Radical Cystectomy and Orthotopic Urinary Reconstruction in Patients With Bladder Cancer After Renal Transplantation: Clinical Outcomes and Description of Technique

Abstract

Objectives Radical cystectomy (RC) with pelvic lymph node dissection and urinary diversion is the gold-standard treatment for muscle-invasive bladder cancer. In the setting of prior renal transplantation, surgical treatment remains the mainstay but is technically challenging. We report our patient outcomes in this unique population with a description of the technique. Methods We identified five patients with a prior history of renal transplantation who underwent RC and orthotopic urinary diversion. Preoperative clinical and demographic features were compiled and disease-specific and functional outcomes were assessed. Intraoperative technical challenges and maneuvers for avoiding complications are highlighted. Results Four patients were male and 1 was female, with a median age of 64 years. Gross hematuria was the most common sign at presentation. Clinical staging was T2, T2 with CIS, HG Ta with CIS, T2 with squamous differentiation, and HG T1, and pathologic tumor stage was pTisN1, pT3N0, pTisN0, pT3N0 and pT0N0, respectively. One patient received a Studer-type diversion and 4 underwent Hautmann diversion. Median followup after cystectomy was 12.9 months. Graft ureteral identification was aided by the use of intravenous dye in all patients. Ipsilateral pelvic lymph node dissection was not possible in any patient. All patients are alive at followup, with two experiencing recurrence at 7.2 months and 66.8 months. No patient experienced a significant decrease in estimated creatinine clearance (eCrCl) post-operatively. Postoperative daytime control was reported by all patients while 2 noted complete nighttime control. Conclusions RC with orthotopic diversion is a technically demanding procedure in patients with a history of prior renal transplantation. Meticulous technique and careful attention to the altered anatomy are required for successful outcomes.

Multicenter evaluation of complex urinary diversion for renal transplantation: outcomes of complex surgical solutions

“…However, other studies argue that urinary diversion after KT is associated with a lower risk of damaging important structures [ 2 , 22 ]. It may even be considered necessary in some cases, such as when dealing with newly diagnosed bladder cancer due to immunosuppression [ 23 ]. In our cohort, intraoperative complications occurred only in two patients and therefore synchronous change of urinary diversions during KT seems also feasible.…”

De Novo Urological Malignancies After Renal Transplantation: An Asian 30‐Year Experience

“…Care should be taken during dissection of the ureter to avoid inadvertent injury and devascularization. Like in most studies, lymph node dissection was not performed on the side of the graft due to scarring and adhesions to the iliac vessels [37]. Nevertheless, both patients experienced metastatic recurrence and demised shortly after treatment, similar to other series that report a significantly poorer CSS of MIBC in RT recipients [31, 38], possibly related to more aggressive tumors in a setting of immunosuppression, limited lymph node dissection on the side of the allograft, and inability to administer chemotherapy or radiotherapy due to risks of graft toxicity.…”

Radical cystectomy, bilateral lymphadenectomy and native ureteral ligation in a patient with history of kidney transplantation

“…In a study, Moses et al . [ 9 ] reported five patients with BCa and a history of renal transplantation, who underwent RC and orthotopic urinary reconstruction. PLND on the side of graft was impossible in all patients.…”

“…In these patients, there is a greater risk of injury to the main vessels and grafted ureter due to absence of clear surgical plane and presence of peri-graft adhesions. PLND on the side of the transplanted kidney was not feasible in several reports [ 9–11 ].…”