Ask the Experts - Treatment of Bladder Cancer in Renal Transplant...
Ask the Experts - Treatment of Bladder Cancer in Renal Transplant...
What is the first-line treatment of bladder cancer in the renal transplant patient? Is an ileal neobladder associated with a high risk of infectious complications?
It is true that neobladders have a poor reputation due to a higher rate of infection, but the results have improved and excellent graft survival rates can now be reached. In order to limit the incidence of infection I would personally recommend the following: (1) perform an antireflux procedure when anastomosing the ureter into the reservoir; (2) position the ureter anastomosis as high as possible in order to prevent permament reflux of urine into the kidney graft in case the anastomosis would be refluxing; (3) during the first weeks posttransplant, leave a urinary stent in place, with one extremity in the pelvis of the kidney and the other draining freely in the plastic bag around the stoma site; this is again to avoid stagnation of urine in the neobladder, particularly early posttransplantation at the time of maximal immunosuppression; (4) try to use as little immunosuppression as possible; and (5) meticulous care of the stoma, regular changes of the bag, and emphasize the importance of patient hygiene. A technique that we use at our center in Leuven, Belgium, is to place the kidney upside down. This gives more length to the ureter to reach the upper part of the reservoir.
There are not much data available in the literature on the treatment of bladder cancer in the renal transplant patient. A study by the Wisconsin group pointed out the higher incidence of bladder cancer in the transplant population (relative risk of 3.31) and, therefore, emphasized the importance of screening by means of careful urologic evaluation in noninfected patients with microscopic or gross hematuria. First-line treatment should be the same as in the nontransplant situation. One difference, however, is that in the transplant situation one should try to reduce the immunosuppression to improve the anti-tumor immunity.
If it is a superficial tumor, then fulgurations or local treatment is indicated followed by frequent cystoscopies. I am not aware of a published case of construction of a neobladder for bladder cancer after transplantation. But in theory, this is a feasible option and has probably already been done. If one follows the principles outlined above, there would be no reason to believe that the incidence of infection would be higher compared with the more standard setting. The only difficulty that I could anticipate (after consulting Arthur Matas, MD, from the University of Minnesota in Minneapolis) would be the length of the ureter that may be shorter with a kidney graft already in place and particularly if a segment of ureter has to be resected for oncologic reasons. In more advanced metastatic bladder cancers, a radical option would be to stop immunosuppression and perform a transplantectomy. But in case the prognosis is unlikely to be influenced by the therapy, one would be tempted to keep a functioning kidney in place. This should be openly discussed with the patient.
What is the first-line treatment of bladder cancer in the renal transplant patient? Is an ileal neobladder associated with a high risk of infectious complications?
It is true that neobladders have a poor reputation due to a higher rate of infection, but the results have improved and excellent graft survival rates can now be reached. In order to limit the incidence of infection I would personally recommend the following: (1) perform an antireflux procedure when anastomosing the ureter into the reservoir; (2) position the ureter anastomosis as high as possible in order to prevent permament reflux of urine into the kidney graft in case the anastomosis would be refluxing; (3) during the first weeks posttransplant, leave a urinary stent in place, with one extremity in the pelvis of the kidney and the other draining freely in the plastic bag around the stoma site; this is again to avoid stagnation of urine in the neobladder, particularly early posttransplantation at the time of maximal immunosuppression; (4) try to use as little immunosuppression as possible; and (5) meticulous care of the stoma, regular changes of the bag, and emphasize the importance of patient hygiene. A technique that we use at our center in Leuven, Belgium, is to place the kidney upside down. This gives more length to the ureter to reach the upper part of the reservoir.
There are not much data available in the literature on the treatment of bladder cancer in the renal transplant patient. A study by the Wisconsin group pointed out the higher incidence of bladder cancer in the transplant population (relative risk of 3.31) and, therefore, emphasized the importance of screening by means of careful urologic evaluation in noninfected patients with microscopic or gross hematuria. First-line treatment should be the same as in the nontransplant situation. One difference, however, is that in the transplant situation one should try to reduce the immunosuppression to improve the anti-tumor immunity.
If it is a superficial tumor, then fulgurations or local treatment is indicated followed by frequent cystoscopies. I am not aware of a published case of construction of a neobladder for bladder cancer after transplantation. But in theory, this is a feasible option and has probably already been done. If one follows the principles outlined above, there would be no reason to believe that the incidence of infection would be higher compared with the more standard setting. The only difficulty that I could anticipate (after consulting Arthur Matas, MD, from the University of Minnesota in Minneapolis) would be the length of the ureter that may be shorter with a kidney graft already in place and particularly if a segment of ureter has to be resected for oncologic reasons. In more advanced metastatic bladder cancers, a radical option would be to stop immunosuppression and perform a transplantectomy. But in case the prognosis is unlikely to be influenced by the therapy, one would be tempted to keep a functioning kidney in place. This should be openly discussed with the patient.
Source...