Cystectomy and orthotopic ileal neobladder in a male patient 12 years after kidney transplantation; good preservation of the renal function

Abstract

In case of cystectomy, some forms of urinary diversion can impair the graft function of renal transplant patients. Here we present the case of a 70-year-old male with carcinoma of the bladder 12 years after renal transplantation. Immunosuppression was achieved with Cyclosporin A (200 mg/day) and Prednisone (5 mg/day). The patient's serum creatinine level was 1.4 mg/dl. Following cystectomy, an orthotopic ileal neobladder was constructed by means of Studer technique, and the afferent ileal loop was anastomosed to the graft ureter.Pathology revealed pT1 G3 N + transitional cell carcinoma. Ten months later, periaortic nodal recurrences necessitated four cycles of chemotherapy with Epidoxorubicyn and Gemcytabine. To date, 20 months after cystectomy, the patient is stable, with day and nighttime urinary continence. His serum creatinine level is 1.3 mg/dl, and there is no evidence of hydronephrosis or acidosis. We conclude that the orthotopic ileal neobladder is an effective form of urinary diversion in renal transplant patients requiring cystectomy, allowing good preservation of the renal function. Keywords Kidney transplantationBladder neoplasms . Urinary diversion Abbreviations BCG Bacillus Calmette GulrinImmunosuppression following renal transplantation increases the risk of tumor development, including that of bladder carcinoma [l]. Radical cystectomy may be necessary in these patients, however, some forms of urinary diversion, such as an ileal conduit, may impair graft function. Here we report the case of an orthotopic ileal neobladder allowing good preservation of renal function in a renal transplant patient. Case reportThe patient, a 70-year-old male, had undergone cadaveric kidney transplantation 12 years previously. The graft, with a cold ischemia time of 14 h, was from a 15-year-old female donor of identical haplotype.The initial immunosuppressive regimen was Cylosporine A (CSA) 230 mg/day, Azathioprine 50 mg/day and Prednisone 15 mg/day. Due to patient age, the immunosupperessive regimen was tapered over the years to CSA 200 mg/day and Prednisone 5 mg/day. The graft was functioning well with a serum creatinine level of 1.4 mg/dl. During the previous year, two transurethral superficial bladder tumors had been resected, and a recent third resection revealed pT1 G3 transitional cell carcinoma. Spiral CT scan failed to demonstrate enlarged pelvic lymph nodes and showed two shrunken native kidneys, the chest X-ray was normal.The patient underwent radical cystectomy with right-sided pelvic lymphadenectomy, since the graft was placed in the left iliac fossa. An ileal orthotopic neobladder was fashioned by means of Studer technique using 55 cm of the terminal ileum, which was detubularized and folded twice, leaving a 14 cm afferent ileal loop, which was anastomosed to the graft ureter in the left iliac fossa by means of the "split cuff' technique (Fig. 1). The postoperative

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

“…The occurrence of non-urothelial carcinoma in the bladder after renal transplantation poses several therapeutic problems. First, patients who undergo cystectomy re-quire a form of urinary diversion that minimizes the risk of graft dysfunction 6 . Second, immunosuppressive agents may hamper intestinal healing and promote urinary leakage and urosepsis.…”

“…However, a review of the literature reveals the report of Colombo et al 2 which describes the construction of a continent orthotopic ileal neobladder in a female patient, after renal transplant. Since then, the cases of several kidney transplant recipients who received an orthotopic ileal neobladder have been reported [4][5][6][7][8][9][10][11][12] . These reports demonstrate the feasibility of radical cystectomy and orthotopic urinary reconstruction in renal transplant patients who have good functional and oncological results, despite the fact that this group suffers a high rate of comorbidity.…”

“…However, in our experience and that of others, the Studer technique is particularly suitable for tract reconstruction following renal transplantation. This is because this technique generates an intact afferent ileal loop that can be anastomosed to the short graft ureter; its preserved peristalsis prevents reflux and hydronephrosis 6 .…”

“…However, urologists are reluctant to construct a neobladder in renal transplant recipients because of the altered pelvic anatomy and the possibility that the chronic immunosuppression will increase the rate of complications. As a result, the literature includes relatively few reports describing the construction of an orthotopic ileal neobladder in kidney transplant recipients [2][3][4][5][6][7][8][9][10][11][12] . The case of a female patient who developed squamous cell carcinoma of the bladder 16 years after a kidney transplant and then received an orthotopic neobladder is reported here.…”

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

“…Radical cystectomy and Studer orthotopic ileal neobladder were performed as previously described (Fig. 1) [4].…”