139) months. Conclusions: Compound papillae are more likely to bleed than simple papillae. Therefore, we recommend evaluating the Top and Bottom calices carefully during the initial ureteroscopic observations. Since the patients with confirmed gross hematuria from the unilateral orifice had a higher rate of bleeding point detection than those without confirmation, it is important to perform cystoscopy while the bleeding is persistent.

Successful outcomes of endoscopic lithotripsy in completely bedridden patients with symptomatic urinary calculi.

Due to the aging population, the number of completely bedridden individuals is expected to increase, and such individuals are at high risk of developing urinary calculi. This retrospective study included 32 consecutive bedridden patients, who had undergone endoscopic lithotripsy between 2010 and 2019, and aimed to identify the treatment outcomes of endoscopic lithotripsy for bedridden patients. A total of 45 endoscopic lithotripsies were performed to treat stones (median cumulative diameter, 24 mm). The stone-free rate (SFR) < 4 mm and complete SFR (0 mm) were achieved in 81% and 63% of patients, respectively. Postoperatively, 10 patients (22%) developed symptoms of systemic inflammatory response syndrome, and three patients (7%) had bloodstream infections. Except for one patient (3%) having a retained ureteral stent ultimately died from septic shock, drainage tube-free discharge was achieved in all patients. The 2-year cumulative incidence of stone-related events, and overall mortality rate, were 18% and 27%, respectively. Endoscopic lithotripsy is well tolerated and is associated with a high success rate, even with severe comorbidities and a relatively large stone burden. Physicians should consider performing endoscopic lithotripsy in bedridden patients with symptomatic urinary calculi regardless of their relatively short life expectancy and the remote risk of perioperative mortality.

The significance of intraoperative renal pelvic urine and stone cultures for patients at a high risk of post-ureteroscopy systemic inflammatory response syndrome.

We examined the renal pelvic urine culture (RPUC) and stone culture (SC) during ureteroscopy and evaluated their associations with postoperative systemic inflammatory response syndrome (SIRS). We prospectively collected data of 224 patients who underwent ureteroscopic laser lithotripsy from March 2015 to December 2017. We examined the bladder urine culture pre-operatively. If the patients had positive culture results, we treated them with antibiotics for 5-7 days before surgery based on the sensitivity profile. We collected RPUC and SC samples during surgery. After ureteroscopy, patients were closely monitored for any signs of SIRS. Using a logistic regression model, we analyzed how the clinical factors affected the incidence of SIRS. Pre-operative bladder urine culture (PBUC) was positive in 111 patients (49.6%). Intraoperative RPUC was positive in 43 patients (19.2%), and SC was positive in 34 patients (15.2%). Postoperatively, 23 patients (10.3%) were diagnosed with SIRS. A multivariate analysis revealed that female gender, struvite calculi and positive intraoperative RPUC results were significantly associated with postoperative SIRS. Among the 31 patients who were positive for both PBUC and intraoperative RPUC, the pathogens were not consistent in 11 patients (35.5%). Among the 25 patients who were positive for both PBUC and intraoperative SC, the pathogens were not consistent in 13 patients (52.0%). We recommend collecting RPUC and SC samples during ureteroscopy, especially for patients with high risk factors, including female gender, expected struvite calculi and positive PBUC results.

Proposal for a Simple Anatomical Classification of the Pelvicaliceal System for Endoscopic Surgery.

We herein propose a nomenclature for renal calices and anatomical classification of the renal pelvis for endoscopic surgery. We prospectively collected data on a total of 270 patients (540 kidneys) who underwent CT-urography. We then constructed three-dimensional images of the renal pelvis and examined their morphologic classification. Forty-eight kidneys were excluded from this study because of severe hydronephrosis or large renal cysts. The remaining 492 kidneys were included. We systematically categorized each minor calix into five levels: top, upper, middle, lower, and bottom. The upper, middle, and lower calices were typically found in pairs: anterior and posterior. The most common total number of minor calices was eight (51%), followed by seven (30%). We also classified the form of the pelvis into type I: single pelvis (58%) and type II: divided pelvis (42%), according to the branch patterns of the renal pelvis. In type II, the renal pelvis is always bifurcated into the upper branch (top and upper) and lower branch (middle, lower, and bottom). Type I was subclassified into three types: type Ia (43%), the standard type; type Ib (4%), with a wide pelvis; and type Ic (11%), with a narrow pelvis. This anatomical classification can divide the renal pelvis into two major types (subdivided into four types) and name each minor calix. This simple classification enables to share common intrarenal information, thus leading to the development of concrete treatment strategies.

Predictive risk factors for systemic inflammatory response syndrome following ureteroscopic laser lithotripsy.

The objective of this study was to investigate risk factors for the development of systemic inflammatory response syndrome following ureteroscopic laser lithotripsy. We retrospectively collected data of 469 patients who underwent ureteroscopic laser lithotripsy at our single institution from February 2008 to June 2016. Details for the patient, the stone, and the surgical factors that potentially contributed to postoperative infection were extracted. Using a logistic regression model, we analyzed how the clinical factors affected the incidence of systemic inflammatory response syndrome. Twenty-seven patients (5.7%) were postoperatively diagnosed with systemic inflammatory response syndrome; of these, 25 patients were diagnosed within 24 h after ureteroscopy. One patient required intensive care unit admission, but no death was reported. A preoperative stent was significantly associated with postoperative systemic inflammatory response syndrome only on univariate analysis, and the reasons for stenting were varied. Multivariate analysis revealed that obstructive pyelonephritis, a positive preoperative bladder urine culture result, and female gender were significantly associated with postoperative systemic inflammatory response syndrome. Patients who experienced obstructive pyelonephritis preceding ureteroscopic laser lithotripsy or had a positive preoperative bladder urine culture result were at an increased risk of systemic inflammatory response syndrome despite receiving appropriate preoperative antibiotic therapy. Regarding the impact of a preoperative stent on postoperative infection, further investigation focusing on reasons for stenting is needed.

Ureteral Involvement Is Associated with Poor Prognosis in Upper Urinary Tract Urothelial Carcinoma Patients Treated by Nephroureterectomy: A Multicenter Database Study.

BACKGROUND: The prognostic significance of tumor location for patients with upper urinary tract urothelial carcinoma (UUT-UC) has been disputed. Several papers have reported that ureteral cancer is associated with worse prognosis. OBJECTIVE: To investigate the prognostic significance of the presence of ureteral tumors in UUT-UC patients who underwent radical nephroureterectomy (RNU). DESIGN, SETTING, AND PARTICIPANTS: In this multicenter retrospective study, 1068 eligible patients (median follow-up: 40 mo [interquartile range: 17-77 mo]) were divided into three groups based on tumor location: renal pelvic, ureteral, and both-regional (having both renal pelvic and ureteral tumors). The ureteral and both-regional groups were subsequently integrated into the ureteral involvement group to evaluate its prognostic impact. INTERVENTION: All patients underwent RNU. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The prognostic impact of tumor location on survival was analyzed. RESULTS AND LIMITATIONS: The renal pelvic, ureteral, and both-regional groups consisted of 507 (47.5%), 430 (40.3%), and 131 (12.3%) patients, respectively. The ureteral and both-regional groups had a higher rate of lymphovascular invasion and lymph node metastasis compared with the renal pelvic group. The renal pelvic and both-regional tumors presented more frequently with locally advanced stages (pT3/T4) compared with the ureteral tumors. The 5-yr cancer-specific survival (CSS) and progression-free survival (PFS) rates of patients in the ureteral (70.5% and 66.7%, respectively) and both-regional groups (64.8% and 57.8%, respectively) were significantly worse than those in the renal pelvic group (81.9% and 78.1%, respectively). In a multivariate analysis, the presence of ureteral involvement was a significant prognostic factor for CSS (hazard ratio [HR]: 1.50; p=0.006) and PFS (HR: 1.35; p=0.023). This study is inherently limited by the biases associated with its retrospective and multicenter design. CONCLUSIONS: The presence of ureteral involvement had a significant impact on the survival of surgically treated UUT-UC patients associated with a poor prognosis. PATIENT SUMMARY: We demonstrated that the ureteral involvement was associated with poor survival compared with patients with renal pelvic tumor only in upper urinary tract urothelial patients treated by nephroureterectomy.

Appropriate kidney stone size for ureteroscopic lithotripsy: When to switch to a percutaneous approach.

Flexible ureteroscopy (fURS) has become a more effective and safer treatment for whole upper urinary tract stones. Percutaneous nephrolithotomy (PNL) is currently the first-line recommended treatment for large kidney stones ≥ 20 mm and it has an excellent stone-free rate for large kidney stones. However, its invasiveness is not negligible considering its major complication rates. Staged fURS is a practical treatment for such large kidney stones because fURS has a minimal blood transfusion risk, short hospitalization and few restrictions on daily routines. However, as the stone size becomes larger, the stone-free rate decreases, and the number of operations required increases. Therefore, in our opinion, staged fURS is a practical option for kidney stones 20 to 40 mm. Miniaturized PNL combined with fURS should be considered to be a preferred option for stones larger than 40 mm. Moreover, URS is an effective treatment for multiple upper urinary tract stones. Especially for patients with a stone burden < 20 mm, URS is a favorable option that promises a high stone-free rate after a single session either unilaterally or bilaterally. However, for patients with a stone burden ≥ 20 mm, a staged operation should be considered to achieve stone-free status.

Risk stratification for bladder recurrence of upper urinary tract urothelial carcinoma after radical nephroureterectomy.

OBJECTIVES: To identify risk factors and develop a model for predicting recurrence of upper urinary tract urothelial carcinoma (UTUC) in the bladder in patients without a history of bladder cancer after radical nephroureterectomy (RNU). PATIENTS AND METHODS: We retrospectively reviewed 754 patients with UTUC without prior or concurrent bladder cancer or distant metastasis at 13 institutions in Japan. Univariate and multivariate Fine and Gray competing risks proportional hazards models were used to examine the cumulative incidence of bladder recurrence of UTUC. A risk stratification model and a nomogram were constructed. Two prediction models were compared using the concordance index (c-index) focusing on predictive accuracy and decision-curve analysis, which indicate whether a model is appropriate for decision-making and determining subsequent patient prognosis. RESULTS: The cumulative incidence rates of bladder UTUC recurrence at 1 and 5 years were 15 and 29%, respectively; the median time to bladder UTUC recurrence was 10 months. Multivariate analysis showed that papillary tumour architecture, absence of lymphovascular invasion and higher pathological T stage were both predictive factors for bladder cancer recurrence. The predictive accuracy of the risk stratification model and the nomogram for bladder cancer recurrence were not different (c-index: 0.60 and 0.62). According to the decision-curve analysis, the risk stratification was an acceptable model because the net benefit of the risk stratification was equivalent to that of the nomogram. The overall cumulative incidence rates of bladder cancer 5 years after RNU were 10, 26 and 44% in the low-, intermediate- and high-risk groups, respectively. CONCLUSIONS: We identified risk factors and developed a risk stratification model for UTUC recurrence in the bladder after RNU. This model could be used to provide both an individualised strategy to prevent recurrence and a risk-stratified surveillance protocol.

Bimodal pattern of the impact of body mass index on cancer-specific survival of upper urinary tract urothelial carcinoma patients.

AIM: To clarify how body mass index (BMI) affects the risk of death from upper urinary tract urothelial carcinoma (UUTUC) we investigated the impact of BMI on UUTUC using a Japanese multicenter database. PATIENTS AND METHODS: Between January 1995 and December 2010, 1,329 patients with upper urinary tract tumors were treated in 13 institutions in Japan. From this group, a cohort of 1,014 patients treated with radical nephroureterectomy was retrospectively reviewed. BMI was categorized into the following three groups: BMI <22.5, BMI 22.5 to <25 and BMI ≥ 25. The association between each group and cancer-specific survival (CSS) was analyzed using Cox proportional hazards regression models. RESULTS: The median BMI was 22.4 kg/m(2) (interquartile range, 20.5-24.8). Out of all patients, 213 (21%) died of UUTUC. Hazard ratios of the BMI ≥ 25 and the BMI <22.5 group were 1.76 and 1.66, respectively. CONCLUSION: Both higher and lower BMI affect the prognosis of UUTUC treated with radical nephroureterectomy.

Equivalent survival and improved preservation of renal function after distal ureterectomy compared with nephroureterectomy in patients with urothelial carcinoma of the distal ureter: a propensity score-matched multicenter study.

OBJECTIVES: To investigate the oncological and functional outcome of distal ureterectomy compared with nephroureterectomy in the management of distal ureteral urothelial carcinoma. METHODS: Using a database including upper urinary tract urothelial carcinoma patients (n = 1329), 282 patients were identified with urothelial carcinoma localized in the distal ureter on clinical evaluation. To adjust for potential baseline differences between groups, 43 patients undergoing distal ureterectomy were matched with 86 patients undergoing nephroureterectomy using propensity scoring. Cox regression models tested the effect of surgery type on recurrence-free survival and cancer-specific survival. Estimated glomerular filtration rate was measured before and after surgery. RESULTS: The median follow-up period was 50 months. There were no significant differences in 5-year recurrence-free survival and cancer-specific survival rates between the distal ureterectomy and nephroureterectomy groups (P = 0.22 and P = 0.70, respectively). Multivariate analysis showed that surgery type was not associated with recurrence-free survival and cancer-specific survival (P = 0.90 and P = 0.28, respectively). In the subanalysis, recurrence-free survival and cancer-specific survival in the distal ureterectomy group were equivalent to those of the nephroureterectomy group in both pTa-1 and pT2-4 patients. Renal function was better preserved in the distal ureterectomy group than in the nephroureterectomy group (rate of change in estimated glomerular filtration rate 2% vs -20%; P < 0.001). CONCLUSIONS: The oncological outcome of distal ureterectomy is comparable with that of nephroureterectomy in distal ureteral urothelial carcinoma patients, and distal ureterectomy provides better preservation of renal function. Distal ureterectomy would be feasible for carefully selected patients with distal ureteral urothelial carcinoma.

Single-session ureteroscopy with holmium laser lithotripsy for multiple stones.

Multiple stones are found in 20-25% of patients with urolithiasis. The stone multiplicity is a powerful adverse factor influencing the treatment outcome after shockwave lithotripsy, although guidelines for the treatment of multiple stones have not been well established yet. Herein we report our most recent experience of a single-session ureteroscopy for multiple stones. Between September 2008 and December 2011, 51 patients with multiple stones (total 146 stones) in different locations (37unilateral, 14 bilateral) underwent a total of 65 ureteroscopic procedures. Operative time, stone-free rates and complications were evaluated. Stone-free status was defined as no fragments in the ureter and the absence of >2 mm fragments in the kidney. The mean stone number per patient was 2.9 ± 1.7 and the mean stone burden (cumulative stone length) was 21.5 ± 11.6 mm. The mean number of procedures was 1.3 ± 0.6. Overall, the stone-free rate after a single session was 80% (41/51). In patients with stone burden <20 mm and ≥20 mm, stone-free rates after a single session were 92% (23/25) and 69% (18/26), respectively. Multivariate analysis showed that the stone burden and the presence of impacted stones were the factors significantly influencing the treatment outcome. Stone location did not have a strong influence on the outcome. No major intraoperative complications were identified. Our findings suggest that ureteroscopy is an efficient treatment for multiple stones. For patients with stone burden <20 mm, either unilaterally or bilaterally, a single session of ureteroscopy is a favorable treatment option with a high stone-free rate.

Successful outcome of flexible ureteroscopy with holmium laser lithotripsy for renal stones 2 cm or greater.

Although percutaneous nephrolithotomy has been recommended as the first-line treatment for renal stones larger than 2 cm, its major complication rate is not negligible and less invasive approaches are to be explored. Thanks to the recent advances in endoscopic technology, flexible ureteroscopy has become another option in this setting. Herein we report our most recent experience with flexible ureteroscopy for large renal stones. Between September 2008 and May 2011, 20 patients with renal stones ≥ 2 cm underwent a total of 28 procedures of ureteroscopy with holmium laser lithotripsy, using the Olympus URF-P5 and a ureteral access sheath. The number of procedures, operative time, stone-free rates, stone compositions and complications were evaluated. Stone-free status was defined as the absence of fragments or fragments of ≤ 4 mm. Mean stone size was 3.1 cm (range 2.0-5.0). The average number of procedures was 1.4. One, two and three procedures were required in 13, six and one patients, respectively. Overall, the stone-free rate was 90%. The stone-free rate for preoperative stone size of 2 to ≤ 4 cm and >4 cm was 100% (14/14) and 67% (4/6), respectively. No major intraoperative complications were identified. Postoperative high-grade fever was observed in three patients, including one patient who developed sepsis. All these patients were successfully treated conservatively. Our findings suggest that ureteroscopy represents a favorable option for selected patients with renal stones, especially those 2 to ≤ 4 cm in size.

[Transurethral lithotripsy with rigid and flexible ureteroscopy for renal and ureteral stones: results of the first 100 procedures].

We evaluated the clinical outcome of transurethral lithotripsy (TUL) using rigid & flexible ureteroscopy and holmium : yttrium-aluminum-garnet (YAG) laser in our hospital. We retrospectively reviewed 100 consecutive transurethral lithotripsy procedures performed on 82 patients from May 2008 to June 2010 at our hospital. Twenty-five patients (30%) had multiple stones and 10 patients (12%) had bilateral stones. The main stones were located in the renal pelvis, ureteropelvic junction, upper ureter, middle ureter, and lower ureter in 14, 12, 26, 3, and 27 cases, respectively. Median operative time was 75 minutes (range, 18-238 minutes). Operative complications were 5 cases of pyelonephritis and 1 case of ureteral perforation that was managed conservatively with percutaneous nephrostomy. The average number of procedures was 1.22 with 65 patients requiring one, 16 requiring two, and 1 requiring three procedures. Three patients had shock wave lithotripsy (SWL) and two patients had minipercutaneous nephrolithotomy (mini-PNL) after first TUL. However, all of these patients eventually needed additional TUL. The overall success rate was 99% (81/82). Rigid & flexible ureteroscopy and holmium : YAG laser lithotripsy achieved excellent results of treatment for urolithiasis. TUL gave a high stone-free rate with low complication rates. In Japan, where shock wave lithotripters are widely used, trend of treatment for urolithiasis will shift from SWL to TUL.

Young age as favorable prognostic factor for cancer-specific survival in localized renal cell carcinoma.

OBJECTIVES: To evaluate the prognostic effect of age in patients with localized renal cell carcinoma (RCC) and investigate the incidence of Xp11 translocation RCC in young patients who developed recurrence. METHODS: From 1990 to 2007, 2403 Japanese patients underwent nephrectomy for presumed RCC at 9 institutions. Of those, 1143 patients had localized RCC (Stage pT1-2N0M0). Their clinical data were retrospectively reviewed. In the present study, 131 patients (11%) were considered young (≤45 years at diagnosis). In the young patients with recurrence, the nephrectomy specimens were immunostained with TFE3 to determine the incidence of Xp11 translocation RCC. RESULTS: During the median follow-up of 47 months, 3 cancer deaths (2.2%) occurred among young patients and 51 (5.0%) among older patients. The 5-year cancer-specific survival (CSS) rate was significantly better for the younger patients than for the older patients (P = .049). Multivariate analysis showed that age was significantly associated with CSS, as were the pathologic T stage, tumor grade, and symptoms at diagnosis. The hazard ratio of young age was 0.31 (95% confidence interval 0.077-0.87). The recurrence-free survival curves revealed no difference between these 2 groups. Of the 74 patients with recurrence, the CSS after recurrence was significantly better in the younger patients than in the older patients (P = .0010). Of the 8 young patients with recurrence, 4 had Xp11 translocation RCC, and 3 survived for >5 years after recurrence. CONCLUSIONS: Compared with the older patients, the young patients with RCC had similar recurrence-free survival rates but better CSS rates. This might have been because significant numbers of the young patients had Xp11 translocation RCC.

[A case of urachal carcinoma with transverse colon fistula].

A 61-year-old woman was admitted to our hospital because of abdominal pain. Computed tomography showed an abscess in the anterior abdominal wall and an intraabdominal tumor. Biopsy from bladder dome presented adenocarcinoma. We diagnosed the tumor as urachal carcinoma and operation was performed. The resected specimen showed transverse fistula. In Japan, there is no report of urachal carcinoma with fistula to digestive duct. We think it is a cause of strong infiltration of the carcinoma. Curative resection for urachal carcinoma with fistula can lead to a better prognosis, in spite of its invasive character.

Simple and effective local anesthesia for transperineal extended prostate biopsy: application to three-dimensional 26-core biopsy.

We developed a local anesthetic procedure for three-dimensional 26-core prostate biopsy (3D26PBx), a combination of transperineal 14-core biopsy (TP14PBx) and transrectal 12-core biopsy (TR12PBx). At first, a periapical triangle, confined by the levator ani, the rhabdosphincter and the external anal sphincter muscle, was made visible by transrectal ultrasound. After administration of 1 mL of 1%-lidocaine into the midline perineal skin 1.5 cm above the anus, we inserted a spinal needle toward the periapical triangle for injection of 1.5-2.0 mL of 1%-lidocaine and performed the TP14PBx. After administration of the periprostatic nerve block with 10 mL of 1%-lidocaine, we performed the TR12PBx. The efficacy of the procedure was evaluated prospectively in 45 consecutive men undergoing the 3D26PBx. The 3D26PBx was completed with just local anesthesia in all patients. The pain levels, assessed by an 11-point visual analog scale, were not different between the TP14PBx and the TR12PBx.