case report

Management of Squamous Bladder Cancer post Bladder-drained Kidney-Pancreas Transplantation

Mariangela Mancini1,2*, Alessandro Morlacco1,2, Federico Goffo1,2 , Cristina Silvestre1,3, Paolo Rigotti1,3, Massimo Iafrate1,2, and Fabrizio Dal Moro1,2

1 Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy

2 Urological Clinic, University Hospital of Padova, Padova, Italy

3 Kidney-Pancreas Unit, University Hospital of Padova, Padova, Italy

*Corresponding author: Mariangela Mancini, Urological Surgeon, University Hospital of Padova, Via Giustiniani, 2, 35121 Padova, Italy

Received Date: 19 August, 2022

Accepted Date: 05 September, 2022

Published Date: 08 September 2022

Citation: Mancini M, Morlacco A, Goffo F, Silvestre C, Rigotti P, et al. (2022) Management of Squamous Bladder Cancer post Bladder-drained Kidney-Pancreas Transplantation. J Urol Ren Dis 07: 1278. DOI: https://doi.org/10.29011/2575-7903.001278.

Abstract

A 53-year-old female patient with a previous kidney-pancreatic transplant connected to the bladder, developed muscle-invasive bladder cancer with direct invasion of the duodenal wall of the transplant. A curative approach was undertaken, with radical cystectomy with ileal conduit diversion and pancreatic-duodenal graft explant, with excellent oncological and clinical outcomes. Bladder cancer following kidney-pancreas transplant with bladder drainage is rare with only a few cases reported in the literature. However, it is crucial in these cases not to underestimate symptoms such as hematuria or dysuria, in order to avoid a diagnostic delay. The rare case we report highlights the importance of fast management of this challenging clinical condition, without delay and with radical intent.

Introduction

Kidney-Pancreas Transplantation (KPT) is a procedure performed in patients with type 1 diabetes mellitus complicated by End-Stage Renal Disease (ESRD). This procedure improves the quality of life of the patients and decreases the mortality rate. After transplantation, exocrine pancreatic secretion can be drained to the bowel or via the bladder. The latter implies the implantation of a whole pancreas graft, with a duodenal segment forming a side-to-side anastomosis to the bladder. In this paper we report about a case of muscle-invasive urothelial cancer involving the bladder and the transplanted duodenum in a patient who had previously undergone KPT with bladder drainage.

Keywords: Bladder cancer; Cystectomy; Kidney-pancreas transplant; Squamous cancer

Case Report

C.R., a 53 year-old woman suffering from type 1 diabetes mellitus, underwent kidney transplantation in 1996 for ESRD, after dialytic treatment. In 2002 she received a pancreatic transplantation; the pancreaticoduodenal graft was anastomosed to the bladder for the exocrine drainage (pancreas-duodeno-cystostomy). In 2000 she underwent VLS surgical removal of an ovarian cyst, in 2002 she had two transitory ischemic episodes treated with aspirin; two laser treatments for diabetic retinopathy; hypothyroidism in replacement therapy and, in 2018, surgical correction of an incisional hernia. The immunosuppressive therapy included 2 mg/day of tacrolimus, 720 mg/day of mycophenolic acid and 5mg of prednisone every other day. In June 2019, the patient went to the Emergency Room with hematuria and dysuria. Abdomen US showed parietal thickening on the right posterolateral side of the bladder, with evidence of clots. A cystoscopy was performed and showed the presence of a bladder tumor. Trans-urethral resection of the bladder tumor (TURBT), performed elsewhere, documented a high-grade muscle-invasive transitional cell carcinoma (TCC), with squamous aspects and Carcinoma in Situ (CIS). The patient came at this point to our attention and was admitted to the Urology, part of the ERN eUROGEN, a European network for treatment of rare and complex urological conditions [1]. A rigid cystoscopy under anaesthesia showed the presence of neoplasia in the bladder lumen, reaching the anastomosis of the pancreaticoduodenal graft. A contrast-enhanced CT-scan (Figure 1) showed the bladder with neoplastic wall, atrophic native kidneys and no hydroureteronephrosis in the renal graft. Complete angiographic rendering was obtained in order to have clear information on the vascular anatomy of the grafts. A radical cystectomy with ileal conduit diversion and pancreatic-duodenal graft explant was performed (Figure 2: intraoperative view). The bladder with the pancreas-duodenum graft was isolated and the bladder-duodenum anastomosis was resected. The sample was sent for frozen section, showing a squamocellular infiltration. This, due to oncological reasons, requested the explant of the whole graft (Figure 3). The ureter of the kidney graft and the native ureters were isolated and accurately dissected from the bladder. The ureteral sections, sent for extemporaneous histological exams, were negative for neoplastic infiltration. Radical cystectomy and ileal conduit according to Wallace technique was performed. Pelvic lymph node dissection was carried out with the limitations of the presence of the kidney graft. Only the ureter of the transplanted kidney was anastomosed, while the two native ureters were ligated due to absence of residual diuresis from the native atrophic kidneys.

Operative time was 360 minutes with a blood loss of 1000 mL, three blood units were transfused during the surgical time. The postoperative course was characterized by challenging glycemic peaks, which required multiple adjustments of insulin doses, and difficult pain management. 24 days after surgery the patient was discharged in good clinical conditions. Definitive histologic examination showed an invasive urothelial and squamous carcinoma of the bladder, with infiltration of the detrusor muscle, the peripheric fat tissue (pT3b pN0), and the duodenum of the pancreatic graft. No adjuvant chemotherapy treatment was advised due to the post-transplantation status and multiple comorbidities. The patient is alive and disease-free at follow-up after 36 months.

Figure 1: Contrast-enhanced CT scan.