Robot-Assisted Radical Prostatectomy in a Heart Transplant Patient

Literature on major urological surgery in heart transplant recipients remains limited because these patients historically had shorter life expectancies, limiting long-term surgical follow-up. However, advances in medical care, immunosuppressive therapy, and patient management have prolonged survival, increasing the incidence of age-related diseases, including prostate cancer. This intersection of cardiac transplantation and urological disease presents unique clinical challenges requiring further study of optimal surgical and postoperative management. Heart transplant patients receiving lifelong tacrolimus-based immunosuppression are particularly prone to impaired wound healing and postoperative complications. The authors report a 71-year-old man who underwent heart transplantation in November 2015 for ischemic cardiomyopathy. His immunosuppressive regimen included tacrolimus (target trough 5-7 µg/L), mycophenolate mofetil, and low-dose steroids. The patient underwent robot-assisted radical prostatectomy (RARP) with bilateral pelvic lymphadenectomy for prostate adenocarcinoma (iPSA 9.3 ng/mL). Histopathology revealed pT3b pN1 (5/30) Gleason 7b (4 + 3, 80% + 20%) disease with negative margins. Recovery was initially uneventful, and he was discharged on postoperative day 5, catheter-free after spontaneous micturition. Fifteen days postoperatively, the patient was readmitted with acute flank pain. Imaging demonstrated left ureteral extravasation. Review of the surgical recording excluded thermal injury during lymphadenectomy, suggesting tacrolimus-associated impaired healing as a possible cause. Management included placement of a double-J stent, antibiotics, and cardiac monitoring. Because urinary drainage remained insufficient, urinary diversion with a Mono-J stent and percutaneous nephrostomy (PCN) was performed, considering the patient's cardiologic risk profile. A cystogram demonstrated minimal secondary urethrovesical anastomotic insufficiency, possibly related to endourological manipulation, although tacrolimus-associated healing impairment could not be excluded. The Mono-J stent and the nephrostomy catheter were removed after 2 and 3 months, respectively, following complete ureteral healing. Secondary percutaneous radiotherapy with androgen deprivation therapy was recommended. This case demonstrates the feasibility of RARP in heart transplant recipients while highlighting the potential impact of immunosuppressive therapy on postoperative healing.