Applicability of Robot-Assisted Laparoscopic Radical Prostatectomy in Renal Allograft Recipients

Applicability of Robot-Assisted Laparoscopic Radical Prostatectomy in Renal Allograft Recipients N. Wagener, J.N. Nyarangi-Dix, D. Teber, M. Zeier, and M. Hohenfellner ABSTRACT Purpose. To evaluate the general applicability of robotic-assisted laparoscopic radical prostatectomy (RALP) in renal transplant recipients and potential surgical modifications due to the position of the transplanted kidney in the iliac fossa, as RALP has proven to be an effective and safe treatment option for prostate cancer (PCa) removal. Procedures. A 71-year-old patient who had undergone renal transplantation was diagnosed with biopsy-proven localized Gleason 7a PCa. The prostate-specific antigen value was 12.4 ng/mL. RALP was performed by a transperitoneal approach using six ports. By partial mobilization of the bladder, the working space for the radical prostatectomy was created, while leaving the renal transplant and ureter untouched. Lymph node dissection was performed only on the contralateral side of the transplanted kidney. Results. The procedure concluded after 220 minutes and the estimated blood loss was 300 mL. The perioperative clinical course was uneventful. The kidney function remained normal with a creatinine value of 1.2 mg/dL. A complete extirpation of the prostate with negative surgical margins was achieved. After catheter removal, the patient was completely continent. Conclusions. RALP in renal transplant recipients is feasible and can be achieved with favorable oncological and functional outcome. No modifications to the standard RALP technique are required in these patients, except from a partial dissection of the bladder from the abdominal wall and a one-sided lymph node dissection. ROSTATE CANCER (PCa) is estimated to account for more than 217,000 new cases and 32,000 cancerrelated deaths in the United States in 2010, making it the second leading cause of cancer death.1 It is unclear whether there is a specific association between increased PCa risk and kidney transplantation: Though Dreikorn et al and Webster et al did not describe an increased risk for PCa in patients after kidney transplantation,2,3 Kasiske et al observed a roughly twofold higher PCa rate in renal transplant patients compared with the general population.4 Moreover, disease-specific survival for PCa (stage II, III, and IV) is worse in transplant recipients compared to the general population, suggesting that PCa in transplant recipients are more aggressive biologically at the time of diagnosis.5 Furthermore, at diagnosis, the rate of poorly differentiated tumors seems higher in the renal transplant recipient group than in the general PCa population.6 This, and the expansion of organ transplant criteria, including older donors and recipients, combined with improved allograft survival has enhanced the relevance of PCa treatment in this group of

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patients.7 Therefore, the application of the standard treatment options for PCa should be evaluated in these patients. Robot-assisted laparoscopic radical prostatectomy (RALP) has proven to be a feasible, safe, and effective treatment for prostate cancer removal.8 –10 The aim of our study was to analyze the applicability of RALP for the management of PCa in a renal transplant recipient and to reveal if modifications in the surgical technique are necessary compared to a standard RALP in PCa. METHODS We report a 71-year-old man who had undergone cadaveric renal transplantation to the left iliac fossa in 1983 because of end-stage From the Departments of Urology (N.W., J.N.N.-D., D.T., M.H.) and Nephrology (M.Z.), University of Heidelberg, Heidelberg, Germany. Address reprint requests to Nina Wagener, MD, Department of Urology, University of Heidelberg, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany. E-mail: Nina.Wagener@med. uni-heidelberg.de

© 2012 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710

0041-1345/–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.01.120

Transplantation Proceedings, 44, 1287–1292 (2012)

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1288 renal disease due to polycystic kidney disease. Maintenance immunosuppression consisted of cyclosporine only. The interval between organ transplantation and the diagnosis of PCa was 27 years. An elevated total prostate-specific antigen (PSA) value of 12.4 ng/mL on routine screening preceded diagnosis. Ultrasound guided transrectal biopsy revealed a moderately differentiated adenocarcinoma of the prostate (Gleason grade 7a), with both lobes infiltrated by the tumor. The prostate volume was 73 mL, as determined by transrectal ultrasound. Radionuclide bone scintigraphy showed no metastases, magnetic resonance imaging of the abdomen and pelvis revealed organ-confined disease with no lymphatic metastases. The preoperative creatinine level was 1.28 mg/dL, and the calculated glomerular filtration rate (GFR) was 55.2 mL/min/1.73 m2. The patient was sexually active, with an International Index of Erectile Function score of 22. No preoperative treatment (eg, hormone therapy) was administered to the patient.

RESULTS Surgical Technique

The patient underwent a standard six-port transperitoneal RALP using the Montsouris technique. Erectile nerve sparing was performed bilaterally. The six ports were positioned as shown in Fig 1. No modifications in port placement to a standard RALP were necessary due to the transplanted kidney positioned in the left iliac fossa. The abdomen was insufflated with a pressure of 20 mm Hg for initial port placement and then reduced to 15 mm Hg for the remainder of surgery. No extensive adhesiolysis was necessary. The transplanted kidney was seen in the left iliac fossa during the laparoscopic approach (Fig 2), as expected by the preoperatively performed magnetic resonance imaging (Fig 3). In accordance with the Montsouris technique,11

Fig 1. Port positions. Gibson incision at left lower quadrant overlying the transplanted kidney is marked with black line.

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retrovesical dissection of the seminal vesicles and vas deferens was the first step of surgery. Pelvic lymph node dissection in the obturator region was deliberately not performed on the side of the allograft because of the anatomic location of the transplant kidney overlying the iliac vessels. The dissection of the bladder from the anterior abdominal wall was performed only partially, and therefore different to the standard RALP procedure. The mobilization started on the contralateral side of the transplanted kidney, carefully transecting the median umbilical ligament, without preparation of the left obturator fossa and under continuous visual control of the transplant kidney and ureter. No other modifications to the standard RALP technique were required in this patient. After incision of the endopelvic fascia and identification of the dorsal venous plexus, the plexus was ligated. Bladder neck preservation could easily be applied. The vascular pedicles were controlled with hemolock clips after releasing the neurovascular bundles. Finally, the apex of the prostate was dissected and the specimen removed. A Rocco suture to reconstruct the rabdhosphincter posterior was done, as is routine in our institution. A tension-free vesicourethral anastomosis was performed in van Velthoven technique. The procedure concluded after 220 minutes, the estimated blood loss was 300 mL. Oncological and Functional Outcome

Tumor stage was classified according to the tumor node metastasis staging system of 2010, and revealed an adenocarcinoma of the prostate (pT2c pN0 Gleason grade 7a), involving 25% by tumor volume, with negative surgical

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Fig 2. Laparoscopic view at the transplanted kidney in left iliac fossa. In the lower part of the picture, the renal artery is visible (arrow).

margins. The perioperative clinical course was uneventful. Within 4 weeks of catheter removal, the patient was completely continent without any use of security pads. Follow-up was performed at 1, 3, 6, and 9 months after surgery and included medical history, physical exam, blood chemistry including serum PSA, and ultrasound. No biochemical recurrence occurred on PSA testing during this time. The patient was potent with erections sufficient for vaginal penetration while taking oral phospodiesterase-5 inhibitors and completely continent with a maximum flow of 22 mL/s. Kidney Function

Overall, the kidney function remained normal with a creatinine value of 1.28 mg/dL at admission to the hospital, a postoperative ascent to 1.69 mg/dL on day 1, and a creatinine value of 1.2 mg/dL at the time of discharge. Calculated GFR dropped temporarily from 55.2 mL/min/1.73 m2 to a nadir of 40.1 mL/min/1.73 m2. At discharge, GFR had completely recovered to 59.5 mL/min/1.73 m2. This suggests that the pneumoperitoneum intraoperatively did not induce severe hypoperfusion to the transplanted kidney. During follow-up, the kidney function remained completely stable with creatinine values of 1.1 mg/dL at 9 months after radical prostatectomy. DISCUSSION

Several treatment modalities have been described for PCa in renal transplant recipients: In 1989, Manson and Landsberg first described a case of PCa diagnosed after renal

transplantation. The treatment option retropubic radical prostatectomy proved to be technically feasible after renal transplantation.12 Further series reported retropubic radical prostatectomy as a safe and efficient approach in renal transplant recipients.13–16 Certain modifications were introduced to the standard operation technique: placement of the retractors away from the renal allograft, limiting mobilization of the peritoneum ipsilateral to the allograft, and catheterization of the ureter to identify the ureteroneocystostomy.17 Nevertheless, diverse morbidities emerged: Kleinclauss et al reported 2 of 20 patients suffering graft ureteral injuries and a significantly greater rate of systemic bacterial infection in renal transplant recipients undergoing retropubic radical prostatectomy.16 A perineal approach for radical prostatectomy in renal allograft recipients was advocated by Hafron et al18 after a first description in 1999.19 Hafron stated that this approach has many advantages over other treatments (eg, no alteration of the approach or postoperative management by the renal allograft, avoidance of any manipulation of the renal graft or transplant ureter and thereby reducing the chances of harm, and preservation of the bladder and the contralateral iliac fossa for future transplants). Three-dimensional conformal radiotherapy for localized PCa in kidney transplant recipients was reported by Mouzin et al in 2004,20 with two out of eight patients showing isolated biochemical recurrence after a mean follow-up of 28 months and significant obstruction of the terminal ureter in two patients, as revealed by furosemide-stimulated diethylenetriaminepentaacetic acid renograms. The doses deliv-

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Fig 3. Preoperative magnetic resonance imaging scan showing precisely the location of the transplanted kidney in the left iliac fossa (arrow).

ered to the utereroneocystostomy were calculated to range from less than 20 Gy to more than 45 Gy depending on the bladder repletion. A single Spanish case report presented the application of high-intensity focused ultrasound in a 62-year-old kidney transplant recipient with satisfactory results, achieving pathological and biochemical success with minimal morbidity.21 Shah et al reported the first case of laparoscopic radical prostatectomy (LRP) in a renal allograft recipient in 2006.22 They advocated a transperitoneal approach because it avoids the adhesions present in the retroperitoneal space surrounding the graft. In addition, complete dissection of the bladder, careful dissection of the neurovascular bundles, constant awareness of the vesicoureteral anastomosis, and the presence of a transplant surgeon in the operating room who can assist in identification of vital structures were some of the critical points in their description of the procedure. Further publications regarding LRP in renal allograft recipients also used a transperitoneal approach,23–25 except a series of nine patients reported by Robert et al, who used an extraperitoneal approach.26 Most of the authors stated that it is a technically feasible and safe

treatment of localized PCa in renal transplant recipients without major complications and no different surgical challenges compared to standard LRPs.24,25 Furthermore, the laparoscopic approach in the renal allograft recipient offers all the minimally invasive benefits that it confers to other radical prostatectomy candidates.25 On the other hand, Robert et al reported that the rectal injury rate was significantly higher in renal transplant recipients than in other patients (22.2% vs 1.8%, P ⫽ .022). One patient of the series developed delayed thrombosis of the iliac vein with extension to the renal allograft vein 6 months after LRP. Despite appropriate anticoagulant therapy, the renal allograft lost function a week later and hemodialysis was reintroduced. In accordance to higher complication rates, certain steps in the operation can be more difficult, such as making the vesicourethral anastomosis, since the position of the renal allograft can interfere with the surgeon’s movements and instruments. In 2008, Jhaveri et al first reported a transperitoneal RALP in a renal allograft recipient.27 He stated that RALP is feasible in carefully selected renal allograft recipients when accomplished with technical modifications to avoid injuring the renal allograft, transplanted ureter, and uret-

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eroneocystostomy. Jhaveri et al advocated (1) the use of an extended length bariatric port to bypass the allograft side and deliver the ipsilateral robotic instrument directly into the pelvis; (2) development of the retropubic space from the contralateral side; and (3) meticulous posterior dissection of the seminal vesicles via the medial avascular plane to avoid injury to the proximal neurovascular plate. Beside Jhaveri et al,27 most authors address port placement modifications for LRP in renal allograft recipients, thereby to some extent complicating the surgical technique.23,25 However, in our surgical approach the six trocars were placed in the standard RALP positions as shown in Fig 2, with no necessary modifications due to the transplanted kidney positioned in the left iliac fossa. We performed the mobilization of the seminal vesicles and vas deferens in accordance to the Montsouris technique as is a routine in our institution. This helps significantly to attain a clear view to the Denonvilliers fascia and to reach the dorsal aspect of the prostate as an early step in the procedure. Furthermore, with this technique the neurovascular bundles can be easily separated laterocaudally. To our opinion, especially in renal transplant recipients, RALP should be performed according to the Montsouris technique, allowing excellent functional and oncological outcome. In addition, the dissection of the bladder from the anterior abdominal wall was started at the contralateral side from the renal transplant without mobilization of the ipsilateral obturator fossa. The mobilization of the bladder from the anterior abdominal wall bears the risk of iatrogenic lesion of the transplant ureter, the ureteroneocystostomy and the transplanted kidney. Up to 10% of graft ureteral injuries are documented in the literature.16 Unlike Shah et al,22 Doerfler et al decided not to divide the right lateral part of the bladder to identify the ureterovesical anastomosis.23 As a future direction, the partial dissection of the bladder from the anterior abdominal wall, as described in our case, could be omitted to even make the procedure more secure for iatrogenic lesion of the transplant kidney and ureter. Furthermore, to our experience there is no need for catheterization of the transplant ureter before RALP, as described in earlier reports in retropubic radical prostatectomy.17 In this case of RALP in a kidney transplant recipient, nearly no modifications in the operation technique were necessary compared to a standard RALP in PCa. Merely, a partial mobilization of the bladder from the anterior abdominal wall and a one-sided lymph node dissection on the contralateral side of the allograft was performed. In contrast, bladder neck preservation, bilateral erectile nerve sparing, a Rocco suture, and a tension-free vesicourethral van Velthoven anastomosis could easily be applied. In conclusion, renal transplant recipients can undergo an almost highly standardized RALP procedure using the Montsouris technique with favorable surgical results. In conclusion, RALP in renal transplant patients is feasible and can be realized with good functional and oncological results. As caution must be exerted to the

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transplant kidney and ureter, a partial dissection of the bladder from the anterior abdominal wall and a one-sided lymph node dissection only should be performed. No further modifications to the standard RALP technique are required in these patients.

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WAGENER, NYARANGI-DIX, TEBER ET AL 24. Thomas AA, Nguyen MM, Gill IS: Laparoscopic transperitoneal radical prostatectomy in renal transplant recipients: a review of three cases. Urology 71:205, 2008 25. Maestro MA, Gomez AT, Alonso YGS, et al: Laparoscopic transperitoneal radical prostatectomy in renal transplant recipients: a review of the literature. BJU Int 105:844, 2010 26. Robert G, Elkentaoui H, Pasticier G, et al: Laparoscopic radical prostatectomy in renal transplant recipients. Urology 74: 683, 2009 27. Jhaveri JK, Tan GY, Scherr DS, et al: Robot-assisted laparoscopic radical prostatectomy in the renal allograft transplant recipient. J Endourol 22:2475, 2008