Laparoscopic Radical Prostatectomy in Kidney Transplant Patient: Our First Experience—A Case Report

Radical prostatectomy outcomes in renal transplant recipients: a retrospective case series of Thai patients

Background

The incidence of prostate cancer in renal transplant recipients (RTR) is similar to the general population. Radical prostatectomy (RP) is the standard of care in the management of clinically localized cancer, but is considered complicated due to the presence of adhesions, and the location of transplanted ureter/kidney. To date, a few case series or studies on RP in RTR have been published, especially in Asian patients. This study aimed to evaluate the efficacy and safety and report the experience with RP on RTR.

Methods

We retrospectively reviewed data of 1270 patients who underwent RP from January 2008 to March 2020, of which 5 patients were RTR. All available baseline characteristics, perioperative and postoperative data (operative time, estimated blood loss (EBL), complications, length of hospital stay, complication), pathological stage, Gleason score, surgical margin status, and pre/postoperative creatinine were reviewed.

Results

Of the 5 RTR who underwent RPs (1 open radical prostatectomy (ORP), 1 laparoscopic radical prostatectomy (LRP), 2 robotic-assisted laparoscopic radical prostatectomies (RALRP), and 1 Retzius-sparing RALRP (RS-RALRP)) prostatectomy, the mean age (± SD) was 70 (± 5.62) years. In LRP and RALRP cases, the standard ports were moved slightly medially to prevent graft injury. The mean operative time ranged from 190 to 365 min. The longest operative time and highest EBL (630 ml) was the ORP case due to severe adhesion in Retzius space. For LRP and RALRP cases, the operative times seemed comparable and had EBL of ≤ 300 ml. All RPs were successful without any major intra-operative complication. There was no significant change in graft function. The restorations of urinary continence were within 1 month in RS-RALRP, approximately 6 months in RALRP, and about 1 year in ORP and LRP. Three patients with positive surgical margins had prostate-specific antigen (PSA) persistence at the first follow-up and 1 had later PSA recurrence. Two patients with negative margins were free from biochemical recurrence at 47 and 3 months after their RP.

Conclusions

Our series suggested that all RP techniques are safe and feasible mode of treatment for localized prostate cancer in RTR.

Safety and Clinical Outcomes of Robot-Assisted Radical Prostatectomy in Kidney Transplant Patients: A Systematic Review

OBJECTIVE

To evaluate the safety and outcomes of robot-assisted radical prostatectomy (RARP) in renal transplant recipients (RTRs) based on available literature.

MATERIALS AND METHODS

A literature search was performed using PubMed, Embase, and Web of Science through "robot" AND "prostatectomy" AND "transplant." Three authors separately reviewed the records to select the relevant articles with any discrepancies solved by open discussion. Patient age, prostate-specific antigen, Gleason score, and tumor stage were recorded as well as intraoperative and postoperative complications, length of stay, surgical margin status, and disease recurrence, if provided. The operative techniques and modification/adjustments to standard port placements were also reviewed. We also include our case report in this review.

RESULTS

We retrieved 10 articles reporting clinical data on RARP for kidney transplant patients, including 5 case series (level 4) and 5 case reports (level 4). A total of 35 kidney transplant recipients undergoing RARP were analyzed in this systematic review, one case in our institution included. None of the cases had major technical difficulties precluding the operation. Technical modifications to the standard technique were described in 10 of the 11 articles specifically including modifications to port placement (54% of patients), development of the space of Retzius (60% of patients), and performance of lymphadenectomy. Mean operative time was 220 minutes. Perioperative complication rate was 17.1% (6 of 35 patients), with only one Clavien III or greater complication. The rate of positive surgical margins was found to be 31.4%. Data on biochemical recurrence revealed a combined rate of 18.1%.

CONCLUSIONS

RARP is technically feasible for treating localized prostate cancer in RTRs. Graft function did not deteriorate in any patient. Modifications to the standard technique should be considered specifically for port placement, development of the space of Retzius, and performance of lymphadenectomy. Oncologic outcomes remain difficult to interpret given the small number of reported cases.

Radical retropubic and perineal prostatectomy for clinically localised prostate cancer in renal transplant recipients

Objective

To analyse the functional and oncological outcome of consecutive renal-transplant recipients (RTRs) with clinically localised prostate cancer who underwent radical retropubic (RRP) or perineal (RPP) prostatectomy.

Patients and methods

Between January 2000 and July 2011 16 patients underwent RRP (group 1) and seven RPP (group 2). In all, 200 consecutive non-RTRs served as the control group, of whom 100 each underwent RRP and RPP, respectively. The mean (range) interval between renal transplantation and RP was 95 (24–206) months, the PSA at the time of diagnosis was 4.5 (3.0–17.5) ng/mL, and the mean patient age was 64 (59–67) years.

Results

The mean follow-up was 39 (RRP) and 48 months (RPP). There was no deterioration in graft function. In group 1, 13 and three patients had pT2a-cpN0 and pT3a-bpN0 prostate cancer, respectively, with a Gleason score of 6, 7 and 8 in 11, three and one patients, respectively. In group 2, three and four patients had pT2a-c and pT3a-b disease, respectively, with a Gleason score of 6 and 7 in two and five, respectively. In both groups one patient had a positive surgical margin and was followed expectantly, and all patients have no evidence of disease. Wound infections developed more often in the RPP group (29% vs. 7%), but there were no Clavien grade III–V complications. All patients achieved good continence, and two need one pad/day.

Conclusions

RRP and RPP are suitable surgical treatments for prostate cancer in RTRs. RRP might be preferable, as it has the advantage of simultaneous pelvic lymphadenectomy and a lower risk of infectious complications.

Modifications to facilitate extraperitoneal robot-assisted radical prostatectomy post kidney transplant

Extraperitoneal robotic-assisted radical prostatectomy in carefully selected renal allograft recipients may be feasible in avoiding injury to the renal allograft, transplanted ureter, and ureteroneocystostomy.

Introduction:

Renal transplantation is the treatment of choice for patients with end-stage renal failure. With advances in immunosuppression, the short-term and long-term outcome has improved significantly. Subsequently, urologists are encountering more transplant recipients with genitourinary malignancies, and therefore urologists are becoming increasingly compelled to offer curative treatment options.

Materials and Methods:

We present modifications to facilitate E-RARP in these patients that include modified trocar arrangement, delayed bladder neck transection, utilizing the robotic Hem-o-lok applier, and posterior reconstruction of the anastomosis using a barbed V-loc suture. A 68-year-old male with a history of polycystic kidney disease, end-stage renal failure, and an allograft renal transplantation in the right iliac fossa, presented with T1c, Gleason 3+4 prostate cancer. He had a preoperative PSA of 6.93ng/mL, ASA score of 3, and a BMI of 26kg/m². Follow-up for metastasis (MRI and bone scan) was negative. E-RARP was performed via the extraperitoneal approach using a 5-port 2-arm approach at an insufflation pressure of 10mm Hg.

Results:

The radical prostatectomy was successfully performed. Ureterovesical anastomosis was completed, and total console time was 130 minutes, with an estimated blood loss of 125mL. Final pathology was T2bNx, Gleason 3+4 with negative surgical margins. The patient was discharged with no change in serum creatinine or GFR. The catheter was removed on POD 10 with no intraoperative or immediate postoperative complications.

Conclusion:

E-RARP in the carefully selected renal allograft recipient is feasible and accomplished safely with technical modifications to avoid injuring the renal allograft, transplanted ureter, and ureteroneocystostomy.