Oncological and Postoperative Outcomes of Robot-Assisted Laparoscopic Radical Prostatectomy in Renal Transplant Recipients: A Multicenter and Comparative Study

Prostate cancer in solid organ transplant recipients: Results from a multicenter series

INTRODUCTION

Prostate cancer incidence in immunosuppressed transplant recipients increases as life expectancy improves in this population. However, the management of treatments and immunosuppressive (IS) regimens for solid organ transplant recipients diagnosed with prostate cancer remains poorly defined. Therefore, we conducted a multicentric study to investigate these parameters more thoroughly.

METHOD

This multicentric, retrospective study includes all kidney, heart, liver, or combined transplant recipients, diagnosed with prostate cancer between 1998 and 2020. IS regimen management, demographic, oncological and survival outcomes were studied here.

RESULTS

A prostate cancer was diagnosed among 87 SOTRs: 70 RTRs, 10 HTRs, 2 LTRs and 5 combined transplant recipients. The mean age at diagnosis was 64.3years with 10.7years mean time from transplantation to PCa. A 38% low risk, 45% intermediate risk and 11% high risk were recorded at diagnosis. Fifty-six patients underwent radical prostatectomy, 11 patients underwent radiotherapy combined with ADT, 4 patients underwent radiotherapy alone, 6 patients underwent ADT alone, 1 patient underwent brachytherapy, 3 patients underwent watchful waiting, 1 patient was treated by HIFU and 5 patients were under active surveillance. Sixteen patients had complementary treatment following biochemical recurrence or positive margins. IS regimen was modified for 69% of patients. Twelve deaths occurred in total (14%) with a 92% and 86%, 3- and 5-year overall survival respectively. Three- and 5-year progression-free survival were 89% and 83% respectively. There was no significant PFS difference between patients treated with radiotherapy and prostatectomy (P=0.94), and patients with or without a change in immunosuppressants (P=0.88).

CONCLUSION

Guidelines for diagnosis and management of prostate cancer in the general population appears to apply in SOTRs with good oncological outcomes. Active surveillance should also be considered in this population.

LEVEL OF EVIDENCE

Low.

Genitourinary malignancies in kidney transplant recipients

Advances in immunosuppressive therapy and postoperative management have greatly improved the graft and patient survival rates after kidney transplantation; however, the incidence of post-transplant malignant tumors is increasing. Post-renal transplantation malignant tumors are associated with renal failure, immunosuppression, and viral infections. Moreover, the risk of developing cancer is higher in kidney transplant recipients than in the general population, and the tendency to develop cancer is affected by the background and environment of each patient. Recently, cancer after kidney transplantation has become the leading cause of death in Japan. Owing to the aggressive nature and poor prognosis of genitourinary malignancies, it is crucial to understand their epidemiology, risk factors, and best practices in kidney transplant recipients. This review has a special emphasis on the epidemiology, risk factors, and treatment protocols of genitourinary malignancies in kidney transplant recipients to enhance our understanding of the appropriate management strategies. Optimal immunosuppressive therapy and cancer management for these patients remain controversial, but adherence to the general guidelines is recommended.

Radical Prostatectomy in Kidney Transplant Recipients-A Multicenter Experience

Background and objective

Kidney transplant recipients (KTRs) have an increased risk of developing genitourinary cancers, including prostate cancer (PCa), which is expected to become more prevalent due to an aging KTR population. Thus, knowledge of surgical outcomes, including treatment of PCa, within this unique cohort is required.

Methods

Data of 62 KTRs undergoing radical prostatectomy (RP) between 2006 and 2023 at nine urologic transplant centers were analyzed. Complications were assessed using the Clavien-Dindo classification. Perioperative outcomes were evaluated, and a follow-up was conducted. Overall survival (OS), biochemical recurrence-free survival (BRFS), and death-censored graft survival were determined via the Kaplan-Meier method and log-rank testing.

Key findings and limitations

Overall, 50 open radical retropubic RPs and 12 robot-assisted RPs (RARPs) were included. The intraoperative blood loss was lower after RARP, but operative time was longer. Of the patients, 50% experienced no postoperative complication, and grade ≥3 complications were observed in 14.5%. There was no graft loss related to RP. A histopathologic analysis revealed pN1 in 8.1% and positive surgical margins in 25.8% of the cases. At a median follow-up of 48.5 mo, the median OS was 128 (95% confidence interval [CI] 71.2-184.8) mo, BRFS was 106 (95% CI 55.8; 156.2) mo, and graft survival was 127 (95% CI 66.7-187.3) mo. Limitations include the retrospective design, and variations between groups and centers.

Conclusions and clinical implications

Our findings support RP as a feasible and safe treatment option for localized PCa in KTRs with acceptable oncologic outcome. Special care is required in screening and awareness for the risk of understaging.

Patient summary

This study analyzed the safety and effectiveness of two prostate cancer surgery methods-open and robot-assisted surgery-in the special group of kidney transplant recipients. Both surgical methods were performed safely with acceptable oncologic outcomes; however, sample size was too small to draw definite conclusions between the two operative methods.

Postoperative Complications Result in Poor Oncological Outcomes: What Is the Evidence?

The majority of patients with solid tumors undergo a curative resection of their tumor burden. However, the reported rate of postoperative complications varies widely, ranging from 10% to 70%. This narrative review aims to determine the impact of postoperative complications on recurrence and overall survival rates following elective cancer surgeries, thereby providing valuable insights into perioperative cancer care. A systematic electronic search of published studies and meta-analyses from January 2000 to August 2023 was conducted to examine the effect of postoperative complications on long-term survival after cancer surgeries. This comprehensive search identified fifty-one eligible studies and nine meta-analyses for review. Recurrence-free survival (RFS) and overall survival (OS) rates were extracted from the selected studies. Additionally, other oncological outcomes, such as recurrence and cancer-specific survival rates, were noted when RFS and OS were not reported as primary outcomes. Pooled hazard ratios and 95% confidence intervals were recorded from the meta-analyses, ensuring the robustness of the data. The analysis revealed that long-term cancer outcomes progressively worsen, from patients with no postoperative complications to those with minor postoperative complications (Clavien-Dindo grade ≤ II) and further to those with major postoperative complications (Clavien-Dindo grade III-IV), irrespective of cancer type. This study underscores the detrimental effect of postoperative complications on long-term oncological outcomes, particularly after thoracoabdominal surgeries. Importantly, we found a significant gap in the data regarding postoperative complications in surface and soft tissue surgical procedures, highlighting the need for further research in this area.

The role of localised prostate cancer treatment in renal transplant patients: A systematic review

Objective

To systematically review and critically appraise all treatment options for localised prostate cancer in renal transplant candidates and recipients.

Method

A systematic review was conducted adhering to PRISMA guidelines. Searches were performed in the Cochrane Library, Embase, Medline, the Transplant Library and Trip database for studies published up to September 2022. Risk of bias was assessed with the Cochrane Risk of Bias in Non-Randomised Studies of Interventions for non-randomised studies tool.

Results

A total of 60 studies were identified describing 525 patients. The majority of studies were either retrospective non-randomised comparative or case series/reports of poor quality. The vast majority of studies were focussed on prostate cancer after renal transplantation. Overall, 410 (78%) patients underwent surgery, 93 (18%) patients underwent radiation therapy or brachytherapy, one patient underwent focal therapy (high-intensity frequency ultrasound) and 21 patients were placed on active surveillance. The mean age was 61 years old, the mean PSA level at diagnosis was 9.6 ng/mL and the mean follow-up time was 31 months. The majority of patients had low-risk disease with 261 patients having Gleason 6 prostate cancer (50%), followed by 220 Gleason 7 patients (42%). All prostate cancer mortality cases were in high-risk prostate cancer (≥Gleason 8). The cancer-specific survival results were similar between surgery and radiotherapy at 1 and 3 years.

Conclusion

Localised prostate cancer treatment in renal transplant patients should be risk stratified. Surgery and radiation treatment for localised prostate cancer in renal transplant patients appear equally efficacious. Given the limitations of this study, future research should concentrate on developing a multicentre RCT with long-term registry follow-up.

Robot-Assisted Radical Prostatectomy in Renal Transplant Recipients: A Systematic Review

Robot-assisted radical prostatectomy (RARP) has been shown to achieve excellent oncological outcomes with a low rate of complications in patients with prostate cancer. However, data on RARP in renal transplant recipients (RT) are dispersed. A literature search was conducted through April 2023 using PubMed/Medline, Embase and Web of Science databases. The primary aim was to evaluate the safety, oncologic and clinical outcomes of RARP in RT recipients. The secondary aim was to identify surgical technique modifications required to avoid iatrogenic damage to the transplanted kidney. A total of 18 studies comprising 186 patients met the inclusion criteria. Age at the time of treatment ranged 43-79 years. Biopsy results showed a high prevalence of low- and intermediate-risk disease. Operative time ranged between 108.3 and 400 mins, while estimated blood loss ranged from 30 to 630 mL. Length of hospital stay ranged from 3 to 6 days whereas duration of catheterization was between 5 and 18 days. Perioperative complication rate was 17.1%. Overall positive surgical margin rate was 24.19%, while biochemical recurrence was observed in 10.21% (19/186 patients). Modifications to the standard surgical technique were described in 13/18 studies. Modifications in port placement were described in 7/13 studies and performed in 19/88 (21.6%) patients. Surgical technique for the development of the Retzius space was reported in 13/18 studies. Data on lymphadenectomy were reported in 15/18 studies. Bilateral lymphadenectomy was described in 3/18 studies and performed in 4/89 (4.5%) patients; contralateral lymphadenectomy was reported in 7/18 studies and performed in 41/125 (32.8%) patients. RARP in RTRs can be considered relatively safe and feasible. Oncological results yielded significantly worse outcomes in terms of PSM and BCR rate compared to the data available in the published studies, with an overall complication rate highly variable among the studies included. On the other hand, low graft damage during the procedure was observed. Main criticisms came from different tumor screening protocols and scarce information about lymphadenectomy techniques and outcomes among the included studies.

Urological Cancers and Kidney Transplantation: a Literature Review

PURPOSE OF REVIEW

The aim of this review is to provide an overview of epidemiology, risk factors, and treatment of urological malignancies in renal transplant recipients (RTR).

RECENT FINDINGS

Although optimal immunosuppressive therapy and cancer management in these patients remain controversial, adherence to general guidelines is recommended. Kidney transplantation is recognized as the standard of care for the treatment of end-stage renal disease (ESRD) as it offers prolonged survival and better quality of life. In the last decades, survival of RTRs has increased as a result of improved immunosuppressive therapy; nonetheless, the risk of developing cancer is higher among RTRs compared to the general population. Urological malignancies are the second most common after hematological cancer and often have more aggressive behavior and poor prognosis.

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.