Continent orthotopic ileal neobladder after kidney transplant in a female patient with multifocal transitional cell carcinoma

Orthotopic ileal neobladder reconstruction in a woman who developed squamous cell carcinoma of the urinary bladder after kidney transplantation

The case of a 62-year-old woman who developed squamous cell carcinoma of the bladder 16 years after a kidney transplant is reported here. After the transplant, immunosuppressive therapy was maintained with cyclosporin A (200 mg/day) and the patient's serum creatinine level was 0.9 mg/dL. She was diagnosed with squamous cell carcinoma of the bladder 16 years later and underwent radical cystectomy with an orthotopic ileal neobladder. The Studer technique was used and the afferent ileal loop was anastomosed to the graft ureter. The postoperative course was uneventful. At the 6-month follow-up visit, the patient showed no evidence of recurrence. Her serum creatinine level was 1.0 mg/dL. The patient was continent during the day and the night. This case shows that the construction of an orthotopic ileal neobladder after cystectomy is safe and feasible in kidney transplant recipients.

Orthotopic bladder substitute in renal transplant recipients: experience with Studer technique and literature review

Renal transplant recipients with high-risk bladder cancer following cystectomy need a urinary diversion preserving the renal function and possibly maintaining body image, while still offering the best oncological outcome. The aim of this report is to describe our experience of radical cystectomy and orthotopic ileal neobladder with Studer technique in this population, and to review the literature. We performed radical cystectomy and Studer ileal neobladder in four male patients (median age 67 years) after median time of 9.5 years following renal transplantation. Pathology revealed pT1HGN+ transitional cell carcinoma in one case, pT1HGN0 in two and pT3aHGN0 in one. Two patients presenting aggressive disease (N+ and pT3a) died of tumour progression after 20 and 14 months, respectively, while the other two are alive after 56 and 36 months of follow-up with no evidence of disease, stable serum creatinine (2.29 and 1.6 mg/dl) and mild metabolic acidosis. Day and night-time urinary continence were satisfactory in all patients. Good functional outcomes have been reported in the 20 cases of ileal orthotopic neobladder with different techniques published so far and the global experience of 24 cases with a median follow-up of 39 months documents a cancer specific survival of 62.5%.

Management of Bladder Cancer following Solid Organ Transplantation

Objective. Present our experience managing bladder cancer following liver and renal transplantation. Methods. Single institution retrospective review of patients diagnosed with bladder urothelial carcinoma (BUC) following solid organ transplantation between January 1992 and December 2007. Results. Of the 2,925 renal and 2,761 liver transplant recipients reviewed, we identified eleven patients (0.2%) following transplant diagnosed with BUC. Two patients with low grade T1 TCC were managed by TURBT. Three patients with CIS and one patient with T1 low grade BUC were treated by TURBT and adjuvant BCG. All four are alive and free of recurrence at a mean follow-up of 51 ± 22 months. One patient with T1 high grade BUC underwent radical cystectomy and remains disease free with a follow-up of 98 months. Muscle invasive TCC was diagnosed in four patients at a median of 3.6 years following transplantation. Two patients are recurrence free at 24 and 36 months following radical cystectomy. Urinary diversion and palliative XRT were performed in one patient with un-resectable disease. Conclusions. Bladder cancer is uncommon following renal and liver transplantation, but it can be managed successfully with local and/or extirpative therapy. The use of intravesical BCG is possible in select immunosuppressed patients.

Radical Cystectomy for Transitional Cell Carcinoma with Orthotopic Neobladder in Renal Transplant Recipients: Surgical Procedure, Functional and Therapeutic Evaluation

Introduction

Transitional Cell Carcinoma (TCC) shows a high prevalence in renal tranplant recipients, nevertheless urinary reconstruction by way of orthotopic neobladder is rarely reported.

Patients and Methods

Two kidney transplant patients (1 man and 1 woman) affected by TCC underwent radical cystectomy and urinary reconstruction by neobladder according to the “Vescica Ileale Padovana” technique.

Results and Discussion

No patients claimed incontinence or urine retention. The spherical rebuilding assured an adequate bladder capacity and a low endovesical pressure. After 48 months one patient died because of disease progression. The first relapse was detected in ureter two years after cystectomy. The other patient is still alive after 40 months and in good health conditions.

Conclusions

This anecdotal report suggests that the “Vescica Ileale Padovana” technique could be useful in renal transplant recipients with TCC. A possible role of Rapamycin on our results cannot yet be excluded.

Orthotopic ileal neobladder reconstruction after renal transplant

Radical cystectomy and urinary diversion is an effective curative treatment for muscle invasive bladder cancer. The orthotopic ileal neobladder has become a favorable choice of urinary diversion as it offers superior quality of life, cosmetic outcome and the potential for normal voiding. We treated two patients with bladder cancer who previously underwent renal transplant for end-stage renal disease. Radical cystectomy and orthotopic ileal neobladder reconstruction was performed in both patients. One patient had two renal transplants and underwent transplant nephrectomy at the time of cystectomy. In the other patient, the native kidneys were still present and the ureters were anastomosed to the neobladder. There is excellent function of the neobladder. There were no increased complications seen in these patients. Our cases demonstrate that an orthotopic ileal neobladder is safe and feasible after renal transplant and should be offered to these patients.

Bladder carcinoma among live-donor renal transplant recipients: a single-centre experience and a review of the literature

OBJECTIVES

To present our experience with bladder cancer among a renal transplant population and to review critically the relevant literature.

PATIENTS AND METHODS

In all, 1865 renal graft recipients were followed for a mean (SD) of 6.5 (5) years. Seven recipients (all men) developed a urothelial bladder tumour. The stage and grade of the tumours were determined. The method of the treatment was selected on the basis of the tumour characteristics and graft function. Patients were regularly followed; the endpoints were cancer-specific survival, recurrence or metastasis.

RESULTS

All patients presented with gross haematuria. There was non-muscle-invasive disease in two patients who were treated by transurethral resection and adjuvant intravesical bacille Calmette-Guérin immunotherapy. One patient died 24 months later due to complications of end-stage renal disease. To date the second patient is alive and free of the recurrence. Five recipients with muscle-invasive disease had a radical cystectomy and orthotopic bladder substitution. The mean (sd) time to the last follow-up or death was 14.6 (3.1) months. Three patients died with stable graft function; two from distant metastasis and one from a cerebrovascular stroke. The remaining two patients are still alive, free of disease and with good graft function.

CONCLUSIONS

Urothelial bladder tumours are generally uncommon. The presence of haematuria in renal allograft recipients should be thoroughly investigated. Early diagnosis and prompt treatment are required for managing such tumours, because they are aggressive. Orthotopic bladder substitution is feasible with a good functional outcome for patients in whom cystectomy is indicated.

Complete urinary tract extirpation: the University of Maryland experience

OBJECTIVES

Complete urinary tract extirpation (CUTE) involves simultaneous bilateral nephroureterectomy, cystectomy or cystoprostatectomy, and the creation of a urinary diversion, if needed. Case reports of this operation have been published, but to our knowledge, this is the largest case series yet reported. We sought to evaluate the characteristics and outcomes of patients who underwent CUTE.

METHODS

From 1994 to 2005, 9 patients underwent CUTE at our institution. We performed a retrospective chart review of these patients. The data reviewed included demographics, operative time, length of stay, complications, recurrences, and overall survival.

RESULTS

Nine patients who underwent CUTE were identified. The mean patient age at the operation was 61 years. Five patients were men. The mean operative time was 356 minutes. Two patients required a blood transfusion. The length of stay averaged 10.8 days (range 6 to 47). Four patients had functioning renal allografts before and after surgery. Three patients needing dialysis received renal allografts postoperatively. The overall survival rate at a mean follow-up of 31 months was 86%.

CONCLUSIONS

Although this report presented a small number of patients, it has illustrated that CUTE can be performed safely and allow definitive surgical treatment of patients with complex genitourinary pathologic findings.

ORTHOTOPIC ILEAL NEOBLADDER RECONSTRUCTION IN PATIENTS WITH BLADDER CANCER FOLLOWING RENAL TRANSPLANTATION

PURPOSE

We analyzed the safety and clinical outcome in a single institution experience with orthotopic ileal neobladder reconstruction following radical cystectomy for transitional cell carcinoma in renal transplant recipients.

MATERIALS AND METHODS

From April 1986 to December 2003 radical cystectomy and orthotopic ileal neobladder reconstruction were performed in 760 consecutive patients with bladder cancer, of whom 4 had bladder cancer a median of 10.5 years after renal transplantation. The postoperative clinical course and long-term results in these patients were reviewed.

RESULTS

Median followup after surgery was 51.5 months (range 11 to 118). Two patients died at 11 and 15 months of tumor progression and a pulmonary embolism, respectively, whereas 2 were alive at a mean followup of 90 months with no evidence of disease. No neobladder related reoperations were necessary. Serum creatinine as a marker of renal function was stable in 3 patients. In 1 patient chronic graft rejection led to progressive renal failure and hemodialysis. Urinary continence was satisfactory during the day and night with spontaneous voiding in all patients and no significant post-void residual urine.

CONCLUSIONS

To our knowledge this is the largest reported series of orthotopic ileal neobladder replacement following radical cystectomy in renal transplant recipients. Our results demonstrate the feasibility of radical cystectomy and orthotopic urinary reconstruction in patients with a renal transplant who have good functional and oncological results despite the high comorbidity in this group.

Treatment and Outcome of Invasive Bladder Cancer in Patients After Renal Transplantation

PURPOSE

Optimal management and clinical outcome of bladder cancer in renal transplant recipients are not well-defined. We analyzed single institution treatment strategies and outcomes of these patients.

MATERIALS AND METHODS

We retrospectively reviewed the University of California, San Francisco transplant database which contains information on 6,288 renal transplants performed between 1964 and 2002. The United Network for Organ Sharing database and Israel Penn International Transplant Tumor Registry were also queried to characterize the global nature of bladder cancer in renal transplant recipients.

RESULTS

The United Network for Organ Sharing database (1986 to 2001) contained information on 31 patients who were found to have bladder cancer (0.024% prevalence) and the Israel Penn International Transplant Tumor Registry (1967 to 2001) contained information on 135 patients representing 0.84% of all reported malignancies. We identified 7 renal transplant recipients with bladder cancer at our institution. Invasive transitional cell carcinoma developed in 5 patients at a median of 2.8 years after transplant. Three patients underwent uncomplicated radical cystectomy and preservation of the renal allograft. Overall survival at 48 months was 60%.

CONCLUSIONS

Bladder cancer after renal transplantation is not common. For patients who present with invasive disease, traditional extirpative surgery should be considered. Moreover, the allograft is rarely the source of transitional cell carcinoma and can be preserved. In our experience the cancer and urinary outcomes compare favorably with nontransplant patient outcomes after treatment.

[Diffuse involvement and rapid progression of high-grade transitional carcinoma in a kidney transplant recipient]

In renal transplant patients, an increased risk of cancer has been seen, higher than in the general population, and the more frequent genitourinary neoplasms are the kidney and bladder ones. Moreover, in those patients the pattern of tumor growth is very rapid, with early tendency to local and systemic dissemination. The case here presented, a patient with kidney transplant 3 years before, with high grade, superficial transitional cell carcinoma involving the whole bladder, the pelvis and the ureter of the right native kidney, shown this fast progression. Four months after radical cystectomy plus bilateral nephroureterectomy, the disease progressed to intraperitoneal and hepatic metastases.

Surgery for invasive bladder tumors: technique and outcome

The operative management of invasive transitional cell carcinoma has advanced significantly in the past year, particularly with respect to continent urinary diversion. The long term safety and efficacy of this form of urinary reconstruction is being established in terms of both operative and metabolic complications. The availability of continent diversion can decrease the interval to cystectomy and therefore may impact positively on survival. It has also been shown that continent diversion can safely be offered to patients at high risk for local recurrence. The importance of urethral sensory threshold on postoperative continence is being established. These findings and others continue to enhance the survival and quality of life of patients undergoing cystectomy for invasive bladder cancer.

Bladder substitution

Preliminary data have shown that composite reservoirs consisting of gastric segments in combination with ileum or colon may reduce metabolic problems. Orthotopic neobladders are the most natural way to reconstruct the urinary bladder and are a safe option in selected male and female patients. Experimental and preliminary clinical data about new methods using autologous muscle transfer and tissue engineering are promising.