Total urinary tract exenteration including donor nephrectomy for transitional cell carcinoma 41years following transplantation.

Abstract

transitional carcinoma of bladder and an incidental pT2a, Gleason score 6 prostate adenocarcinoma. He recovered uneventfully and started dialysis but died 3 years later in 2011 of dialysis-related complications. Renal transplantation allows the recipient to become dialysis free with significant lifestyle improvements for the individual. However, immunosuppressant medications used following organ transplantation are associated with an increased risk of malignancy with tumours occurring in 1.8–18 % of transplant patients [1–3]. The incidence of solid tumours such as lung and colorectal is not increased in transplant patients [4] but specific posttransplant malignancies (e.g. skin) demonstrate marked geographical variations with higher incidences occurring in Australia [1]. Genitourinary cancers occur in up to 1.9 % of posttransplant patients [3] but geographical disparities also exist for transitional cell carcinoma with increased numbers in Taiwan [5]. Small series have shown that transitional cell carcinoma of the bladder is the most common genitourinary cancer occurring posttransplantation and cite increasing age and male gender as the main risk factors [6]. Chakera et al. [7] have reported an 8-year interval between transplantation and the development of an RCC in a donor allograft. Transitional cell carcinoma in transplant patients is typically high grade, progresses rapidly and despite aggressive surgical treatment is often fatal [8]. Painless haematuria in transplant recipients requires prompt evaluation, reduction in immunosuppressive therapy and adequate resection [9]. Previous authors have recorded a 9-year interval between development of a transitional cell carcinoma posttransplant [10] but intervals of up to 12 years have been reported [8]. We describe an interval of 41 years between transplant and development of TCC and believe this to be the longest interval recorded between transplantation and occurrence Editor A 63-year-old male presented with frank painless haematuria. His past history was remarkable for a livingrelated donor renal transplant in 1967 from a first-degree male relative and concomitant bilateral native nephrectomy for polycystic kidney disease. His medical management was notable for biopsy proven chronic sclerosing nephropathy in 2005 and azathioprine suppressant therapy. He had never developed a cutaneous neoplasm but a previous skin biopsy revealed pityriasis rosacea. Physical examination revealed a midline laparotomy scar and a right iliac fossa scar. Routine investigations revealed a creatinine of 450 μmol/l. Ultrasonography of the transplanted kidney revealed gross hydronephrosis, and he underwent decompression nephrostomy and antegrade stenting which failed to improve his renal function. Subsequent cystoscopy revealed a large papillary lesion overlying the right ureter, which was resected along with the ureteric orifice. Histopathological analysis revealed a pT1 G3 transitional cell carcinoma. Staging with Magnetic Resonance Imaging showed distal ureteric involvement of the right kidney (Fig. 1a, b). Following discussion with the patient and consultation with nephrological and transplant teams, it was felt that the best method of attaining oncological control, given the high-grade histology and radiological findings, was radical surgery with initiation of dialysis postoperatively. He underwent a concomitant nephroureterectomy of the transplanted kidney as well as a radical cystoprostatectomy. Final histopathological analysis revealed a pT2 G3 transitional carcinoma of the right ureter, a pT1 G3