A 70-year-old woman presented to our hospital for workup for chronic cough. A contrast computed tomography (CT) of the thorax and abdomen revealed an incidental finding of multilobulated soft tissue lesions in the abdomen along the left para-aortic region. The lesions measured up to 7.4 cm in diameter and demonstrated mild increased attenuation on pre-contrast images and vivid heterogenous enhancement on post-contrast study (Fig 1a and b). Appearance and location of these lesions raised concern about possible lymphadenopathy so fluorodeoxyglucose-18 positron emission tomography–CT was performed. The lesions demonstrated only mild metabolic activity (maximal standard uptake value=2.6) [Fig 1c]. They showed no interval change in appearance, and no other hypermetabolic lesion could be detected elsewhere. Tumour markers including alpha-fetoprotein, carcinoembryonic antigen, and cancer antigen 125 were not elevated.

The CT-guided biopsy of the para-aortic lesions subsequently showed cuboidal follicular cells arranged in architecture resembling thyroid parenchymal tissue (Fig 2). Immunostaining for thyroglobulin and thyroid transcription factor-1 were positive. There were no nuclear features of carcinoma.

Thyroid scintigraphy using technetium-99m pertechnetate showed intense radiotracer uptake over the corresponding para-aortic lesions (Fig 3). Findings were consistent with ectopic thyroid tissue. The presence of an orthotopic thyroid at its normal pretracheal position was demonstrated on CT and on technetium-99m scan (Fig 4). The patient’s thyroid function was normal.

Ectopic thyroid gland is a rare developmental abnormality with a prevalence of approximately 1 per 100 000 to 300 000 population.1 It results from aberrant embryogenesis of the gland during its migration from the foramen cecum at the posterior aspect of the tongue to its final pretracheal position. Frequent locations include its path of embryological descent along the midline of the neck, with a lingual thyroid at the base of the tongue being most common, accounting for up to 90% of reported cases.2 Other locations include the lateral neck and superior mediastinum. More distant locations such as subdiaphragmatic locations have also been reported but are exceedingly rare. To the best of the authors’ knowledge, this is the first report of ectopic thyroid tissue occurring at the para-aortic region of the abdomen, mimicking the appearance of lymphadenopathy on CT.

Thyroid scintigraphy is the most important and sensitive imaging tool to detect ectopic thyroid tissue. It also has the advantage of being able to demonstrate the presence or absence of an orthotopic thyroid gland. In patients with ectopic thyroid tissue, it is important to evaluate for the presence of orthotopic thyroid and thyroid function. Hypothyroidism may be present, particularly in those without a normal thyroid gland, and more common in patients with lingual ectopic thyroid.2 Ultrasound is also useful to locate and evaluate the orthotopic thyroid gland.

Computed tomography and magnetic resonance imaging are important adjuncts in evaluation. Ectopic thyroid tissue may show similar imaging characteristics to normal thyroid gland with high attenuation on non-contrast CT due to its high iodine content and vivid post-contrast enhancement. When ectopic thyroid tissue is found in a location not consistent with embryologic development, the possibility of malignant metastasis needs to be considered, occurring in 7% to 23% of patients.3 Biopsy is invaluable and the orthotopic gland should be evaluated for possible malignant change. Pathological changes that affect a normal thyroid including malignant change have been reported in ectopic tissues,1 and should be considered in the management and follow-up of ectopic thyroid tissue.

Concept or design: All authors.
Acquisition of data: CHK Wong, HL Tsui, CN Ling.
Analysis or interpretation of data: CHK Wong, HL Tsui, CN Ling.
Drafting of the manuscript: CHK Wong, HL Tsui, CN Ling.
Critical revision of the manuscript for important intellectual content: All authors.

All authors have disclosed no conflicts of interest.

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The patient was treated in accordance with the Declaration of Helsinki. The patient provided written informed consent for all treatments and procedures and consent for publication.

1. Noussios G, Anagnostis P, Goulis DG, Lappas D, Natsis K. Ectopic thyroid tissue: anatomical, clinical, and surgical implications of a rare entity. Eur J Endocrinol 2011:165:375-82. Crossref

2. Guerra G, Cinelli M, Mesolella M, et al. Morphological, diagnostic and surgical features of ectopic thyroid gland: a review of literature. Int J Surg 2014;12 Suppl 1:S3-11. Crossref

3. Ballard D, Patel P, Schild SD, Ferzli G, Gordin E. Ectopic thyroid presenting as supraclavicular mass: a case report and literature review. J Clin Transl Endocrinol Case Rep 2018;10:17-20. Crossref

In September 2020, a 29-year-old woman presented to the emergency department with a 2-day history of upper abdominal pain. The patient had no history of recent trauma around the abdominal area. The patient’s vital signs were stable upon arrival but physical examination revealed tenderness over the right upper quadrant area. The patient reported moderate to heavy alcohol consumption (10-15 standard drinks per week). Laboratory findings revealed a white blood cell count of 3030/mm³, haemoglobin level 12.8 g/dL, and low platelet count of 34 000/mm³. The prothrombin time was mildly prolonged to 14.2 s. Elevated levels of liver enzymes, aspartate transaminase (113 U/L), direct bilirubin (6.18 mg/dL), and gamma-glutamyltransferase (350 U/L), were reported. Computed tomography (CT) scans showed a distended gallbladder with several gallstones and bile duct stones. Moreover, the intraluminal space of the gallbladder was filled with heterogeneous material, and extravasation of the contrast agent was suspected in the arterial phase (Fig 1). Emergency laparoscopic exploration was planned with a preoperative diagnosis of gallbladder haematoma. At the first laparoscope view, cirrhotic change to the liver with ascites and an oedematous gallbladder were evident (Fig 2a). The surgeon tried gallbladder decompression by needle aspiration and made a small opening to remove the blood but it was unsuccessful (Fig 2b). Laparoscopic cholecystectomy was successful without complications such as perforation (Fig 2c and d). Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy was performed 5 days after the initial surgery and remnant common bile duct stones were removed. Pathological evaluation revealed a gallbladder haematoma with 30 to 40 gallstones (Fig 3). Moreover, venous vessels were remarkably dilated in the vicinity of the haemorrhagic site on CD31 immunostaining. The patient was discharged on postoperative day 10 with no complications.

The gallbladder is normally physiologically empty or filled with bile juice. Gallbladder haematoma is defined as filling of the gallbladder with blood. The definition can vary from gallbladder bleeding that comprises active bleeding inside the gallbladder to gallbladder haematoma when already-formed blood clots are evident. Haemorrhagic cholecystitis may be an appropriate term in cases of a gallbladder showing inflammation with blood. Reported risk factors for spontaneous bleeding include atherosclerosis or aneurysm, biliary malignancy, renal failure, cirrhosis, and coagulopathy, or anticoagulant medication.1 2 3 Moreover, abdominal blunt trauma can lead to gallbladder injury and cause gallbladder bleeding.3 Clinical manifestations of gallbladder haematoma similarly represent acute gallbladder disease.2 Upper abdominal pain is frequent due to distension of the gallbladder, and melena or haematemesis may also be present. In cases of cholecystitis, fever may develop, and laboratory study will demonstrate inflammation. The conventional radiological methods to evaluate gallbladder disease like ultrasonography or CT scan have diagnostic value.3 Ultrasonography may reveal a blood clot in the lumen with wall thickening and fluid accumulation around the gallbladder.2 In the CT scan, hyperdense blood and bile shadow with or without fluid level may be suspicious of gallbladder haematoma. Extravasation of contrast material into the lumen of the gallbladder during the arterial phase of contrast-enhanced CT is related to active bleeding.3,4 Surgical treatment produces superior results and the minimally invasive method of a laparoscopic approach has been widely adopted.1 3 Other endoscopic or percutaneous approaches for decompression may be considered before surgery.1 Gallbladder haematoma is associated with high morbidity and mortality. Delayed management potentially increases the risk of perforation and concomitant unfavourable outcomes.4 5

Concept or design: WY Nho.
Acquisition of data: D Je.
Analysis or interpretation of data: SK Kee.
Drafting of the manuscript: SK Kee.
Critical revision of the manuscript for important intellectual content: WY Nho.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The study was reviewed and approved by the Institutional Review Board (IRB) of CHA Gumi Medical Center (GM20-11).

1. Leaning M. Surgical case report—acalculous hemorrhagic cholecystitis. J Surg Case Rep 2021;2021:rjab075. Crossref

2. Itagaki H, Katuhiko S. Gallbladder hemorrhage during orally administered edoxaban therapy: a case report. J Med Case Rep 2019;13:383. Crossref

3. Parekh J, Corvera CU. Hemorrhagic cholecystitis. Arch Surg 2010;145:202-4. Crossref

4. Kwon JN. Hemorrhagic cholecystitis: report of a case. Korean J Hepatobiliary Pancreat Surg 2012;16:120-2. Crossref

5. López V, Alconchel F. Hemorrhagic cholecystitis. Radiology 2018;289:316. Crossref

Intra-operative use of indocyanine green (ICG) angiography and lymphography has been reported as a valuable adjunct during microsurgical subinguinal varicocelectomy (MSV).1 The development of a video microsurgery platform and fluorescence imaging technology further facilitates identification of testicular arteries and lymphatics. We report the intra-operative imaging of two patients who underwent varicocele repair for grade 3 left varicoceles in February and March 2021 using the new platform.

The operations were performed under three-dimensional (3D) optical magnification images on the television monitors using the video microsurgery platform with VITOM® 3D system (KARL STORZ SE, Tuttlingen, Germany) as previously described.2 A pack of 25 mg ICG (Diagnogreen; Daiichi Sankyo Co, Tokyo, Japan) was dissolved in 10 mL water. Identification of testicular arteries was assisted by ICG angiography with intravenous injection of 2 mL (5 mg) ICG solution. After preservation of the testicular arteries, the differentiation between lymphatics and small veins was facilitated by ICG lymphography performed following intra-parenchymal testicular injection of 0.5 mL (1.25 mg) ICG solution followed by gentle testicular massage.3 The setting of ICG fluorescence imaging consisted of an IMAGE1 S™ 4U RUBINA™ with 4K 3D monitor system (KARL STORZ SE, Tuttlingen, Germany) and a HOPKINS™ Straight Forward Telescope 0° (10-mm diameter/20-cm length) [KARL STORZ SE, Tuttlingen, Germany]. We demonstrate intra-operative ICG angiography of patient 1, a 35-year-old man with primary infertility and oligoasthenoteratozoospermia. The testicular artery appeared green on the overlay image mode with clear simultaneous visualisation of white light microscopy images in the background (Fig 1a and b). In addition to the testicular artery, the small (<1 mm) cremasteric artery could also be identified in the monochromatic mode that further enhanced the contrast (Fig 1c). After successful preservation of the testicular arteries in patient 2, a 28-year-old man with left scrotal pain, two probable lymphatics were identified under white light microscopy (Fig 2a). The strong green colouration seen in the overlay mode after ICG injection unambiguously confirmed the successful preservation of lymphatics in MSV (Fig 2b).

Microsurgical subinguinal varicocelectomy is the standard for varicocele repair with excellent surgical outcomes reported.4 Nonetheless identification of testicular arteries and lymphatics under white light microscopy alone is operator-dependent and remains challenging for novice surgeons. Several adjuncts have been introduced to facilitate artery- and lymphatic-sparing procedures during MSV. One such adjunct is ICG fluorescence imaging.1 In our opinion, the new overlay mode provided by the latest platform is particularly useful for MSV. Without the need to switch between different modes, the combined regular white light image and near-infrared/ICG data allow accurate localisation of even the smallest vessel without ambiguity (Fig 3). Moreover, the display of ICG signal alone in white on a black background in the monochromatic mode maximises contrast and further improves identification of target vessels (Fig 3). We believe the advances of this surgical platform and imaging technology play a role in enhancing patient safety by increasing the success of arterial and lymphatic preservation in MSV.

Concept or design: CL Cho.
Acquisition of data: All authors.
Analysis or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have disclosed no conflict of interest.

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Patients were treated in accordance with the Declaration of Helsinki. Patients provided written informed consent for the procedures, and verbal consent for publication.

1. Cho CL. Is there any role for indocyanine green angiography in testicular artery preservation during microsurgical subinguinal varicocelectomy? In: Esteves SC, Cho CL, Majzoub A, Agarwal A, editors. Varicocele and Male Infertility: a Complete Guide. Switzerland AG: Springer Nature; 2019: 603-14. Crossref

2. Cho CL, Chu RW. Use of video microsurgery platform in microsurgical subinguinal varicocelectomy with indocyanine green angiography. Surg Prac 2019;23:20-4. Crossref

3. Cho CL, Chiu PK, Chu RW. Preliminary experience with indocyanine green lymphography during microsurgical subinguinal varicocelectomy. Surg Prac 2021;25:207-10. Crossref

4. Zini A. Varicocelectomy: microsurgical subinguinal technique is the treatment of choice. Can Urol Assoc J 2007;1:273-6.

In July 2019, a 54-year-old woman with type 2 diabetes mellitus and suboptimal drug compliance with metformin and gliclazide presented to the emergency department complaining of abdominal pain, progressive weakness, and confusion. Her body temperature was 39.1°C and blood tests revealed serum glucose 29.1 mmol/L; haemoglobin A1c 10.4%; serum glucose 29.1 mmol/L; haemoglobin A1c 10.4%; C-reactive protein 224.3 mg/L; and white cell count 11.9 × 10⁹/L with 92.8% segmented neutrophils; and serum creatinine 437.4 mmol/L. Computed tomography scan of the abdomen and pelvis without contrast revealed a cystic gas-producing liver lesion and diffuse intramural gas dissecting the urinary bladder wall with extension to the left kidney (Fig). A diagnosis was made of acute emphysematous cystitis complicated by liver abscess.

Percutaneous drainage of the liver abscess was performed under ultrasound guidance. Klebsiella pneumoniae, sensitive to meropenem, was cultured from the urine and drained pus. The patient was transferred to the intensive care unit and treated with resuscitation, glycaemic control, and broad-spectrum antibiotics with intravenous meropenem. Meropenem was continued for the initial 7 days and then changed to ceftazidime plus amikacin according to susceptibility testing results. Her symptoms subsided and blood parameters improved gradually. She made an uneventful recovery and was discharged from the hospital on day 20.

Emphysematous cystitis is an uncommon type of infection characterised by gas collections within the bladder wall and lumen. It is usually caused by gas-producing pathogens such as Escherichia coli and Klebsiella pneumoniae.1 Predisposing factors are diabetes, female sex, obstructive uropathy and possibly immunosuppression. Gas is believed to be produced by fermentation of albumin or glucose by the infecting organisms. Emphysematous cystitis combined with liver abscess is rare. The mechanisms of emphysematous cystitis are not well understood. Some reports emphasise that pathogenesis may be related to hematogenous transmission from the liver abscess.2 3 Immunosuppression related to poorly controlled diabetes is another contributing factor.

Clinical presentation of emphysematous cystitis varies. Our patient presented with systemic manifestations of septic shock and severe upper abdominal pain secondary to the liver abscess. She reported no lower urinary tract symptoms. Computed tomography is the best diagnostic modality with its high sensitivity when assessing the extent of gas patterns. Appropriate antibiotic therapy, correction of the underlying disorder, and adequate drainage is the recommended treatment.

Concept or design: Both authors.
Acquisition of data: L Zeng.
Analysis or interpretation of data: L Zeng.
Drafting of the manuscript: L Zeng.
Critical revision of the manuscript for important intellectual content: Q Wang.

Both authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors declared no potential conflicts of interest.

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This study was approved by the Hospital of Chengdu University of Traditional Chinese Medicine Research Ethics Committee. Informed consent was obtained from the patient.

1. Amano M, Shimizu T. Emphysematous cystitis: a review of the literature. Intern Med 2014;53:79-82. Crossref

2. Lai CC. Concomitant emphysematous cystitis and liver abscess. Korean J Intern Med 2018;33:839-40. Crossref

3. Su YC, Chen CC. Emphysematous cystitis complicating Klebsiella pneumoniae liver abscess. Am J Emerg Med 2006,24:256-7.Crossref

We first performed 10-core transperineal prostate biopsy at our institution in 2018. After having acquired the technique and experience, we developed a biopsy protocol that could be modified according to prostate size (Fig): 10 cores for prostate size <30 cc, 16 cores for prostate size 30 to 50 cc, and 20 cores for prostate size >50 cc.

We currently take a 24-core prostate biopsy (Fig d), irrespective of prostate size, to further improve the detection of prostate cancer. There is no gold standard protocol for total number of cores required in any patient; it is dictated by hospital policy, availability of resources, and the experience of the urologist.

This video demonstrates systematic transperineal prostate biopsy.

The instruments used during the procedure comprised an ultrasound machine with long side-fire sensor probe, a bed with two leg supports to facilitate lithotomy position, one disposable biopsy gun, two needles for local anaesthesia, two metal trocars, and eight specimen bottles.

Before the procedure and in the absence of any contraindication, patients are prescribed a single dose per oral 1 g Augmentin and 500 mg ciprofloxacin. One tube of per rectal 4.5 oz Fleet Enema is administered as bowel preparation. Local anaesthetic (EMLA) cream is applied to the patient’s perineum 1 hour before the procedure.

Step 1: the perineum is disinfected with chlorhexidine.

Step 2: 10 mL of 1% lidocaine is injected through each side of the perineum into the periprostatic plane as local anaesthesia, at an angle of 45° and 15 mm away from the anus as shown.

It is vital to maintain the needle parallel to the ultrasound probe to ensure continued visualisation of the needle.

Step 3: a 14-gauge metal trocar is inserted through the right side of the perineum under ultrasound guidance.

Step 4: anterior sector prostate biopsies are taken by tilting an 18-gauge disposable biopsy gun downwards.

It is important not to hit the urethra during the procedure.

Step 5: basal sector prostate biopsies are taken.

Step 6: central sector prostate biopsies are taken.

Step 7: posterior sector prostate biopsies are taken.

Step 8: Left lobe prostate biopsies are also taken using a technique similar to that for the right lobe.

Final step: After removing the metal trocars, haemostasis is achieved by compression. A transparent adhesive film dressing is sprayed over the two puncture sites.

No post-procedure antibiotic is required.

All authors contributed to the concept or design of the study, acquisition of the data, analysis or interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have no conflicts of interest to disclose.

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This study was approved by the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee (Ref CREC 2018.323). The patient provided written informed consent.