Radical Retropubic Prostatectomy for Localized Prostate Cancer in Renal Transplant Patients

doi:10.1016/j.urology.2008.03.041

Urology

Volume 72, Issue 6, December 2008, Pages 1362-1365

https://doi.org/10.1016/j.urology.2008.03.041 Get rights and content

Objective

To investigate the feasibility of radical retropubic prostatectomy (RRP) in renal transplant recipients with clinically localized prostate cancer.

Methods

A prospective protocol was established between August 2004 and November 2007. In that period, 8 patients diagnosed with localized prostate cancer were submitted to RRP, and their clinicopathologic data were reviewed.

Results

The mean age (± standard deviation) at surgery was 59.6 ± 6.7 years (range, 49-67 years). All patients had T1C tumors, except for 1 with a T2A tumor. The mean preoperative prostate-specific antigen value was 4.5 ± 1.8 ng/mL (range, 1.6-7.0 ng/mL). The mean interval between renal transplantation and RRP was 89.9 ± 65.1 months (range, 40-209 months). The procedure was well tolerated without major complications, and all patients were discharged on the fifth postoperative day. There was no impairment to bladder descent caused by the presence of the allograft or the ureteroneocystostomy. Urethrovesical anastomosis was easily performed in all cases in the standard manner. Blood transfusion was needed in 2 patients (1 received 2 U and another 5 U of blood). The mean operative duration was 183 ± 29.7minutes (range, 150-240 minutes), the mean estimated blood loss was 656 ± 576 mL (range, 100-2000 mL), and no deterioration of graft function was observed. All patients were followed, and the mean follow-up was 10.5 months (range, 2-30 months). Prostate-specific antigen was undetectable in all cases during this time frame.

Conclusions

Radical retropubic prostatectomy in renal transplant patients is safe, effective, and can be easily performed in the same manner as described by Walsh, regardless of the presence of the allograft. The only necessary technical modification is the avoidance of ipsilateral lymphadenectomy to prevent damage to the transplanted organ.

Section snippets

Material and Methods

To study the feasibility and necessary technical modifications of RRP in renal transplant recipients, a prospective protocol of surgical treatment for clinically localized prostate cancer was established between August 2004 and November 2007. In that period, 8 patients were found to have prostate cancer. They were screened according to digital rectal examination (DRE) and a total PSA value (chemiluminescence; Diagnostic Products, Los Angeles, CA) with a cut-off value of 2.5 ng/mL. We use the

Results

Eight cancers were diagnosed (6.3%). The indication for biopsy was based on PSA elevation in all but 1 patient, who presented exclusively with abnormal findings on DRE. The preoperative characteristics and pathologic data are summarized in Table 1. Radical retropubic prostatectomy was well tolerated by all patients, and no major complications were observed. The mean age (± standard deviation) at surgery was 59.6 ± 6.7 years (range, 49-67 years). The mean interval between renal transplant and

Comment

In the near future the incidence of prostate cancer in renal transplant patients is expected to increase because of such factors as better survival rates of renal transplant patients and their increasing age at transplantation.1, 4 Most patients (84%) with prostate cancer detected after solid organ transplantation are diagnosed with localized disease.¹⁷ There is controversy regarding the ideal treatment modality for localized prostate cancer in the general (non-transplant) population, and the

Conclusions

In renal transplant recipients with localized prostate cancer, curative treatment should be offered despite the fact that there is no consensus about the best treatment modality in this setting. Kidney transplantation does not interfere with surgical access to the prostate gland. Radical retropubic prostatectomy in renal transplant patients is safe and can be used to effectively treat localized prostate cancer achieving equivalent results to non transplant patients. The only technical

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Cited by (23)

Management of Localised Prostate Cancer in Kidney Transplant Patients: A Systematic Review from the EAU Guidelines on Renal Transplantation Panel
2018, European Urology Focus
Cancer development after kidney transplant (KT) has become a major problem, and currently, it is one of the primary causes of death in this population. Urological cancers after KT such as prostate cancer (PCa) have also increased, partly due to the increasing age of recipients and prolonged survival. PCa is the second most commonly diagnosed cancer in men, accounting for 15% of all cancers. Managing localised PCa after KT remains challenging because of treating an immunosuppressed patient with a kidney graft in the pelvic cavity. Several papers reporting PCa treatment after KT have been published. Merging all the available data and summarising most important evidence could be useful for scientific community involved in this issue.
To systematically review all the available evidence in literature regarding the management of localised PCa after KT.
Computerised bibliographic search of Medline, Embase, and Cochrane databases was performed for all studies reporting outcomes of localised PCa diagnosed in KT patients undergoing curative treatments, including surgery, external beam radiotherapy (EBR) and brachytherapy.
In total, 41 studies included 319 patients with localised PCa after KT. Their mean age was 61.8 (range, 47–79) yr and mean time from KT to PCa was 122 (range, 2–336) mo. Mean prostate-specific antigen was 8.5 (range, 0.3–82), most frequent biopsy Gleason score was 3 + 3 (50.5%), 62.1% were cT1-cT2, and 56.1% belonged to low-intermediate D’Amico-risk groups. Surgery was performed in 82.1%. After mean follow-up of 33 (range, 1–240) mo, cancer-specific survival at 5 yr was 97.5%, 87.5%, and 94.4% after surgery, EBR, and brachytherapy, respectively.
Radical prostatectomy is the preferred treatment of localised PCa after KT. Overall oncological outcomes do not seem to be worse than general population when performed in referral centres. Other curative treatments such as EBR or brachytherapy were less frequently used; however, brachytherapy showed promising results in a small number of patients. Further better-quality studies should help to clarify the optimal method of managing localised PCa after KT.
Localised PCa after KT seems to have similar oncological outcomes after curative treatments than in general population, with surgery being the most common option for treatment.
Urologic malignancies in renal transplant candidates and recipients
2016, Progres en Urologie
Rapporter l’épidémiologie et décrire la prise en charge des cancers urologiques chez les candidats et les receveurs d’une transplantation rénale.
Une recherche bibliographique exhaustive à partir de Medline (http://www.ncbi.nlm.nih.gov) et Embase (http://www.embase.com) a été réalisée entre 2000 et 2016 en utilisant les mots clés suivants en combinaison : prostate ; bladder ; testicular ; urologic malignancy ; cancer ; kidney ; transplantation ; renal cell carcinoma ; screening ; solid tumour. Les articles obtenus ont été sélectionnés sur leur méthodologie, leur langue de publication (anglais/français) et leur pertinence. Ainsi, 7730 articles ont été identifiés dont 781 pour les tumeurs solides en général, 1565 pour le carcinome rénal, 2674 pour le cancer de la prostate, 385 pour le carcinome urothélial et 56 pour le cancer testiculaire. Après élimination des doublons et analyse des articles, 221 ont été sélectionnés.
Les receveurs d’une transplantation rénale présentent un sur-risque de cancer urologique tout comme les patients dialysés. Le cancer de la prostate est de présentation similaire à la population générale ; toutes les options thérapeutiques sont possibles. La prostatectomie présente l’avantage de pouvoir préciser le stade et affirmer rapidement le succès thérapeutique. La lymphadénectomie doit être discutée et le dépistage systématique par PSA et toucher rectal doit être proposé. Les cancers des reins natifs sont le plus souvent de bas grade et stade, et sont traités par néphrectomie totale. Pour les patients en attente de transplantation, il est inutile d’imposer un délai de surveillance après traitement d’une tumeur rénale à faible risque de récidive selon les scores prédictifs. Les tumeurs du transplant rénal ont une prévalence de 0,2 à 0,5 %, avec une survie sans retour à la dialyse allant de 40 à 75 % pour des suivis réels de 21,5 à 43 mois. Leur traitement repose sur la chirurgie conservatrice, l’ablation percutanée ou la transplantectomie (immédiate ou différée). Contrairement aux cancers du rein et de la prostate, les carcinomes urothéliaux sont de présentation et de pronostic défavorables par rapport à la population générale. La prise en charge présente des spécificités liées à la diminution de l’efficacité du BCG et à la problématique de la dérivation urinaire.
Dans tous les cas, la décision de transplantectomie doit mettre en balance le bénéfice de l’arrêt de l’immunosuppression avec la diminution de survie (et de qualité de vie) du patient retournant en dialyse ; il n’existe pas de recommandation robuste concernant la modification du traitement immunosuppresseur. Les facteurs pronostiques du cancer et la facilité d’accès à une transplantation ultérieure sont des éléments décisionnels fondamentaux.
To review epidemiology and management of urologic neoplasms in renal transplant candidates and recipients.
Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, “neoplasms”; “prostate cancer”; “renal carcinoma”; “renal transplantation”; “transitional carcinoma”; “waiting list”. Articles were selected according to methods, language of publication and relevance. A total of 7730 articles were identified including 781 for solid tumors, 1565 for renal cell carcinoma (RCC), 2674 for prostate cancer (Pca), 385 for transitional carcinoma (TC) and 56 for testicular cancer; after careful selection, 221 publications were eligible for our review.
Renal transplant candidates and recipients are at higher risk of urologic neoplasms than general population, but prostate cancer has similar features. Thus, all therapeutic options are valid. Conversely to radiation therapy, radical prostatectomy provides precise staging and immediate affirmation of therapeutic success. Lymph nodes dissection needs to be discussed; systematic screening using PSA level and digital rectal examination should be offered in this specific population. RCC arising in native kidneys are usually low grade and stage and require total nephrectomy. In transplant candidates, there is no need to delay transplantation after treatment of low risk RCC according to published predictive nomograms. RCC of the allograft are rare, with a prevalence of 0.2 to 05% with a dialysis free survival ranging from 40 to 75% at 21.5 to 43 months. Treatment options are nephron sparing surgery, percutaneous ablation and immediate or deferred transplantectomy. Conversely to RCC or PCa, TC present with more unfavorable features as general population. Their management faces specific difficulties such as lower efficacy of BCG instillation or the technical challenge of urinary diversion.
Application of appropriate indication for transplantectomy relies on benefit-risk balance between the interruption of immunosuppressive agents versus survival and quality of life impairment after returning to dialysis. No robust recommendation exists regarding switch of immunosuppressive drugs. Cancer predictive factors and access to a subsequent transplantation are key decisive elements.
Robot-Assisted Radical Prostatectomy for Localized Prostate Cancer in Asian Renal Transplant Recipients
2016, Transplantation Proceedings
The purpose of this study was to present our experience with robot-assisted radical prostatectomy (RARP) for localized prostate cancer in renal transplant recipients (RTRs) and to determine the feasibility and efficacy of RARP in these patients.
We retrospectively reviewed the medical records of 236 patients who underwent RARP for localized prostate cancer at our institution between August 2011 and July 2015 and identified 3 patients who were RTRs. We reviewed the available clinical data of the 3 patients.
All patients underwent RARP successfully without any major complications. The mean operation time was 162 minutes (range, 127–195 minutes). The mean estimated blood loss was 52 mL (range, 30–75 mL); therefore, the patients did not need any perioperative blood transfusion. In all cases, graft function, as determined according to the serum creatinine level, was stable during and after the operation. Pathological examination showed negative surgical margins with organ-confined disease in all patients.
We reported 3 RTRs with localized prostate cancer who were treated with RARP. RARP might be a feasible and effective minimally invasive technique for the treatment of localized prostate cancer in carefully selected RTRs.
Efficacy and Feasibility of Low-Dose Rate Brachytherapy for Prostate Cancer in Renal Transplant Recipients
2016, Transplantation Proceedings
Citation Excerpt :
The other half of the patients were given only androgen deprivation therapy (data not shown). Recently, there have been several reports about radical prostatectomy for RTRs, including robot-assisted radical prostatectomy or laparoscopic radical prostatectomy [7–18]. Most authors have concluded that radical prostatectomy is feasible and acceptable, even for RTRs.
In young patients with localized prostate cancer, radical prostatectomy is the treatment of choice in the general population. Radiotherapy, such as low-dose rate (LDR) brachytherapy or intensity-modulated radiotherapy, is a viable alternative as well. However, in transplant patients, irradiation is not proposed as often as it is in healthy adults because of the risk of post-radiation ureteral stenosis and gastrointestinal toxicity as the result of fragile tissue. The objective of the study was to assess the efficacy and feasibility of LDR brachytherapy for prostate cancer in renal transplant recipients (RTRs).
Between May 2007 and December 2014, all patients who had undergone LDR brachytherapy for clinically localized prostate cancer at our institution were retrospectively identified (n = 203). Of these patients, 2 had a history of renal transplantation. We reviewed all available clinical data retrospectively. One patient had a functioning graft and the other had re-started hemodialysis 7 years after the transplantation.
The mean time from renal transplantation to prostate cancer diagnosis was 16 years. The mean follow-up after seed implantation was 45 months. There were no peri-operative complications after seed implantation. The 2 patients remained free of prostate-specific antigen progression during the follow-up period. The renal function of the patient with a functioning graft, as measured by serum creatinine, was stable during and after the operation.
LDR brachytherapy is technically feasible and acceptable as a minimally invasive treatment in carefully selected RTRs with localized prostate cancer. This treatment should be considered a suitable option for RTRs with localized prostate cancer.
Efficacy and Feasibility of Intensity-Modulated Radiation Therapy for Prostate Cancer in Renal Transplant Recipients
2016, Transplantation Proceedings
In transplant patients with localized prostate cancer, irradiation is not proposed as often as it is in healthy adults because of the post-radiation risks, such as ureteral stenosis and gastrointestinal toxicity as the result of fragile tissue. The objective of the study was to analyze the efficacy and feasibility of intensity-modulated radiation therapy (IMRT) for prostate cancer in renal transplant recipients (RTRs).
Between May 2005 and December 2014, all patients who had undergone IMRT for clinically localized prostate cancer at our institution were retrospectively identified (n = 365). Of these patients, 2 had a history of renal transplantation. We reviewed all available clinical data. One patient had a functioning graft and the other had restarted hemodialysis 7 years after the transplantation.
The mean time from renal transplantation to prostate cancer diagnosis was 11 years. The mean follow-up after irradiation was 43 months. The 2 patients remain free of prostate-specific antigen progression. There was no severe acute and chronic genitourinary and gastrointestinal toxicity. Renal function of the patient with a functioning graft as measured by serum creatinine was stable during and after the irradiation.
IMRT is feasible and acceptable as a minimally invasive treatment in the carefully selected RTRs with localized prostate cancer. This treatment should be considered a good option for RTRs with localized prostate cancer.
Development of urologic de novo malignancies after renal transplantation
2014, Transplantation Proceedings
Citation Excerpt :
Radical prostatectomy is safe, effective, and can be performed in transplanted patients. The surgical approaches used are the classic retropubic [19], the pure laparoscopic [20], or robot-assisted laparoscopic [21]. They all have shown similarities in safety and oncologic outcomes, although the newer techniques have a logical lack of long-term follow-up.
The incidence of neoplasms in renal transplant recipients is higher than in general population. The increasing age of donors and recipients also increases the risk of developing malignancies, including genitourinary. The aim of this study is to analyze clinical aspects and management of this complication.
We conducted a retrospective analysis of 1365 patients who underwent renal transplantation between 1977 and 2010 who were 44.6 ± 14.9 years old at the time of transplantation. The median follow-up was 95.6 months (range, 18.0–236.0). Data were analyzed for sex, age, time from transplant to diagnosis, location, clinical stage, immunosuppression, treatment, follow-up, and evolution.
We diagnosed 25 de novo urologic neoplasms (25/1365; 1.8%) in 24 patients, with a median follow-up of 32 months (range, 12.5–51.8) from the diagnosis. Sixteen were male (66.7%) and 8 female (33.3%), with a median age at diagnosis of 59 years (range, 56.0–65.5). The median time between the transplant and the diagnosis of the malignancy was 69 months (range, 40.0–116.5). There were 11 renal cell carcinomas (RCC; 11/25; 44%), 8 in native kidney and 3 in renal allograft; 9 prostate cancers (PCa; 9/25; 36%), 8 localized and 1 metastatic; and 5 transitional cell carcinomas (TCC; 5/25; 20%), 3 in bladder and 2 in renal allograft pelvis. Treatments performed were similar to those used in the nontransplanted population. RCC were treated with radical nephrectomy when affecting the native kidney, partial nephrectomy when affecting the allograft, or immunotherapy when metastatic. Patients with localized PCa were treated with radical prostatectomy, radiotherapy, or androgenic deprivation if there were comorbidities, and those metastatic with hormonal deprivation. Bladder TCCs were treated with transurethral resection or radical cystectomy. Pelvis TCCs affecting the allograft were treated with radical nephroureterectomy of the allograft including bladder cuff and pelvic lymphadenectomy.
There exists an increased incidence of urologic tumors in kidney transplant recipients. Conventional treatments of these tumors are technically feasible. The risk of developing these tumors remains even in the long term. Because of their suitability for curative treatments, it is advisable to perform periodic screening for urologic cancers to achieve an early diagnosis.

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Surgical Challenges in Radical ProstatectomyRadical Retropubic Prostatectomy for Localized Prostate Cancer in Renal Transplant Patients

Objective

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusions

Urology

Transplant Proc

J Urol

Urology

Urology

Urology

Urol Clin North Am

USRDS 2007: Annual Data ReportAtlas of End-Stage Renal Disease in the United States

malignant disease in renal transplant patients

Transplant

Improved graft survival after renal transplantation in the United States, 1988–96

N Engl J Med

Neoplastic complications of organ transplantation

Cancer risk after renal transplantation in the Nordic countries, 1964–86

Int J Cancer

Surgical Challenges in Radical Prostatectomy
Radical Retropubic Prostatectomy for Localized Prostate Cancer in Renal Transplant Patients