Robot-assisted laparoscopic radical prostatectomy after heart transplantation
A 54-year-old Caucasian male with a past history of doxorubicin (therapy for neck sarcoma in the 1980s) induced non-ischemic dilated cardiomyopathy diagnosed on endomyocardial biopsy in 1995 was initially seen in the urology clinic for evaluation of an elevated serum prostate specific antigen (PSA). Since the time of diagnosis of his cardiomyopathy, the patient had a progressive worsening of his cardiac function, ultimately requiring orthotropic cardiac allograft in 2007. He has had excellent post-transplant graft function with a recent echocardiogram showing an ejection fraction of 50% and a New York Heart Association functional class of I. His maintenance immunosuppression included cyclosporine, mycophenolate mofetil and prednisone.\nRoutine laboratory assessment revealed that the patient had an elevated PSA of 9.1 ng/ml with a past history of rising PSA (a year before, his PSA was 3 ng/ml). Under appropriate pre-procedure prophylaxis, he underwent an uncomplicated 12-core prostate biopsy that revealed Gleason's 7 (4 + 3) adenocarcinoma of the prostate in 3/12 cores. After a long discussion with his spouse, primary care physician and his cardiologist, the patient decided to undergo RALRP with bilateral lymphadenectomy.\nOn the morning of his surgery, the patient took all his home medication and withheld aspirin with the permission of his cardiologist for 10 days. Preoperatively, the patient received broad-spectrum antibiotic prophylaxis (ciprofloxacin and cefazolin) and stress doses of steroids. He had an arterial line placed and two peripheral IVs. Anesthesia was induced with fentanyl and maintained with isoflurane. He was placed in the dorsal lithotomy with extreme Trendelenberg position. A bilateral nerve sparing robot-assisted laparoscopic prostatectomy (RALP) with bilateral pelvic lymph node dissection was performed in the manner as previously described.[] A urethral catheter and an anastomotic drain were left in place.\nPostoperatively, the patient was monitored on the floor with telemetry and his antibiotic prophylaxis was continued for 24 hours. The stress doses of steroids were continued for 24 hours and then he was weaned back to his preoperative dose. His drain was removed on postoperative day 2 and he was ultimately discharged home on postoperative day 3 without complications and with his urethral catheter. His urethral catheter was removed in clinic on postoperative day 10. The specimen was consistent with bilateral adenocarcinoma of the prostate (Gleason 4 + 3 = 7) with extensive perineural invasion and negative tumor margins and the pathologic tumor stage was pT2cN0M0. The follow-up PSA at 30 months was undetectable. Patient achieved continence in 6 weeks. Patient was very keen to have recovery of sexual functions; in order to achieve that, he was inducted on sexual rehabilitation program using a combination of vacuum constriction device and a phosphodiesterase (PDE-5) in hibitor. He is currently under regular follow-up of cardiology team.