[A Case of Acute Postrenal Renal Failure Caused by Hematuria Due to Vitamin K Deficiency].

A 51-year-old male was hospitalized at another hospital for aspiration pneumonia during gastrostomy management due to sequelae related to a cerebral hemorrhage. The patient was referred to our hospital because of gross hematuria and renal dysfunction following fasting and antibiotic administration. Serum creatinine was 10.54 mg/dl. Prothrombin time (PT) and PT-international standard ratio (PT-INR) were beyond the measurement range, while activated partial thromboplastin time (APTT) was 125 seconds, and protein induced by vitamin K absence or antagonist-II (PIVKA-II) was 117,591 mAU/ml. Computed tomography (CT) imaging showed blood clots in both upper urinary tracts and urinary tract obstruction was considered to be the cause of renal dysfunction. Based on the findings following fasting and long-term administration of antibiotics, including the N-methyl tetrazole thiol (NMTT) group, we considered that the cause was vitamin K deficiency. The patient was immediately treated with menatetrenone (20 mg). Four days after beginning administration, PT, PT-INR, and APTT were improved, and gross hematuria had disappeared. Thereafter, urine volume was increased and renal function became normalized, while PIVKA-II was decreased to the normal range. When a fasting patient has a bleeding tendency during antibacterial administration, it is necessary to consider treatment with vitamin K deficiency.

[Small cell carcinoma in a vesical diverticulum: a case report].

We report a case of small cell carcinoma located within the vesical diverticulum. A 73-year-old woman referred to our hospital with a chief complaint of gross hematuria. Cystoscopy confirmed a non-papillary tumor within the vesical diverticulum. Histopathologic diagnosis with transurethral resection of the tumor (TURBT) specimen was small cell carcinoma. Later, tumor recurrence occurred within the same diverticulum. TURBT and biopsy of the vesical mucosa were performed. After confirming that no tumor was detected outside of the diverticulum, partial cystectomy was done including an adequate margin around the diverticulum in September, 2010. Since the histopathologic finding of the specimen revealed urothelial carcinoma (UC) this time and microinvasion and venous invasion were detected, we performed an adjuvant chemotherapy according to the protocol of gemcitabine and cisplatin therapy. To our knowledge, this is the 4th case report of small cell carcinoma located in a vesical diverticulum in Japan.

Antimicrobial prophylaxis to prevent perioperative infection in urological surgery: a multicenter study.

We prospectively investigated the rates of incidence of surgical site infection (SSI), urinary tract infection (UTI), and remote infection (RI) in 4,677 patients who underwent urological surgery from January to December 2010, including 2,507 endourological cases, 1,276 clean cases, 807 clean-contaminated cases, and 87 contaminated cases involving bowel segments. A single dose of antimicrobial prophylaxis (AMP) was administered in the endourological, clean, and clean-contaminated surgery cases, except for patients who underwent transurethral resection of the prostate (TURP) or percutaneous nephrolithotripsy (PNL). AMP was administered within 72 h in TURP and PNL, and AMP was administered within 48 h in contaminated surgery cases. In cases of endourological surgery, UTI was observed in 4% and RI in 0%, and SSI, UTI, and RI were seen in 1%, 1%, and 1%, respectively, of clean surgery cases, in 3%, 3%, and 2%, respectively, of clean-contaminated surgery cases, and in 17%, 30%, and 10%, respectively, of contaminated surgery cases. In multivariate analysis of the risk factors for infection, operative time was a significant risk factor for UTI in endourological surgery, and American Society of Anesthesiologists score and operative time were significant risk factors for RI in clean surgery. No significant risk factor was found in analyses of clean-contaminated and contaminated surgery cases. A single-dose AMP regimen was shown to be effective and feasible for prevention of perioperative infection in urological surgery.

Lymphoproliferative disease of the kidney developing in fibro-inflammatory lesion.

An 80-year-old man presented with continuous spike fever and night sweats. Computed tomographic scans revealed a poorly demarcated mass in the upper part of the right kidney, which was resected. At surgery, tumorous lesions were not found in the abdominal cavity. Serum IgG4 level measured after surgery was 40.1mg/dl. Macroscopically, renal parenchyma of the upper part was replaced by an irregularly shaped grayish-white lesion of elastic, firm consistency. Histologically, the lesion consisted mostly of fibrous tissue in which small lymphoid cells, often with formation of aggregates, were evident. IgG4-positive plasma cells were few in number. Careful macroscopic examination revealed several minute nodules, which histologically consisted of large lymphoid cells, small lymphoid cells, and macrophages. These large lymphoid cells were positive for CD20 and contained Epstein-Barr virus (EBV) genome. Taken together, a diagnosis of EBV-positive B-cell lymphoproliferative disease (LPD) developing in inflammatory pseudotumor (IPT) of the kidney was made. This is the first report of B-LPD in IPT of the kidney. In addition, a presence of EBV in renal lymphoma cells has not yet been reported.

[A questionnaire survey on the theory of postoperative infection prophylaxis in urologic surgery].

The implementation of the Japanese guidelines for prevention of postoperative infection in urological surgery, based on the Centers for Disease Control and Prevention (CDC) was surveyed. In October 2006, questionnaires about selection of prophylactic antibiotics, timing and period of administration, were distributed to 25 urologists. Surgical procedures were classified into four categories by contamination levels: 1. clean surgery, 2. clean-contaminated surgery, 3. contaminated surgery (surgery with urinary tract diversion using the intestine), and 4. laparoscopic surgery. Implementation of recommendations was about 70% in the selection of prophylactic antibiotics, and 20-30% for the timing of administration in four categories. Adequate implementation was low for the timing of administration. Period of administration in contaminated surgery was longest in all categories. Concerning the administration period and the selection of antibiotics for contaminated surgery, marked differences from recommendations were seen. Therefore further education in hospitals in Japan is needed.

Primary carcinoid tumor of the urinary bladder.

A polyp of about 1.0 cm diameter was incidentally found at the center of the posterior wall of the urinary bladder in a 73-year-old man on cystoscopic examination. A polyp was resected through a transurethral route without recurrence for 22 months. A polyp consisted of a tumor covered with mucosa of the bladder. Tumor cells have round or oval nuclei with fine chromatin and one or two nucleoli per nucleus, and finely granular eosinophilic cytoplasm, being arranged in a trabecular or tubular pattern. Furthermore, they showed positive staining for chromogranin-A and with Grimelius stain, indicating that the tumor is a carcinoid tumor. Since there was no evidence of carcinoid tumors in organs other than the urinary bladder, the present case is a primary carcinoid tumor (well differentiated endocrine tumor) of the urinary bladder which is extremely rare.