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.

Adenocarcinoma in ectopic prostatic tissue at the trigone of urinary bladder.

Introduction: Ectopic prostatic tissue is prostatic tissue located distant from the prostate gland. Although its existence is not uncommon, the occurrence of adenocarcinoma in ectopic prostatic tissue is rare. Case presentation: A 68-year-old man was suspected to have a nodular-type tumor in the bladder trigone and a tumor in the prostate based on magnetic resonance imaging and cystoscopy results. Transurethral tumor resection and transrectal prostate needle biopsy revealed the coexistence of ectopic prostatic adenocarcinoma in the bladder trigone and low-risk orthotopic prostate cancer. Four years later, the tumor evolved to intermediate-risk prostate cancer during active surveillance, and the patient underwent prostatectomy with resection of the bladder trigone. Pathology indicated no residual ectopic prostatic tissue or adenocarcinoma at the bladder trigone. Conclusion: Adenocarcinoma in ectopic prostatic tissue is very rare; however, when found, the possibility of concurrent cancer in the prostate gland should be considered.

Maintaining Serum Hemoglobin Levels Within the Physiological Range Prevented Bladder Tamponade Recurrence Due to Radiation-Induced Hemorrhagic Cystitis: A Case Report.

Radiation-induced hemorrhagic cystitis is a refractory disease that can cause severe hematuria and bladder tamponade. Bladder tamponade due to radiation-induced hemorrhagic cystitis can often recur repeatedly and markedly reduce the quality of life. However, no blood test parameter has been studied yet regarding the prevention of bladder tamponade recurrence. An 84-year-old patient with a history of radiation therapy for cervical cancer was repeatedly hospitalized for bladder tamponade due to radiation-induced hemorrhagic cystitis. At each hospitalization, blood transfusions were performed to treat severe anemia as the first treatment, resulting in hematuria improvement, and the patient was discharged without invasive treatments such as transurethral coagulation. However, anemia developed gradually after each discharge. The anemia progression was obviously unrelated to macrohematuria because macrohematuria did not appear during that period. When the serum hemoglobin level decreased below the physiological range, bladder tamponade recurred. Based on these findings, we posited that the monitoring of the serum hemoglobin level could be useful to predict the occurrence of bladder tamponade. We hypothesized that if the serum hemoglobin level did not fall below the physiological range, bladder tamponade would not occur. We treated chronic anemia after determining its cause and kept serum hemoglobin levels within the physiological range. Since the treatment was initiated, bladder tamponade has not recurred in over 27 months. In this case, the monitoring of the serum hemoglobin level was useful to predict the occurrence of bladder tamponade due to radiation-induced hemorrhagic cystitis. By maintaining serum hemoglobin levels within the physiological range, we successfully prevented the recurrence of bladder tamponade due to radiation-induced hemorrhagic cystitis.

[A Case of Panperitonitis Due to Bladder Rupture Caused by Spinal Metastasis of Colorectal Cancer].

A 74-year-old patient was undergoing treatment for ascending colon cancer (cT4aN2M1a) in the Department of Surgery at our hospital. During treatment for increased lymph node metastasis and spinal metastasis, she complained of numbness in her dorsal thigh. Magnetic resonance imaging showed spinal canal stenosis due to L4 bone metastasis. Immediately after starting radiation therapy for L4 bone metastasis, bladder rupture occurred and led to generalized peritonitis. We performed emergency laparotomy and drainage. Later, the patient's general condition improved, but irreversible neurological symptoms remained, and activities of daily living decreased markedly. This was thought to be caused by weakening of the bladder wall due to chronic cystitis, and hyperextension of the bladder due to neurogenic bladder. Bacteriuria leaked into the abdominal cavity, resulting in generalized peritonitis.

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.

[Primary Pulmonary Cryptococcosis Mimicking Lung Metastases of Bladder Cancer : A Case Report].

A 70-year-old woman was diagnosed with bladder cancer (muscle invasive adenocarcinoma) via transurethral resection of bladder tumor in 2013. A month after the procedure, she underwent total cystectomy and ileal conduit diversion. Histopathological diagnosis was adenocarcinoma pTis pN0. In 2019, a computed tomography showed multiple nodules, each up to 1 cm in diameter, mainly in the right lower lobe. Metastatic lung cancer was suspected. She underwent thorascopic partial resection of the right lung, and was diagnosed with primary pulmonary cryptococcosis.

[A Case Report : FDG Uptake to Brown Adipose Tissue Activated by Elevated Serum Catecholamine in a Patient with Pheochromocytoma].

A 69-year-old woman was admitted to the previous hospital because of a right adrenal tumor detected by a medical checkup. Although the tumor was diagnosed as non-functional adrenal adenoma, abdominal computed tomography (CT) revealed a left renal mass which was suspected to be renal cell carcinoma. Chest CT seeking for metastatic lesions revealed lung cancer of the left lung. First, laparoscopic radical nephrectomy was performed. After the surgery, 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) CT performed for staging of the lung cancer demonstrated FDG uptake to the left lung mass, the heart, the right adrenal mass and perirenal regions of the right kidney. The patient showed elevated serum catecholamine level and hypertensive emergency. She was admitted to our hospital with a suspicion of pheochromocytoma of the right adrenal gland and multiple paraganglioma. CT and magnetic resonance imaging showed that the heart and the perirenal regions had no tumors. We considered these lesions brown adipose tissue. Under the diagnosis of pheochromocytoma of the right adrenal gland, laparoscopic partial adrenalectomy was performed. The clinical course after the surgery was uneventful. FDG PET-CT revealed that FDG uptake to brown adipose tissue disappeared 6 months after the partial adrenalectomy.

[Inflammatory Pseudotumor of the Ureter : A Case Report and a Review].

We report a case of inflammatory pseudotumor of the ureter. An 81-year-old man who had an operation of pelvic exenteration with ileal conduit presented with right flank pain. Computed tomography revealed a 16 mm mass of the right ureter with right hydronephrosis and renal atrophy. The mass increased in size during follow up. Right nephroureterectomy was performed with suspicion of ureteral cancer. Histopathological finding showed an inflammatory pseudotumor. No obvious recurrence has been observed for 33 months after the surgery.

[A Case of Retroperitoneal Cavernous Hemangioma Difficult to Differentiate from Retroperitoneal Liposarcoma].

We report a case of retroperitoneal cavernous hemangioma. A 77-year-old woman complaining of nausea was admitted to a different hospital in September 2013. Computed tomography (CT) detected a retroperitoneal mass in the left pararenal space. Three years later, repeated CT showed that the tumor had gradually grown in size. On dynamic contrast-enhanced magnetic resonance imaging (MRI), the tumor demonstrated radiographic signs of a liposarcoma. Resection of the mass with left nephrectomy was performed in June 2016, and histopathology showed cavernous hemangioma. Clinical diagnosis of cavernous hemangioma is difficult, and imaging modalities, including CT and MRI, may not be conclusive. The final diagnosis in most cases is established through surgery. This is the 29th case of retroperitoneal cavernous hemangioma to be reported in Japan.

[Case of Behcet's disease diagnosed by bilateral epididymitis].

A 24-year-old man visited our emergency room with testicular pain and left shoulder pain, and was admitted to our hospital for diagnosis of bilateral epididymitis. Antibiotics and anti-inflammatory medication were started, but the symptoms did not improve. During hospitalization, ulcerous lesions, erythema nodosum, folliculitis-like exanthema and multiple oral aphtha appeared. Then, we consulted the department of dermatology. As he had a combination of arthritis and epididymitis, he was diagnosed with the abortive form of Behcet's disease. After diagnosis, we began administering colchicine. Then, all symptoms improved in a few days, and he has remained free of the disease after the discontinuation of colchicine.

[A case of giant testicular tumor in a schizophrenic patient].

A 55-year-old man with schizophrenia presented with right scrotal enlargement. Clinical examination revealed a right adult -head-sized testicular tumor, multiple lymph node metastasis with marked elevation of serum lactic dehydrogenase (LDH) and ß -human chorionic gonadotropin (ß -HCG). Right high orchiectomy followed by chemotherapy with bleomysin, etoposide and cisplatin (BEP) for 4 cycles was performed. The tumor weighed 5,270 g, and was pathologically diagnosed as seminoma. After the treatment, the tumor markers were normalized, but he refused to undergo retroperitoneal lymph node dissection.

[Castleman's disease of the kidney: a case report].

Castleman's disease is a rare disorder characterized by benign proliferation of lymphoid tissue. A 61-year-old man was referred to our department for a renal mass incidentally detected by magnetic resonance imaging. Computed tomography showed a 18 × 20 × 14 mm mass in the upper pole of the right kidney, which enhanced at the early phase and washed out at the late phase. On the diagnosis of renal cell carcinoma, laparoscopic partial nephrectomy was performed. Pathological examinations revealed a hyaline-vascular type of Castleman's disease confined to the kidney.

[Panhypopituitarism caused by an intrasellar cystic mass in late-onset hypogonadism clinic].

A 74-year-old man who was referred to our late onset hypogonadism clinic presented with sweating and loss of appetite. His aging males' symptoms (AMS) and international index of erectile function (IIEF-5) scores were 59 and 2, respectively. His hormonal examination revealed extremely low free testosterone values. The patient was started on androgen replacement therapy, but his symptoms did not improve. Additional hormonal examinations revealed low values for other anterior pituitary hormones. Magnetic resonance imaging revealed an intrasellar cystic mass with suprasellar extension. We considered this mass caused hypothalamic hypopituitarism. A load test for anterior pituitary hormones revealed panhypogonadism. His symptoms improved after administration of adrenal and thyroid hormones and androgen. Five months after start of drug administration, his AMS score improved to 29, but IIEF-5 score showed little change. As a matter of course, not only androgen but all pituitary-related hormones are needed for hypopituitarism patients.

[Primary adenocarcinoma of the seminal vesicle difficult to differentiate from rectal carcinoma : a case report].

A 78-year-old man with urinary retention visited our hospital in June 2011. He presented with intestinal bleeding one month later and was admitted immediately. Contrast enhancement computed tomography revealed a lobulated intrapelvic tumor and liver metastasis. The prostate specific antigen level was normal, but his carcinoembryonic antigen level was elevated. Based on these results, his tumor was diagnosed as rectal carcinoma. On day 26, total pelvic exenteration and pelvic lymph node dissection to arrest bleeding were performed. We created an ileal conduit for urinary diversion and performed a sigmoid colostomy. The final histopathological assessment confirmed that he had primary adenocarcinoma of the seminal vesicle. The patient received the best supportive care because he rejected postoperative adjuvant chemotherapy and hormonal therapy. He died three months postoperatively. Primary adenocarcinoma of the seminal vesicle is very rare. The prognosis for this carcinoma is poor.

[Poor outcome due to spontaneous rupture of renal cell carcinoma : a case report].

A 54-year-old man experienced sudden onset of severe pain in his left lower back. Because the pain persisted for two days, he visited our hospital. Abdominal computed tomography revealed a hematoma around his left kidney, which was diagnosed as spontaneous rupture of a renal tumor. He was immediately admitted and was scheduled to undergo elective surgery. However, because his hemoglobin level decreased suddenly on Day 9 and rebleeding from the renal tumor was suspected, we chose to perform left radical nephrectomy following emergency transcatheter arterial embolization of his left renal artery. The resected specimen was a solid brownish-red mass surrounded by hematoma, and the histopathological findings revealed that it was a renal clear cell carcinoma (G3＞G2, INFα, pT1b, and pV0). On Day 51, he was found to have a local recurrence of carcinoma, and died five months after surgery. Spontaneous rupture of renal cell carcinoma is relatively rare : this is the 104th report on surgery for this carcinoma in Japan.

[A case of metabolic acidosis and tetany after ileal neobladder replacement].

A 64-year-old man visited our hospital with the complaint of macrohematuria and bilateral hydronephrosis. He had undergone total cystectomy and ileal neobladder replacement under the diagnosis of muscle invasive bladder cancer (cT2bN0M0). Tetany due to hyperventilation syndrome appeared on postoperative day 42. Blood gas analysis showed metabolic acidosis (pH 7.260, pO2 148.1 mmHg, pCO2 20.7 mmHg, HCO3 9.1 mmHg, BE -16.0 mmol/l). His condition was immediately improved after a urethral catheter was placed and sodium bicarbonate was administered. After re-removal of the urethral catheter, however, hyperventilation syndrome recurred. He was discharged from the hospital with the urethral catheter placed.

[IgG4-related idiopathic segmental ureteritis which was difficult to distinguish from ureteral cancer: a case report].

A 79-year-old woman was admitted with a chief complaint of gross hematuria, pollakisuria, lower abdominal pain. Urine cytology, intravenous pyelography, and cystoscopy were performed but showed no abnormal findings. About 6 months later, abdominal computed tomography (CT) revealed a 5cm long segment of ureteral narrowing with wall thickening, hydronephrosis, para-aortic lymph node swelling. Retrogradepyelography (RP) was done. Pelvic urine cytology was class IV. Under the clinical diagnosis of ureteral carcinoma and lymph node metastasis, a left nephroureterectomy with lymph node dissection was performed. The pathological diagnosis was IgG4-related idiopathic segmental ureteritis.

[A case of bladder cancer with metastasis to the bone of the hand].

Metastasis to the bone of the hand is rare. In addition, metastasis to the bone of the hand from bladder cancer is extremely rare. We herein report a case of distal phalanx metastasis from bladder cancer. A 64- year-old man who was diagnosed with bladder cancer (cT2bN0M0) received total cystectomy (pT3bN2). Two months after the surgery, a roentgenogram revealed lung metastasis. Then we administered 2 cycles of chemotherapy using gemcitabine and cisplatin. Computed tomography revealed a partial response. However, several months after chemotherapy, we noted that his left ring finger was swollen and showed erythema. We made a diagnosis of metastasis to the distal phalanx of the left ring finger and amputated the finger. Pathological findings showed no conflict with metastasis from bladder cancer. Postoperative course was good, but he died about three months after the diagnosis of metastasis.

[Successful treatment of spontaneous rupture of pheochromocytoma with laparoscopic adrenalectomy: a case report].

A 46-year-old man had sudden onset of severe left hypochondrial pain and went into shock following hospitalization. Computed tomography, echocardiography, and endocrinological tests revealed spontaneous rupture of a pheochromocytoma associated with catecholamine cardiomyopathy. After he underwent conservative management with fluid replacement, his blood pressure stabilized and cardiac function improved. Twenty-two days later, he was referred to our hospital. After admission, as his circulatory dynamics was stable, we performed elective laparoscopic left adrenalectomy. He was discharged on the tenth postoperative day. Spontaneous rupture of a pheochromocytoma is very rare : laparoscopic surgery for this condition has been reported only on 2 previous occasions worldwide.

[Three cases of penile self-mutilation].

Penile self-mutilation is rare. We report our experience with 3 cases of penile self-amputation. One case was in a 48-year-old man who had no background history of mental disorders. He amputated his penis using a utility knife. He was referred to our hospital and underwent suture of the wound, but he took his own life one week after the surgery. Another case was in a 42-year-old man who had intelligence impairment. He amputated his penis using a kitchen knife. The other case was in a 41-year-old man who had schizophrenia. He amputated his penis using a piece of broken glass.