Fourth national Japanese antimicrobial susceptibility pattern surveillance program: Bacterial isolates from patients with complicated urinary tract infections.

INTRODUCTION: Antimicrobial susceptibility patterns of bacterial pathogens isolated from patients with complicated urinary tract infections were analyzed using the national surveillance data, comprising 793 bacterial strains from eight clinically relevant species. MATERIALS AND METHODS: Data were collected for the fourth national surveillance project from July 2020 to December 2021 by the Japanese Society of Chemotherapy, the Japanese Association for Infectious Disease, and the Japanese Society of Clinical Microbiology. Surveillance was supervised with the cooperation of 43 medical institutions throughout Japan. RESULTS: Fluoroquinolone required a minimum inhibitory concentration (MIC) of 2-64 mg/L to inhibit the 330 tested Escherichia coli strains. The proportion of levofloxacin-resistant E. coli strains increased from 28.6% in 2008 to 29.6% in 2011, 38.5% in 2015, and 44.5% in 2021. The proportion of levofloxacin-resistant strains of Pseudomonas aeruginosa also increased from previous survey results, showing a continuing downward trend. Conversely, the proportion of levofloxacin-resistant strains of Enterococcus faecalis decreased relative to previous reports. Neither multidrug-resistant P. aeruginosa nor carbapenem-resistant Enterobacteriaceae were detected. For methicillin-resistant Staphylococcus aureus (MRSA), the proportion of vancomycin-susceptible strains (MIC of 2 µg/mL) decreased from 14.7% to 7.7%. DISCUSSION: Bacterial strains that produced extended-spectrum ß-lactamase included E. coli (82/330 strains, 24.8%), Klebsiella pneumoniae (11/68 strains, 16.2%), and Proteus mirabilis (4/26 strains, 15.4%). As compared to previous surveillance reports, these strains showed an increase in proportion over the years.

Laparoscopic port site Richter's hernia after robot-assisted radical prostatectomy.

Introduction: Postoperative small bowel obstruction is a rare complication. One of its less frequent causes is port site hernia. We report a case of Richter's port site hernia in a patient who underwent robot-assisted radical prostatectomy. Case presentation: A 73-year-old man who underwent robot-assisted radical prostatectomy noted acute abdominal pain and nausea on the 11th postoperative day. Computed tomography scans revealed dilated small bowel loops. Adhesive ileus was initially suspected, which was relieved with conservative management, including ileus tube insertion. However, his symptoms worsened. Thus, a laparotomy was performed. The camera port wound was reopened, and the repaired fascia and small intestine were found incarcerated into the peritoneal defects. These findings were consistent with Richter's hernia. Conclusion: Port site hernia was not detected on computed tomography scans. Patients presenting with small bowel obstruction following laparoscopic surgery should be evaluated for port site hernia, and surgical management should be considered.

Pathological complete response after nivolumab therapy following angiogenesis inhibitors in a patient with metastatic renal cell carcinoma.

INTRODUCTION: Nivolumab is effective for advanced renal cell carcinoma; however, reports are limited wherein nivolumab is combined with sequential therapy of angiogenesis inhibitors and metastasectomy. CASE PRESENTATION: A 65-year-old man was diagnosed with left renal cell carcinoma of cT2aN0M1 with lung metastasis. The patient underwent nephrectomy and sequential therapy with interferon-α and angiogenesis inhibitors. Lung metastasis decreased by angiogenesis inhibitors, but new right adrenal gland metastasis appeared. Nivolumab as the fifth systemic therapy remarkably shrank the metastasis. After discontinuing nivolumab therapy, the metastasis continued to shrink. The patient underwent adrenalectomy, and pathological analysis revealed no remnant cancer cells in the specimen, confirming a pathological complete response. Twenty months postoperatively, he remains in good health without recurrence. CONCLUSION: We report a rare case with renal cell carcinoma of a pathological complete response by nivolumab after angiogenesis inhibitors.

Is the membranous urethral length related to postoperative urinary incontinence after holmium laser enucleation of the prostate?

OBJECTIVES: To investigate the findings of preoperative magnetic resonance imaging associated with the occurrence of transient urinary incontinence after holmium laser enucleation of the prostate. METHODS: At a single institution, 360 patients underwent holmium laser enucleation of the prostate between January 2014 and December 2018. Of those, we retrospectively evaluated 237 who underwent preoperative magnetic resonance imaging and for whom postoperative evaluations were available for >3 months after holmium laser enucleation of the prostate. We carried out preoperative magnetic resonance imaging, and measured the periurethral sphincter complex, levator ani thickness, membranous urethral length and minimal residual membranous urethral length. Logistic regression analysis was carried out to assess the variables associated with incontinence. RESULTS: Transient urinary incontinence occurred after holmium laser enucleation of the prostate in 68 patients (28.7%); 46 (67.6%) of whom recovered within 3 months. Multivariate analysis showed that the membranous urethral length was independently associated with postoperative urinary incontinence at 1 and 3 months after surgery. The operative time was also independently associated with postoperative transient urinary incontinence at 1 month after surgery. CONCLUSION: Preoperative membranous urethral length and operative time are independent predictors of transient urinary incontinence after holmium laser enucleation of the prostate. These findings should be considered by surgeons before surgery.

Successful embolization of ileal conduit stomal varices with N-butyl cyanoacrylate via a recanalized paraumbilical vein.

A 77-year-old woman with liver cirrhosis was admitted to our hospital for marked hemorrhage in her ileal conduit stoma. She had a history of cystectomy and urinary diversion for bladder carcinoma 2 years ago. Contrast-enhanced CT demonstrated varices in the ileal conduit stoma. We accessed the varices via a recanalized paraumbilical vein to avoid pain from the transhepatic approach, and selectively embolized the varices with N-butyl cyanoacrylate (NBCA). We consider antegrade embolization of ileal conduit stomal varices with NBCA to be effective and feasible. Access via a paraumbilical vein is a useful alternative to the transhepatic approach.

Risk factors for refractory febrile neutropenia in urological chemotherapy.

During chemotherapy, patients are more susceptible to infectious complications as a result of bone marrow suppression, leading to neutropenia. The purpose of this study is to investigate risk factors for refractory febrile neutropenia (FN) during urological chemotherapy. Our method for suppressing FN is to use granulocyte colony-stimulating factor and prevent upper respiratory infection by masking and gargling. We studied 47 episodes of FN in 39 patients that occurred during urological chemotherapy for urothelial cancer, testicular cancer, and prostate cancer. Among our cases, there were 5 patients with refractory FN; we set risk factors for refractory FN and performed statistical analyses. The average age of the 39 patients was 60.6 years (range, 18-80 years). In 47 FN episodes, the chemotherapy regimen before the occurrence of FN included 15 (31.9 %) MVAC (methotrexate, vinblastine, adriamycin, cisplatin) for urothelial cancer, 5 (10.6 %) DE (docetaxel, estramustin) for prostate cancer, and 3 (6.4 %) TIP (paclitaxel, ifosfamide, cisplatin) for testicular cancer. The antibiotics used to treat FN included 17 (36.3 %) meropenem and 23 (49.0 %) cefepime, and the average duration of antibiotics was 4.4 days (range, 1-12). We investigated risk factors for refractory FN and showed a significant relationship between refractory FN and indwelling urinary catheter or smaller Multinational Association for Supportive Care in Cancer score by multivariate analysis. A future prospective study is needed for further evaluation for risk factors and establishing treatment protocols and guidelines for FN.

How long should double J stent be kept in after ureteroscopic lithotripsy?

Ureteroscopic lithotripsy (UL), for renal or ureteral stones, is a standard technique for every urologist. However, the length of time the double J (DJ) stent needs to be kept in postoperatively is still controversial. This study investigated how the duration of DJ stenting after UL affects postoperative adverse events, especially infection and pain. One hundred and twenty-five patients were enrolled in this study and data were analyzed retrospectively. We set the median duration for keeping the DJ stent postoperatively as 14 days from median value in all cases and compared it to a longer duration group (>15 days) and a shorter duration group (<14 days) in terms of febrile complications, urinalysis, and the need to give antibiotics at the time of DJ stent removal. The duration of DJ stenting was from 3 to 61 (median 14) days. Thirteen patients had adverse events related to DJ stent removal (febrile complications, 11 patients; lumbago, 2 patients). Thirty-one patients were given antibiotics at the time of DJ stent removal. Patients with longer durations (>15 days) of DJ stenting had a significantly higher ratio of adverse events such as fever or lumbago (p = 0.041). In conclusion, this study demonstrated that shorter duration (<14 days) DJ stent use after UL may decrease adverse events and require less antibiotic use. Further prospective studies are needed to determine the optimal duration of DJ stent use after UL.

Mechanisms of and risk factors for fluoroquinolone resistance in clinical Enterococcus faecalis isolates from patients with urinary tract infections.

We examined Enterococcus faecalis strains clinically isolated from 100 patients with urinary tract infections (UTIs) for their susceptibility to levofloxacin (LVX) by measuring the MIC and investigated amino acid mutations by direct DNA sequencing, which were then correlated with LVX resistance. Next, we studied risk factors for LVX resistance, such as age, gender, and previous fluoroquinolone use, and investigated the statistical correlation of these risk factors with each amino acid mutation and LVX resistance. Of the 100 isolates tested, 14 isolates showed LVX resistance and all of these isolates had amino acid mutations. We demonstrated that 2 out of 4 mutations (Ser83-to-Ile in gyrA and Ser80-to-Ile in parC) had a significant correlation with LVX resistance. There was a significant relationship between isolates with 2 or 3 amino acid mutations and LVX resistance. In addition, we found a significant correlation between the previous use of fluoroquinolones and LVX resistance or the presence of mutations and also demonstrated that previous use of other types of antibiotics was significantly related to the presence of mutations by multivariate analysis. In conclusion, we found significant correlation between amino acid mutations in E. faecalis, LVX resistance, and risk factors such as previous use of fluoroquinolones.

Risk factors and mechanisms of fluoroquinolone resistance in 156 Escherichia coli strains clinically isolated from urinary tract infections.

As fluoroquinolone-resistant strains of Escherichia coli emerge, several risk factors for fluoroquinolone resistance have become evident, such as amino acid mutations in the quinolone resistance determining regions (QRDR) of gyrA and parC and previous use of fluoroquinolone. This study investigated risk factors for fluoroquinolone resistance and amino acid mutation in the QRDR in E. coli. We investigated the statistical correlation between each amino acid mutation and resistance to levofloxacin. We examined the minimum inhibitory concentration (MIC) of levofloxacin and the amino acid mutations of gyrA and parC by direct DNA sequence in E. coli clinically isolated from urinary tract infection (UTI) patients. We investigated risk factors for levofloxacin resistance, such as age, sex, and previous use of fluoroquinolone. We found a significant correlation between the number of mutations and resistance to levofloxacin (p < 0.001) and between the presence of underlying urinary tract disease and the presence of mutations (p = 0.004) by multivariate analyses. Three mutations in QRDR were demonstrated to be significantly correlated with levofloxacin resistance. In conclusion, these findings contribute to our understanding of the molecular mechanisms and risk factors for fluoroquinolone resistance.

Selection of first-line i.v. antibiotics for acute pyelonephritis in patients requiring emergency hospital admission.

Febrile urinary tract infections (UTIs) often require the intravenous infusion of antibiotics and/or hospitalization. Acute pyelonephritis (AP) is one of the most severe forms of UTI, and the antibiotics we should use as the first line and the risk factors for treatment failure remain controversial. The objective of this study was to investigate the efficacy of i.v. antibiotics selected for the treatment of febrile AP and to examine the risk factors for antibiotic resistance. We set risk factors for antibiotic treatment failure such as age, sex, and the presence of underlying urinary tract disease. We classified all cases into 49 cases of complicated AP and 24 cases of uncomplicated AP according to the presence of underlying urinary tract diseases, and examined the characteristics of the patients and the efficacy of the antibiotics used in this study. We investigated risk factors which relate to initial treatment failure and the duration of antibiotic treatment. Initial antibiotic treatment failure was significantly correlated to C-reactive protein in complicated AP and to positive blood culture in uncomplicated AP. We revealed a significant correlation between the duration of the given antibiotics and diabetes mellitus or positive blood culture in uncomplicated AP, and tazobactam/piperacillin was significantly related to prolongation of antibiotic treatment in complicated AP. In conclusion, in this study, a positive blood culture was the representative risk factor that related to both initial treatment failure and longer duration of the given antibiotics in uncomplicated AP.

Correlation of overexpression of efflux pump genes with antibiotic resistance in Escherichia coli Strains clinically isolated from urinary tract infection patients.

Escherichia coli is one of the most common pathogens in urinary tract infections (UTIs), and antibiotic resistance in E. coli is becoming a serious problem in treating UTI. Efflux system overexpression is reported to contribute to E. coli resistance to several antibiotics. This study investigated the correlation of antibiotic susceptibilities with the overexpression of the efflux pump genes such as marA, yhiU, yhiV, and mdfA and with risk factors for antibiotic resistance in E. coli isolated from UTI patients. We examined the expression level of efflux pump genes using quantitative real-time reverse transcription-PCR (qRT-PCR). We also tested the in vitro susceptibilities to 12 kinds of antibiotics in 64 clinical strains of E. coli isolated from UTI patients. By multivariate analyses we revealed significant relationships between the overexpression of (i) marA and MICs of cefepime (FEP) and nalidixic acid (NAL), (ii) yhiV and MICs of minocycline (MIN), and (iii) mdfA and MICs of sitafloxacin (STX). In our investigation of the efflux pump genes, risk factors such as gender and the previous use of fluoroquinolones correlated with the overexpression of marA, and indwelling catheter use correlated with the overexpression of mdfA. In conclusion, we demonstrated that the increased expression of efflux pump genes such as marA and mdfA can lead to fluoroquinolone resistance in E. coli. These results contribute to our knowledge of the efflux system and raise the possibility of developing new agents, such as efflux pump inhibitors (EPIs), to antibiotic-resistant E. coli.

Limited hydration may reduce intraoperative blood loss in retropubic radical prostatectomy.

Retropubic radical prostatectomy (RRP) may involve major intraoperative blood loss. This study focuses on how limited intraoperative hydration, especially in the early part of the surgery, affects the total blood loss. Fifteen prostate cancer patients were enrolled in this study in which the RRPs were performed by a single surgeon with limited (no more than 1500 ml as a rule) intraoperative hydration in the first 2 hours of the surgery when ligation of intrapelvic lymph node, dorsal vein complex (DVC), neurovascular bundle (NVB) and cut of urethra are assumed to be finished, and were compared with the control group in which no intervention of hydration was undertaken. Intervention group (n=15) had significantly less intraoperative blood loss (p<0.05) compared with control group even though blood pressure at the first 2 hours was not significantly different. Limited hydration did not cause apparent adverse events resulted from dehydration. In conclusion, limited hydration especially in the first half of operation may reduce intraoperative blood loss without any side effects of dehydration. This study could help to establish detailed guidelines for hydration methods for less blood loss during RRP.

Efficacy of combining flexible and rigid ureteroscopy for transurethral lithotripsy.

Transurethral lithotripsy (TUL) is a common procedure in urology. However, controversy persists about how to deal with stones pushed up into kidney from the ureter during the procedure of TUL. This study investigated the efficacy of combining flexible ureteroscopy and rigid ureteroscopy for pushed-up stones into kidney during TUL. Fotry-one patients underwent TUL by a single surgeon from July 2007 to May 2009. Eight cases resulted in pushed-up stones during operation or involved existing kidney stones. We used a Zero-tip or Litho Catch Basket catheter and a flexible ureteroscope to carry these stones in kidney down into the ureter where the rigid ureteroscope could then reach and handle the stone for lithotripsy or being taken away. A Lithoclast system was used for lithotripsy. Five cases involved stones pushed up during surgery and 3 cases involved stones already in the kidney in detail. We pulled the stones down into the ureter in all cases and successfully completed lithotripsy or removed the stone, thus avoiding the performance of additional extracorporeal shock wave lithotripsy (ESWL). In conclusions, combined use of flexible ureteroscopy and rigid ureteroscopy for upper urinary tract stones pushed up into the kidney during TUL or renal stones could be useful for avoiding additional ESWL.

Efficacy of early use of snake retractor in retroperitoneoscopic nephrectomy or nephroureterectomy.

BACKGROUND AND PURPOSE: A snake retractor is generally used to create a better surgical field and space, but when to start using it is still controversial. In this study, we used a snake retractor starting in an early stage of the procedure to safely perform surgery and compared the results with a control group in which the procedure depended on operator discretion. PATIENTS AND METHODS: Twelve patients were enrolled in this study and compared with a control group (n = 12) in which no special technique was used. We used four ports in both right- and left sided cases and used a snake retractor when removing the flank pad to create a better surgical space and field. We compared two groups in operative time, intraoperative blood loss, and body mass index (BMI). RESULTS: Three surgeons were enrolled. In the intervention group (early use of snake retractor), operative time was 107 to 300 minutes (median 162 min), and intraoperative blood loss was 0 to 462 g (69.5 g). In the control group, operative time was 185 to 485 minutes (258 min) and intraoperative blood loss was 0 to 302 g (40 g). Operative time was significantly shorter in the intervention group than the control group (P = 0.0034). There was no significant correlation with intraoperative blood loss volume and BMI in these two groups. We did not have any patients with metastasis or recurrence of cancer in either group in post-operative follow-up. Only the control group included a case with a slight duodenum injury. CONCLUSIONS: Early use of the snake retractor in retroperitoneoscopic nephrectomy or nephroureterectomy may produce a significantly safer operative procedure.

Combination chemotherapy with weekly paclitaxel or docetaxel, carboplatin, and estramustine for hormone-refractory prostate cancer.

Paclitaxel (PTX) and docetaxel (DTX) have been reported to be effective for treating hormone-refractory prostate cancer (HRPC). The objective of this study was to examine the efficacy of weekly DTX (PTX)-based chemotherapy and compare weekly DTX-based chemotherapy with triweekly (once every 3 weeks) DTX-based chemotherapy. We performed a combination chemotherapy on a weekly cycle with an i.v. PTX 100 mg/m(2) or i.v. DTX 30 mg/m(2) (days 1, 8, 15, and 22), i.v. carboplatin (CBDCA) (day 1, area under the plasma concentration time curve = 6), and oral estramustine phosphate 10 mg/kg daily for 10 HRPC patients. In addition, we investigated the patient characteristics and treatment efficacy and toxicity. Among all cases, serum prostate-specific antigen (PSA) decreased by 50% or more in 90% of patients, by 75% or more in 70%, and 90% or more in 40% after chemotherapy. The effectiveness of weekly DTX-based chemotherapy was comparable with previous reports, and we showed no toxicity serious enough to require cancellation of chemotherapy. In conclusion, weekly DTX-based chemotherapy was no less effective and less toxic than triweekly DTX-based chemotherapy for HRPC patients and therefore can be useful as the first-line chemotherapy regimen for HRPC patients, especially the elderly or those with a poor performance status.

Surgical site infections may be reduced by shorter duration of prophylactic antibiotic medication in urological surgeries.

In this study, we investigated whether the occurrence of surgical site infection (SSI) could be decreased by a shorter duration of prophylactic antibiotic medications. Prophylactic antibiotic selection was a 1st or 2nd generation cephalosporin or sulbactam/ampicillin for 2 days for open surgery, laparoscopic surgery, transurethral lithotripsy (TUL), and transurethral resection of the prostate (TURP) as a rule, and 1 day for transurethral surgery other than TUL and for extracorporeal shock wave lithotripsy (ESWL). The kind of prophylactic antibiotics used was switched every 4 months in a year. Three patients had SSI out of the total 389 surgeries included in this study (0.77%). One had pyelonephritis after ESWL, one had urinary tract infection (UTI) after transurethral cutting and coagulation of bladder diverticulum, and one had UTI after TURP. There was no significant difference related to the kind of antibiotics used. However, the SSI occurrence was significantly lower than in the control group in which no definite intervention was performed with longer trends of prophylactic antibiotic usage (14/362, 3.87%) (P=0.0111). In conclusion, we performed 389 urological surgeries with significantly decreased SSI rates using a shorter duration of prophylactic antibiotic medications than in the control group. The results indicate that this method might reduce the occurrence of SSI in urological surgeries.

Prophylactic use of isepamicin and levofloxacin for transrectal prostate biopsy: a retrospective single center study.

OBJECTIVES: To evaluate the combination of isepamicin and levofloxacin in the prophylaxis of infectious complications associated with prostate biopsy (PBX). METHODS: A total of 586 patients who underwent transrectal PBX in a single center were included in this retrospective analysis. They received 400 mg isepamicin once just before PBX plus 300 mg oral levofloxacin each day for three days as a rule. Clinical and laboratory data were evaluated. RESULTS: A total of three (0.51%) patients presented a febrile complication after PBX. All of them were diagnosed as acute prostatitis. Serum white blood cell count and C-reactive protein in the 131 patients whose laboratory data were available for statistical analyses did not rise significantly after PBX. CONCLUSIONS: Isepamicin plus fluoroquinolone can be considered a valuable regimen for antibiotic prophylaxis of PBX.

[Carcinomatous meningitis from prostate cancer diagnosed by cerebrospinal fluid cytology and magnetic resonance image: a case report and review of the literature].

A 55-year-old man was treated with 10 courses of intermittent Paclitaxel, estramustine phosphate sodium and carboplatin (PEC) chemotherapy for hormone-refractory prostate cancer. He was admitted to our department with a complaint of severe headache 2 years after initiating chemotherapy. Enhanced computed tomography (CT) of the brain demonstrated no obvious lesion, but a brain dynamic magnetic resonance image (MRI) showed a diffusely enhanced lesion on the surface of the brain. Cerebrospinal fluid cytology revealed adenocarcinoma cells; and therefore it was diagnosed as carcinomatous meningitis metastasized from prostate cancer. After glycerin and betamethasone were used to control brain edema, the patient's headache temporarily improved. However, he died on the 36th day after admission in the natural course of the disease after he and his family selected not to undertake further active treatment. To our knowledge, only 6 cases of carcinomatous meningitis associated with prostate cancer have been reported in Japan. It is generally difficult to diagnose carcinomatous meningitis because the symptoms vary considerably. Once diagnosed, active treatment is not undertaken in most cases since the patient cannot tolerate further treatment. The prognoses for patients with advanced prostate cancer and metastatic carcinomatous meningitis are generally quite poor. Early diagnosis and prompt initiation of therapy could improve the quality of life for such patients. In this case study, MRI was superior to CT for imaging a metastatic carcinomatous meningitis lesion.

[Traumatic urethral disruption treated by endoscopic management with transluminal puncture under fluoroscopic guidance: a case report and review of the literature].

A 76-year-old man injured in a car accident was admitted with urinary retention and urethral bleeding. Cystoscopic findings revealed disruption of the bulbous urethra and we performed cystostomy. At sixty days after the injury, we performed endoscopic urethroplasty with a steel needle puncturing from the proximal end of the disruption to the distal end under the guidance of C-Arm fluoroscopy. We removed the urethral catheter at the 37th day after surgery and then performed urethral dilation for postoperative urethral stricture. Retrograde urethrocystography showed no urethral stricture at 5 months after surgery. The patient had no dysuria or urinary incontinence. Endoscopic urethroplasty generally needs some guiding device to perform urethrotomy. C-Arm fluoroscopy and transluminal puncture were used in this case and proved useful for guidance from the proximal to the distal end of the urethral disruption. In particular, three dimensional imaging could demonstrate clearly the direction of the needle, making it easier to perform endoscopic urethroplastic surgery safely. Endoscopic urethroplasty which is minimally invasive for patients can be performed with shorter operating time and less blood loss than open surgery by urologists used to endoscopic treatment. Endoscopic surgery can be useful for selected patients of advanced age, in poor general condition, or with severe complications.

Bilateral emphysematous pyelonephritis cured by antibiotics alone: a case and literature review.

Emphysematous pyelonephritis (EPN) is a rare but severe infectious disease. This disease sometimes presents bilaterally, making it difficult to cure. Diabetes mellitus is a common cofactor in this disease. Drainage or nephrectomy, often combined with antibiotics, is ordinarily used for treatment. To our knowledge, only 8 cases of bilateral EPN cured by antibiotics alone have been reported. We report the case of an 86-year-old woman with bilateral EPN cured by antibiotic therapy alone, thus avoiding surgery or drainage in a frail elderly patient.