title: Modifications to facilitate extraperitoneal robot-assisted radical prostatectomy post kidney transplant.
abstract: BACKGROUND
  Renal transplantation is the treatment of choice for patients with end-stage renal failure. With advances in immunosuppression, the short-term and long-term outcome has improved significantly. Subsequently, urologists are encountering more transplant recipients with genitourinary malignancies, and therefore urologists are becoming increasingly compelled to offer curative treatment options.
  
  
  METHODS
  We present modifications to facilitate E-RARP in these patients that include modified trocar arrangement, delayed bladder neck transection, utilizing the robotic Hem-o-lok applier, and posterior reconstruction of the anastomosis using a barbed V-loc suture. A 68-year-old male with a history of polycystic kidney disease, end-stage renal failure, and an allograft renal transplantation in the right iliac fossa, presented with T1c, Gleason 3+4 prostate cancer. He had a preoperative PSA of 6.93ng/mL, ASA score of 3, and a BMI of 26kg/m2. Follow-up for metastasis (MRI and bone scan) was negative. E-RARP was performed via the extraperitoneal approach using a 5-port 2-arm approach at an insufflation pressure of 10 mm Hg.
  
  
  RESULTS
  The radical prostatectomy was successfully performed. Ureterovesical anastomosis was completed, and total console time was 130 minutes, with an estimated blood loss of 125mL. Final pathology was T2bNx, Gleason 3+4 with negative surgical margins. The patient was discharged with no change in serum creatinine or GFR. The catheter was removed on POD 10 with no intraoperative or immediate postoperative complications.
  
  
  CONCLUSIONS
  E-RARP in the carefully selected renal allograft recipient is feasible and accomplished safely with technical modifications to avoid injuring the renal allograft, transplanted ureter, and ureteroneocystostomy.
authors.affiliation: Department of Urology, University of Rochester Medical Center, Rochester, New York 14642, USA. ahmed_ghazimd@yahoo.com
authors.forename: Ahmed
authors.initials: A
authors.lastname: Ghazi
authors.forename: Erdal
authors.initials: E
authors.lastname: Erturk
authors.forename: Jean V
authors.initials: JV
authors.lastname: Joseph
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000368:Aged; D000714:Anastomosis, Surgical; D006801:Humans; D016867:Immunocompromised Host; D007327:Insufflation; D016030:Kidney Transplantation; D008279:Magnetic Resonance Imaging; D008297:Male; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D012371:Robotics; D014184:Transplantation, Homologous; D014513:Ureter / Q000601:surgery; D001743:Urinary Bladder / Q000601:surgery