Abstract
Background:
With a rise in age and number of renal transplant recipients, prostate cancer (PC) prevalence in this population is increasing. Surgical management of PC traditionally includes radical prostatectomy with pelvic lymph node dissection (PLND). However, patients with indwelling renal transplants are often managed nonoperatively or spared of a lymph node dissection ipsilateral to the transplanted kidney out of concern for transplant vascular or ureter injury.
Case Presentation and Methods:
We report two cases of robot-assisted laparoscopic radical prostatectomy (RALP) with bilateral PLND in a 69-year-old (Patient A) and 73-year-old (Patient B) African American renal transplant recipient. Both patients had extraperitoneal placement of their renal transplants adjacent to the right iliac vessels. Patient A had Gleason 4 + 4 cT1c disease in 12/12 cores with prostate-specific antigen (PSA) of 22.8. Patient B had left-sided Gleason 3 + 3 with 50% involvement of 3/6 cores as well as 50% involvement in 6/6 right-sided cores and PSA of 8.0. In both patients, bone scan was completed and did not show metastases. Ports on the patients' right sides were adjusted in a cephalad direction so as to avoid the transplanted kidney. The remaining ports were otherwise placed in the standard manner. Transplanted ureters were identified and dissected as a first step before proceeding with the prostatectomy. Bilateral PLND was possible in both cases without any vascular or ureteral injury. Notwithstanding PLND, prostatectomy, reconstruction technique, and postoperative care were otherwise unchanged. Immunosuppressant regimens continued throughout hospitalization.
Results:
Robotic console operative time and estimated blood loss was 3 hours 49 minutes and 200 mL for Patient A and 2 hours 48 minutes and 300 mL for Patient B. Patient A had bilateral obturator and internal iliac lymphadenectomy with eight negative lymph nodes harvested on the right side. Patient B received a bilateral obturator lymphadenectomy with two negative lymph nodes dissected on the right side. No intraoperative complications occurred for either patient. Patient A required fluid resuscitation for a creatinine bump that resolved and was safely discharged on POD 2. Patient B was discharged on POD 1. Both patients were prescribed a 60- to 90-day course of penile rehab with a PDE-5 inhibitor (tadalafil 5 mg). At 8 weeks follow-up, Patient A had a PSA of <0.1, was nonadherent on tadalafil, lacked erectile function, and continued having urinary incontinence, saturating two pads per day with nocturia. At 10- and 24-week follow-ups, Patient B maintained continence with partial return of erectile function on tadalafil, although not sufficient for penetration. His PSAs at 8- and 20-week follow-up were 0.036 and 0.102, respectively. At follow-up, neither patient had symptoms (abdominal pain and unilateral edema), suggestive of lymphocele formation.
Conclusion:
In our limited experience with two patients, RALP and bilateral PLND can be safely achieved in renal transplant recipients.
D.D.E. is a proctor/lecturer for Intuitive Surgical and consultant for Medtronic. J.K., J.G.R., and B.W. declare that no competing financial interests exist.
Runtime of video: 5 mins 2 secs
