Should post-kidney transplant patients with localized prostate cancer be undergoing robotic radical prostatectomy?

Open surgical approach, either retropubic or perineal approach [4], can be offered to these patients as a feasible surgical option justified by their technical difficulty and the need to preserve the functioning graft. Robot-assisted radical prostatectomy (RARP) is another reasonable minimally invasive alternative for these unique patient populations. We have an experience with five post-kidney transplant prostate cancer patients who had RARP in these challenging surgical scenarios: three patients had single renal graft, one patient had two previous kidney transplants, and one patient had dual kidney transplant and an inflatable penile prosthesis (IPP) in place. No perioperative complications were encountered in any of the patients. Average hospital stay was 2 (1–3) days. Pathologic stage was T2 in four patients and T3a in one patient, with Gleason 6 in three patients and 7 in two patients. All patients had negative surgical margins. All patients had undetectable PSA and continent through their respective follow-up (range: 9 months to 5 years). With this letter, based on our experience in patients with single and dual renal allografts, we suggest that RARP for these patients is feasible with no added perioperative complication risks. Pure posterior antegrade approach can be utilized when anterior dissection is not feasible or too risky. We adapted this approach in a patient with two previous kidney transplants. Pure posterior antegrade technique is based on surgical principles of posterior dissection of the seminal vesicles first (Montsouris) [5], concept of anterior sparing of puboprostatic ligaments and dorsal vein complex (superveil) [6], and the Retziussparing approach [7, 8]. RARP in complex scenarios as post-kidney transplant can be safely and effectively accomplished following certain precautions and modifications to the technique (Table 1). Prostate cancer is the most common solid malignancy and the second leading cause of cancer death among American men [1]. Radical prostatectomy is the treatment of choice for clinically localized prostate cancer. Konety et al. [2] first reported that most of the patients with prostate cancer being detected after solid organ transplantation were diagnosed with localized disease, and an aggressive therapeutic intervention as in the general (non-transplant) population can be considered. With the extension of survival in post-renal transplant population [3], prostate cancer patients should not be excluded from the potentially curative surgical management option. There are no randomized controlled trials that address superiority of any of the treatment options of prostate cancer in post-transplant population. The increasing age of kidney transplant recipients, along with the documented increase in survival in chronic renal failure patients after kidney transplant than being on dialysis [3], have led to more kidney transplant recipients getting diagnosed with prostate cancer. Radical prostatectomy in these patients carries unique challenges posed by the presence of a transplanted kidney in the pelvis with the need to avoid injury of the renal graft, the ureter, or the site of ureteroneocystostomy. Furthermore, these patients usually have history of long-term chronic renal impairment and immunosuppression use, which may further confound the medical situation in patients with already challenging surgical condition.