Retzius‐sparing robot‐assisted radical prostatectomy in renal transplant recipients

Abstract

Prostate cancer is the most prevalent non-skin solid malignancy among male renal transplant recipients. Curative treatment options for localised prostate cancer include robot-assisted radical prostatectomy (RARP) and radiotherapy. The largest multicentre study of transperitoneal RARP post-renal transplant included 41 men treated across four European centres between 2009 and 2019 [1]. While the standard anterior approach is feasible, it poses risks of damaging the transplant kidney and the vesico-ureteric anastomosis during anterior dissection and development of the space of Retzius. Since Galfano et al. [2] published the first series of Retzius-sparing RARP (RS-RARP) involving 200 patients in 2013, the technique whereby the key anterior structures of the bladder such as the endopelvic fascia, dorsal vascular complex (DVC), arcus tendineus, levator ani muscle, pubo-prostatic and pubo-vesical ligaments are preserved has gained popularity [3, 4]. The Milan team reported early continence rates of 92% and low 1-year biochemical recurrence rates. Over the next decade, RS-RARP, despite its technical complexity, was increasingly adopted worldwide. A 2022 meta-analysis comparing RS-RARP with standard RARP, incorporating four randomised controlled trials and six prospective observational studies, found that RS-RARP was associated with significantly better continence at 3 and 6 months [5]. The use of RS-RARP can be viewed as a safer option for renal transplant recipients [6], as it avoids any dissection close to the transplant kidney, which is usually located in either the left or right iliac fossa. Here, we provide a step-by-step guide on how to perform an RS-RARP in renal transplant recipients. The diagnostic evaluation for prostate cancer in renal transplant patients mirrors that conducted for the general male population. A biopsy-confirmed prostate cancer diagnosis and a serum total PSA test within 3 months of surgery are essential. Cross-sectional imaging, including prostate MRI, is crucial for local and systemic staging. MRI provides detailed information about prostate anatomy, volume, membranous urethral length, and tumour foci, aiding surgical planning and patient counselling. For instance, nerve-sparing techniques might be omitted if high-grade cancer or capsular bulging is evident on imaging. Additionally, a CT scan can delineate the relationship between the transplant kidney, bladder, and prostate, facilitating surgical safety. A step-by-step video is provided (Video S1) to illustrate the procedure. In our practice, we start with a supra-umbilical incision to gain intra-abdominal access via Hasson's technique for camera port insertion. A transverse abdominis plane (TAP) block is administered under direct vision, injecting 0.375% bupivacaine to anaesthetise the anterior abdominal wall nerves (T6 to L1), reducing intra- and postoperative pain. To avoid injury to the transplanted kidney, the assistant is positioned on the contralateral side of the transplant. Two robotic ports ipsilateral to the transplanted kidney are placed; the right port is in a traditional position, and the fourth arm situated mid-way between the camera port and the right arm, ~5 cm cranial, mirroring the 5-mm assistant port (Fig. 1). Lastly, a 12-mm assistant port is placed two finger-breadths above the anterior superior iliac spine, on the contralateral side to the transplanted kidney. An AirSeal® device (Lawmed, ConMed) connected to the 12-mm valveless assistant port maintains a more consistent intra-abdominal pressure intra-operatively. As increased intra-abdominal pressure during robotic surgery can pose a risk to a transplanted kidney due to reduced renal perfusion, we typically set a pressure of 10 mmHg throughout most of the operation, and increase this transiently to 20 mmHg during the dissection through the DVC. Patients are placed in a steep Trendelenburg position. The sigmoid colon is separated from any adhesions, then a peritoneal incision is ma