© 2 0 0 5 B J U I N T E R N A T I O N A L | 9 5 , 3 1 9 – 3 2 2 | doi:10.1111/j.1464-410X.2005.05291.x 319 Original Article SURGERY FOR LOCALIZED PROSTATE CANCER AFTER RENAL TRANSPLANTATION HAFRON et al. Surgery for localized prostate cancer after renal transplantation JASON HAFRON, JAMES D. FOGARTY, ARI WIESEN and ARNOLD MELMAN Department of Urology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York USA Accepted for publication 20 October 2004 RESULTS All seven patients successfully tolerated RP with no major complications. The mean (SD, range) age at surgery was 62.3 (2.5, 55–74) years and the mean interval from renal transplant to RP 86.5 (25.25, 24–192) months. There was no evidence of increased blood loss, operative duration, transfusion requirement, hospital stay or deterioration of graft function. The presence of an allograft did not alter the surgical approach or management of the patients after RP. The mean follow-up was 22 (2–130) months and all seven patients were followed. One patient had evidence of biochemical recurrence with no radiographic evidence of metastatic disease. Serum prostate-specific antigen was undetectable in the remaining patients. CONCLUSION A perineal RP in renal transplant recipients for treating localized prostate cancer offers many advantages over other treatments. KEYWORDS prostate cancer, renal transplant, surgery OBJECTIVE To investigate the feasibility of perineal radical prostatectomy (RP) in renal transplant recipients with localized prostate cancer. PATIENTS AND METHODS The study comprised seven consecutive renal transplant patients who had a perineal RP between May 1991 and February 2004. All available clinicopathological data were reviewed. INTRODUCTION The successes in renal transplantation have led to liberal criteria for transplant recipients, in that almost 10% of all transplant recipients in the USA are > 50 years old [1]. The calculated half-life for grafts from living donors between 1988 and 1996 was 21.6 years [2]. Advances in immunosuppressive therapy in the last two decades have led to a substantial improvement in graft and patient survival after renal transplantation. As more older men are being considered for renal transplantation, and men are living longer with functional allografts, it is inevitable that urologists will encounter more renal transplant recipients with prostate cancer. The incidence of prostate cancer in the renal transplant population is difficult to interpret because most transplant registry data were obtained before the existence of systematic screening. In the last update of the Cincinnati Transplant Tumor Registry and the Australian and New Zealand Transplant Registry there was a lower incidence of prostate cancer than in the general population [3,4]. However, in the European Nordic countries the frequency of prostate cancer was much higher [5]. It is impossible to draw significant conclusions from these registries because most patients were not screened before or after their renal transplant. However, when patients were routinely screened with PSA testing and/or a DRE the incidence of prostate cancer appeared to be higher than in the general population [6]. In another series, Malavaud et al. [7] reported on 120 consecutive men receiving a renal transplant, who were > 50 years old and who were routinely screened with PSA. The incidence of prostate cancer in this selected group was 5.8%. Kinahan et al. [8] reported the incidence of prostatic carcinoma in 390 men on immunosuppression undergoing TURP to be 30%; this is three times higher than the commonly reported rate for patients undergoing TURP. Excluding the data from the transplant registries, when patients are systematically screened it appears that long- term immunosuppression may affect the incidence of prostate cancer. Immunosuppression, the presence of a pelvic renal graft and the potential for future transplants in the event of graft failure are all factors that must be considered when managing prostate cancer after renal transplantation. In the largest reported series of patients with prostate cancer after organ transplantation, more were found to have localized disease at the time of diagnosis than in the general population, and aggressive interventions were recommended [9]. We present our experience of renal transplant recipients with localized prostate cancer, and the advantages of radical prostatectomy (RP), specifically perineal. PATIENTS AND METHODS The study included seven consecutive renal transplant recipients who had a perineal RP between May 1991 and February 2004. All available clinicopathological data were reviewed; two men presented with an abnormal DRE and the rest with elevated serum PSA levels (Tandem R, Hybritech, San Diego, CA). The diagnosis was confirmed on TRUS-guided prostate biopsy. Clinical and pathological staging was assigned using the 2002 TNM guidelines. Radionuclide bone scintigraphy and cross-sectional imaging was reserved only for patients with a PSA level of > 20 ng/mL, suspicion of locally advanced disease or the presence of poorly differentiated cancer on needle biopsy (Gleason score > 8). None of the patients in this series received preoperative hormone or radiation therapy.