Radical Cystectomy and Urinary Diversion after Renal Transplantation

Abstract

Introduction: Radical cystectomy remains the gold-standard treatment for patients with muscle invasive bladder cancer. Surgery may be difficult in patients who have previously undergone renal transplantation. We review our experience in this unique patient population with particular emphasis on intraoperative challenges and functional outcomes. Methods: We identified 4 patients with a history of renal transplantation who underwent radical cystectomy at Memorial Sloan-Kettering Cancer Center. Three patients underwent orthotopic neobladder formation and one underwent ileal conduit urinary diversion. Clinical and demographic data were collected. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Intraoperative records were queried to determine operative time, estimated blood loss, transfusion status, ASA score and technical operative difficulties. Results: Mean followup time after surgery was 28.0 months (range 1.3-67.8 months). Three patients were male and one patient was female. Mean age at the time of surgery was 58.6 years (range 27.3-74.6 years). Mean time from transplantation to surgery was 87.6 months. Intraoperative data are summarized in Table 1. Patient 1 underwent neoadjuvant Gemcitabine and Cisplatin prior to radical cystectomy with a Hautmann neobladder, bilateral native nephroureterectomy and sacro-colpopexy. Patient 2 underwent a Studer ileal neobladder and native left ureterectomy after a history of left nephrectomy for renal cell carcinoma. Patient 3 underwent Hautmann neobladder formation and native bilateral nephroureterectomy after prior intravesical therapy with Mitomycin-C and Gemcitabine. Patient 4 underwent an ileal conduit urinary diversion and bilateral native nephroureterectomy with left adrenalectomy. Indigo carmine was used to identify the transplanted ureter in two cases. Final pathology was pTisN1 in Patient 1, pT3N0 in Patient 2, pTisN0 in Patient 3, and pT3N0 in Patient 4. All patients are alive, with one pelvic recurrence in Patient 3 66.8 months after surgery. All three patients with orthotopic diversion are continent.Conclusions: Radical cystectomy and urinary diversion is feasible in patients after renal transplantation. Right pelvic lymph node dissection may be technically impossible due to the position of the graft and associated post-operative adhesions. Assistance with intravenous dye can aid in transplant ureteral identification. Good functional outcomes are expected in centers with experience in orthotopic diversion.