BERKELEY, CA (UroToday Inc.) - Greater numbers of older men undergo renal transplantation; graft half-life has steadily climbed, so it is inevitable that urologists will see more of these patients who eventually develop prostate cancer. Radiation therapy and retropubic prostatectomy are not optimal treatments due to the risks respectively of radiation nephritis or effects of surgery in an area that may be needed for possible repeat transplants.

Dr. Hafron and associates from the Albert Einstein College of Medicine, Bronx, NY report their series of renal transplant patients who subsequently underwent perineal prostatectomy. Their findings appear in the February 2005 issue of the BJU International.

Seven consecutive renal transplant recipients underwent perineal prostatectomy between May 1991 and February 2004. Five were clinical stage T1c, and all had had TRUS-guided prostate biopsies. No patient had clinical evidence of metastatic disease, nor did any receive neoadjuvant therapies.

Mean patient age was 62.3 years, and mean interval from renal transplant to prostatectomy was 86.5 months. Six patients had received a cadaveric transplant, and one had a living-related transplant. One surgeon performed all the prostatectomies. No patient underwent pelvic lymphadenectomy. Typical hospitalization was 2 days, and foley catheters were removed in 9 days.

Mean blood loss was 493ml and mean operative duration was 92.7 min. One patient with prolonged hematuria required blood transfusion, otherwise patients did well. Based upon serum creatinine levels, no patient had worsening graft function. One patient had a detectable PSA post-op and received adjuvant androgen deprivation therapy. Two other patients had focal positive surgical margins, but additional adjuvant or salvage treatment is not mentioned.

Radical prostatectomy for localized cancer is likely the best curative treatment option for men with an existing renal transplant. The perineal approach is optimal because it avoids the pelvic space, where invasion could potentially cause graft damage or damage an area that might be needed in the future should a second transplant be required. While patients on immunosuppression may potentially have a more rapid rate of tumor progression, clinical staging and treatment options in the renal transplant population likely do not differ from the general population, and curative intent should still remain the goal.

BJU Int. 2005;95:319-22