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ORTHOTOPIC NEOBLADDER AFTER KIDNEY TRANSPLANTATION IN A MALE PATIENT WITH RECURRING UROTHELIAL CARCINOMA AND RENAL CANCER
0022-5347/01/1664-1383/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 166, 1383, October 2001 Printed in U.S.A.
ORTHOTOPIC NEOBLADDER AFTER KIDNEY TRANSPLANTATION IN A MALE PATIENT WITH RECURRING UROTHELIAL CARCINOMA AND RENAL CANCER ¨ RK, BERND SCHOENBERGER MARKUS GIESSING, INGOLF TU
AND
STEFAN A. LOENING
From the Department of Urology, Charite´ University Hospital, Berlin, Germany KEY WORDS: kidney transplantation, bladder, bladder neoplasms
Patients with analgesic nephropathy are at high risk for transitional cell carcinoma. Immunosuppression after renal transplantation increases the risk of de novo and recurrent malignancies up to 15%.1, 2 Reports on orthotopic bladder replacement after kidney transplantation are rare.3 We describe a male patient with recurring urothelial carcinoma and detection of renal carcinoma after renal transplantation. To our knowledge we report the first case of an orthotopic neobladder in a male patient with 2 occurrences of urological carcinomas after kidney transplantation. CASE REPORT
A 61-year-old man received a cadaveric kidney transplantation after 4 years on hemodialysis. Underlying disease was analgesic nephropathy. The ureteral implantation was antirefluxing according to the Politano-Leadbetter technique and the renal vessels were connected with the iliac extern arteria and vein. The patient had undergone transurethral resection 52 months before kidney transplantation for TaG1 bladder cancer. Followup included regular cystoscopy plus retrograde ureteropyelography, ultrasound and urine cytology. At 15-month followup urothelial cancer of the right renal pelvis necessitated nephroureterectomy. Followup 27 months later revealed T1G1–2 urothelial cancer of the bladder plus a combination of TaG2 urothelial cancer and carcinoma in situ of the left ureter. Due to the multifocal, partially invasive cancer en bloc nephroureterectomy plus cystectoprostatectomy in combination with the construction of an ileal neobladder (Padua) was performed after negative intraoperative urethral histology. The ureter of the transplanted kidney was implanted according to the Le Duc technique. A Hitch suture fixed the implantation site of the neobladder to the psoas muscle. Final histology revealed 2 additional papillary kidney tumors pT1G2 that had not been detected preoperatively. Convalescence was uneventful. The transplanted kidney function was not altered and creatinine was stable at 0.9 mg./dl. Cyclosporine level was monitored daily and changes in dosing were not necessary due to loss of an ileal segment. At 20-month followup the patient presented with a creatinine of 0.95 mg./ dl. Initial grade III incontinence slightly improved to grades II to III and residual volume after double voiding was not detected (see figure) . The patient used a condom catheter and declined an artificial urethral sphincter.
Pouchogram 3 weeks after reconstruction shows nonleaking orthotopic neobladder.
phropathy.1, 2 Surgical curative therapy for high-grade, multifocal and carcinoma in situ transitional cell cancer includes bilateral nephroureterectomy, cystoprostatectomy and urethrectomy, which provides better survival than the local approach via transurethral resection.1 We recommend the following steps. Patients must be monitored every 3 months after renal transplantation due to an analgesic nephropathy with cystoscopy, retrograde pyelography, urine cytology and ultrasound. An orthotopic neobladder after bilateral nephroureterectomy and cystectomy is a surgically feasible way to cure high grade, multifocal and carcinoma in situ transitional cell cancer in patients after renal transplant with a cancer-free urethra, possibly providing a continent situation and a high quality of life. An ileal loop diversion is the surgical alternative with the disadvantage of incontinence but the advantage of complete resection of the urothelium, including the urethra. Surgical therapy for renal cancer after transplantion is nephrectomy plus adrenalectomy.
DISCUSSION
REFERENCES
Recommendations concerning the waiting time following previous malignant disease before transplantation do not exist. Most propose a general 2-year tumor-free episode for urological tumors. Tumors of the urothelium occur in up to 15% of patients with urothelial carcinoma after transplantation due to analgesic nephropathy and immunosuppression. Some propose a prophylactic bilateral nephroureterectomy in patients with kidney transplantation due to analgesic neAccepted for publication May 18, 2001. 1383
1. Thon, W. F., Kliem, V., Truss, M. C. et al: Denovo urothelial carcinoma of the upper and lower urinary tract in kidneytransplant patients with end-stage analgesic nephropathy. World J Urol, 13: 254, 1995 2. Barrett, W. L., First, M. R., Aron, B. S. et al: Clinical course of malignancies in renal transplant recipients. Cancer, 72: 2186, 1993 3. Colombo, T., Zigeuner, R., Zitta, S. et al: Orthotopic neobladder in a woman after kidney transplantation. J Urol, 158: 2236, 1997
Vol. 166, 1383, October 2001 Printed in U.S.A.
ORTHOTOPIC NEOBLADDER AFTER KIDNEY TRANSPLANTATION IN A MALE PATIENT WITH RECURRING UROTHELIAL CARCINOMA AND RENAL CANCER ¨ RK, BERND SCHOENBERGER MARKUS GIESSING, INGOLF TU
AND
STEFAN A. LOENING
From the Department of Urology, Charite´ University Hospital, Berlin, Germany KEY WORDS: kidney transplantation, bladder, bladder neoplasms
Patients with analgesic nephropathy are at high risk for transitional cell carcinoma. Immunosuppression after renal transplantation increases the risk of de novo and recurrent malignancies up to 15%.1, 2 Reports on orthotopic bladder replacement after kidney transplantation are rare.3 We describe a male patient with recurring urothelial carcinoma and detection of renal carcinoma after renal transplantation. To our knowledge we report the first case of an orthotopic neobladder in a male patient with 2 occurrences of urological carcinomas after kidney transplantation. CASE REPORT
A 61-year-old man received a cadaveric kidney transplantation after 4 years on hemodialysis. Underlying disease was analgesic nephropathy. The ureteral implantation was antirefluxing according to the Politano-Leadbetter technique and the renal vessels were connected with the iliac extern arteria and vein. The patient had undergone transurethral resection 52 months before kidney transplantation for TaG1 bladder cancer. Followup included regular cystoscopy plus retrograde ureteropyelography, ultrasound and urine cytology. At 15-month followup urothelial cancer of the right renal pelvis necessitated nephroureterectomy. Followup 27 months later revealed T1G1–2 urothelial cancer of the bladder plus a combination of TaG2 urothelial cancer and carcinoma in situ of the left ureter. Due to the multifocal, partially invasive cancer en bloc nephroureterectomy plus cystectoprostatectomy in combination with the construction of an ileal neobladder (Padua) was performed after negative intraoperative urethral histology. The ureter of the transplanted kidney was implanted according to the Le Duc technique. A Hitch suture fixed the implantation site of the neobladder to the psoas muscle. Final histology revealed 2 additional papillary kidney tumors pT1G2 that had not been detected preoperatively. Convalescence was uneventful. The transplanted kidney function was not altered and creatinine was stable at 0.9 mg./dl. Cyclosporine level was monitored daily and changes in dosing were not necessary due to loss of an ileal segment. At 20-month followup the patient presented with a creatinine of 0.95 mg./ dl. Initial grade III incontinence slightly improved to grades II to III and residual volume after double voiding was not detected (see figure) . The patient used a condom catheter and declined an artificial urethral sphincter.
Pouchogram 3 weeks after reconstruction shows nonleaking orthotopic neobladder.
phropathy.1, 2 Surgical curative therapy for high-grade, multifocal and carcinoma in situ transitional cell cancer includes bilateral nephroureterectomy, cystoprostatectomy and urethrectomy, which provides better survival than the local approach via transurethral resection.1 We recommend the following steps. Patients must be monitored every 3 months after renal transplantation due to an analgesic nephropathy with cystoscopy, retrograde pyelography, urine cytology and ultrasound. An orthotopic neobladder after bilateral nephroureterectomy and cystectomy is a surgically feasible way to cure high grade, multifocal and carcinoma in situ transitional cell cancer in patients after renal transplant with a cancer-free urethra, possibly providing a continent situation and a high quality of life. An ileal loop diversion is the surgical alternative with the disadvantage of incontinence but the advantage of complete resection of the urothelium, including the urethra. Surgical therapy for renal cancer after transplantion is nephrectomy plus adrenalectomy.
DISCUSSION
REFERENCES
Recommendations concerning the waiting time following previous malignant disease before transplantation do not exist. Most propose a general 2-year tumor-free episode for urological tumors. Tumors of the urothelium occur in up to 15% of patients with urothelial carcinoma after transplantation due to analgesic nephropathy and immunosuppression. Some propose a prophylactic bilateral nephroureterectomy in patients with kidney transplantation due to analgesic neAccepted for publication May 18, 2001. 1383
1. Thon, W. F., Kliem, V., Truss, M. C. et al: Denovo urothelial carcinoma of the upper and lower urinary tract in kidneytransplant patients with end-stage analgesic nephropathy. World J Urol, 13: 254, 1995 2. Barrett, W. L., First, M. R., Aron, B. S. et al: Clinical course of malignancies in renal transplant recipients. Cancer, 72: 2186, 1993 3. Colombo, T., Zigeuner, R., Zitta, S. et al: Orthotopic neobladder in a woman after kidney transplantation. J Urol, 158: 2236, 1997