Tetsuya Miura

Levofloxacin resistant Escherichia coli sepsis following an ultrasound-guided transrectal prostate biopsy: Report of four cases and review of the literature

Abstract:  Fluoroquinolones are the most commonly used prophylactic antimicrobials for ultrasound‐guided transrectal prostate biopsy due to their broad pathogen spectrum, pharmacokinetics, bioavailability and ease of oral administration. However, although Escherichia. coli (E. coli) is the most common pathogen associated with infections after transrectal prostate biopsy, the prevalence of fluoroquinolone resistant strains of E. coli is increasing. Levofloxacin resistant E. coli sepsis occurred in four (0.6%) of 665 patients who received oral levofloxacin prophylaxis and underwent transrectal prostate biopsy from July 2002 to December 2006 in this institute. All patients had obstructions of the lower urinary tract and three of the four had a history of previous use of quinolones. Although two of the four patients developed septic shock, all of the patients were treated with carbapenems immediately and made a complete recovery. Since a case of multiresistant E. coli sepsis and fatal anaerobic sepsis after transrectal prostate biopsy had been reported, intravenous carbapenem is recommended as antimicrobial therapy for sepsis after transrectal prostate biopsy.

Gender as a significant predictor of intravesical recurrence in patients with urothelial carcinoma of the upper urinary tract following nephroureterectomy.

OBJECTIVES To retrospectively assess the significance of gender as a predictor of intravesical recurrence following nephroureterectomy for urothelial carcinoma of the upper urinary tract (UC-UUT). MATERIALS AND METHODS This study included 502 consecutive patients (360 male and 142 female) who were diagnosed as having clinically localized UC-UUT and underwent nephroureterectomy. Clinicopathologic outcomes of these patients were analyzed focusing on the impact of gender. RESULTS The incidence of intravesical recurrence in male patients (41.9%) was significantly greater than that in female patients (27.5%). Despite the lack of significant differences in cancer-specific and overall survivals with respect to gender, the intravesical recurrence-free survival in male patients was significantly worse than that in female patients. Of several parameters examined, univariate analysis identified gender, tumor site, and tumor focality as significant predictors of intravesical recurrence following nephroureterectomy. Of these, only gender and tumor site appeared to be independently associated with intravesical recurrence-free survival on multivariate analysis. Furthermore, there was a significant difference in intravesical recurrence-free survival according to positive numbers of these two independent factors; that is, intravesical recurrence occurred in 12 of 55 patients who were negative for both risk factors (21.8%), 96 of 280 positive for a single risk factor (34.3%), and 82 of 167 positive for both risk factors (49.1%). CONCLUSIONS The incidence of intravesical recurrence following nephroureterectomy for UC-UUT is comparatively high. Therefore, it would be potentially important to perform careful follow-up targeting intravesical recurrence for such patients, particularly for male patients and/or patients with tumor located at the ureter.

Intraoperative Fluorescence Imaging for Detection of Sentinel Lymph Nodes and Lymphatic Vessels during Open Prostatectomy using Indocyanine Green

PURPOSE We investigated the feasibility and validity of intraoperative fluorescence imaging using indocyanine green for the detection of sentinel lymph nodes and lymphatic vessels during open prostatectomy. MATERIALS AND METHODS Indocyanine green was injected into the prostate under transrectal ultrasound guidance just before surgery. Intraoperative fluorescence imaging was performed using a near-infrared camera system in 66 consecutive patients with clinically localized prostate cancer after a 10-patient pilot test to optimize indocyanine green dosing, observation timing and injection method. Lymphatic vessels were visualized and followed to identify the sentinel lymph nodes. Confirmatory pelvic lymph node dissection including all fluorescent nodes and open radical prostatectomy were performed in all patients. RESULTS Lymphatic vessels were successfully visualized in 65 patients (98%) and sentinel lymph nodes in 64 patients (97%). Sentinel lymph nodes were located in the obturator fossa, internal and external iliac regions, and rarely in the common iliac and presacral regions. A median of 4 sentinel lymph nodes per patient was detected. Three lymphatic pathways, the paravesical, internal and lateral routes, were identified. Pathological examination revealed metastases to 9 sentinel lymph nodes in 6 patients (9%). All pathologically positive lymph nodes were detected as sentinel lymph nodes using this imaging. No adverse reactions due to the use of indocyanine green were observed. CONCLUSIONS Intraoperative fluorescence imaging using indocyanine green during open prostatectomy enables the detection of lymphatic vessels and sentinel lymph nodes with high sensitivity. This novel method is technically feasible, safe and easy to apply with minimal additional operative time.

A case of Sweet's syndrome following septic pulmonary emboli after high‐dose chemotherapy for advanced testicular cancer

Abstract  A 33‐year‐old man with advanced testicular cancer underwent high‐dose chemotherapy combined with peripheral blood stem cell transplantation. After administration of granulocyte colony‐stimulating factor (G‐CSF), multiple infiltrative erythema was identified on the face, thigh, and lower leg. A dermatologist diagnosed this as Sweets syndrome caused by G‐CSF; consequently G‐CSF administration was stopped. When the skin lesions had improved, phlebitis was found at the injection site of the peripheral vein catheter. The patient then suffered from sudden left chest pain and dyspnea. Chest computed tomography showed the characteristic findings of septic pulmonary emboli (SPE). He was treated by the administration of vancomycin, fluconazole, and pazufloxacin mesilate. Although Sweets syndrome and SPE are rare diseases, the presence of these diseases must be considered when performing chemotherapy for urological malignancy.

Pictorial review of orthotopic neobladder reconstruction: indication, normal postsurgical anatomy, and complications.

Radical cystectomy with urinary diversion is a common urological procedure performed for the treatment of bladder cancer. Numerous surgical procedures have been developed for urinary diversion. Over the past decade, orthotopic neobladder reconstruction has been used frequently for urinary diversion because of its advantageousness in providing patients with a good quality of life compared with other urinary diversion technique. Knowledge of the indication, surgical procedure, and postsurgical anatomy of orthotopic neobladder reconstruction is essential. While the technique has many advantages, multiple postsurgical complications may occur after reconstruction, including urine leakage, bowel obstruction and fluid collection (lymphocele, urinoma, hematoma, and abscess), neobladder rupture, vesicoureteral reflux, hydronephrosis, urinary tract infection, urinary calculi, abdominal incisional hernia, bowel obstruction, intraneobladder tumor, and tumor recurrence. Radiological imaging including multiple modalities such as intravenous urography, cystography, CT, and MRI plays an important role in the postoperative evaluation of patients with orthotopic neobladder reconstruction and is an accurate method for evaluating complications. In addition, knowledge of appearances on multimodal imaging helps clinicians to select the modality required to achieve an accurate diagnosis of each complication and avoid misdiagnosis.

The Impact of Decreasing Urinary IgA Levels on Decreased Bacteriuria in a Rat Model of Ileal Augmented Bladder

PURPOSE Bacteriuria is frequently observed in patients with urinary tract reconstruction using intestinal segments. These patients have higher urinary IgA levels than those with a normal bladder. We examined the relationship between bacterial adherence and urinary IgA in a rat ileal augmented bladder model. MATERIALS AND METHODS Rat ileal augmented bladder models were divided into groups 3 months and 1 year after surgery. Experimental cystitis was induced in the 2 groups by transurethral inoculation of Escherichia coli. At 14 days after inoculation the rats were sacrificed, and cfu/mg tissue of the bladder and ileal patch was measured. Rats with negative urine culture in the 2 groups were sacrificed, and urine specimens and augmented bladder tissue were collected. Urinary IgA levels were determined and immunohistochemistry staining of the tissue was done with anti-rat IgA antibody. RESULTS In rats with experimental cystitis E. coli significantly adhered to the bladder and ileal patch in the 3-month group but not in the 1-year group. Urinary IgA levels in the 3-month group were significantly higher than in the 1-year group. On immunohistochemistry the number of IgA immunoreactive cells in the ileal patch decreased in the 1-year group compared to that in the 3-month group. CONCLUSIONS These results suggest that increased urinary IgA may be the cause of the higher incidence of bacteriuria in patients with urinary reconstruction using intestinal segments. Therefore, the decrease in IgA production in the inserted intestinal segments may contribute to a spontaneous decrease in of bacteriuria with time.

Retroperitoneal abscess perforating into the thoracic cavity in an immunocompromised host

A 71-year-old man with a retroperitoneal abscess caused by a ureteral stone was successfully treated by retroperitoneal drainage. He was considered to be at high risk of infection because of his bedridden state (resulting from a post-cerebral infarction and malignant rheumatoid disease) and steroid administration for the rheumatoid disease. He also had an empyema adjacent to the retroperitoneal abscess. This was thought to be separate from the retroperitoneal abscess because it did not resolve after the retroperitoneal drainage. Thoracic cavity drainage was undertaken, after which the empyema disappeared. The drainage fluid contained pus, similar to the fluid from the retroperitoneal drainage. Escherichia coli organisms were cultured from both drainage fluids. There were no signs of recurrence on computed tomography (CT) imaging. In conclusion, we report a case of retroperitoneal abscess perforating into the thorax, successfully treated by retroperitoneal and thoracic cavity drainage in an immunocompromised host. CT was a very effective imaging modality for this diagnosis, and we recommend early drainage of abscess in immunocompromised patients.

Clinical study of complicated urinary tract infection using ‘The UTI Criteria (Draft Fourth Edition)’: Measurement methods for pyuria

Objective: To evaluate the influences the change of the measurement method of pyuria from conventional centrifuged sediment to microchamber uncentrifuged urine for the results of evaluation of antimicrobial agents in clinical study against complicated urinary tract infections. From the viewpoint of international harmonization of judgement criteria, the recent method for counting white blood cells (WBC) in urine has changed from using uncentrifuged urine to using a microchamber in all countries.