Jhaveri Jay K, Tan Gerald Y M, Scherr Douglas S, Tewari Ashutosh K
James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, New York, New York 10065, USA.
J Endourol. 2008 Nov;22(11):2475-9. doi: 10.1089/end.2008.0280.
Since the advent of immunosuppressive therapy, patients have been able to lead longer lives as transplant recipients. We report the first case of robot-assisted laparoscopic prostatectomy in the renal allograft recipient.
A 54-year-old man presented with Gleason 3+3 localized prostate cancer with a prostatespecific antigen level of 8.5 ng/mL. He had a history of end-stage renal failure secondary to fulminant acute pyelonephritis necessitating bilateral nephrectomy. Renal allograft transplant in the right iliac fossa was performed in 1981, with adequate renal function while continuing his immunosuppressant regime. The patient also had previous left inguinal herniorrhaphy. Modifications to our surgical approach include placement of a bariatric port superiolaterally to the standard port site; siting the left port inferiolaterally to provide adequate access for pelvic lymph node dissection; and developing the retropubic space largely from the contralateral side to avoid allograft injury. Extensive adhesiolysis was also needed. After negative urethral margin reported on frozen section, vesicourethral anastomosis was fashioned using our Cornell bladder neck anatomic reconstruction technique.
The patient needed a postoperative transfusion of 1 unit of blood and was discharged on postoperative day 2 after recommencement of immunosuppression. The final pathology report revealed pT(2c) Gleason 7 (3+4) disease and negative surgical margins. Continence was recovered within the first week of catheter removal, and erections sufficient for penetration occurred before 6-week follow-up in the clinic.
Robot-assisted radical prostatectomy is feasible in the carefully selected renal allograft recipient with favorable oncologic, continence, and potency outcomes.
自免疫抑制疗法出现以来，移植受者能够活得更长。我们报告了首例肾移植受者接受机器人辅助腹腔镜前列腺切除术的病例。
一名54岁男性，Gleason评分3+3的局限性前列腺癌，前列腺特异性抗原水平为8.5 ng/mL。他有暴发性急性肾盂肾炎继发终末期肾衰竭病史，需行双侧肾切除术。1981年在右髂窝进行了肾移植，肾功能良好，同时继续使用免疫抑制剂。患者既往有左侧腹股沟疝修补术史。我们手术方法的改进包括：在标准端口位置的上外侧放置一个肥胖症专用端口；将左侧端口置于下外侧，以便为盆腔淋巴结清扫提供足够的操作空间；主要从对侧分离耻骨后间隙以避免移植肾损伤。还需要广泛的粘连松解。冰冻切片报告尿道切缘阴性后，采用我们的康奈尔膀胱颈解剖重建技术进行膀胱尿道吻合。
患者术后需要输注1单位血液，在重新开始免疫抑制治疗后第2天出院。最终病理报告显示为pT(2c) Gleason 7（3+4）期疾病，手术切缘阴性。拔除导尿管后的第一周内恢复了控尿功能，在术后6周门诊随访前勃起功能足以进行性交。
对于经过精心挑选的肾移植受者，机器人辅助根治性前列腺切除术是可行的，在肿瘤学、控尿和性功能方面均有良好的结果。
