EURURO Vol. 73 No. 1

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early diagnosis. Cancer-specific and overall survival rates
were similar between dialysed and transplanted patients
).
The conclusion of this systematic review highlights the
requirement for regular annual monitoring of the native
kidney in CKD patients and particularly those with a history
of RCC. The reference treatment for a cancer of the native
kidneys is radical nephrectomy.
4.3.2. Prostate cancer
In this systematic review, the main prognostic factors for
recurrence were: stage, prostate-specific antigen, and
Gleason score. Radical prostatectomy is the preferred
treatment both for staging and curative purposes. Lymph
node resection may be best limited to one side of the pelvis
to preserve the iliac vessels for the transplantation on the
other side Transperineal prostatectomy could also be
an option to preserve the iliac vessels .
The studies reported low recurrence rates consistent
with prognostic nomograms. In the Tillou et al study,
the risk of biochemical recurrence at 10 yr, calculated using
the Memorial Sloan Kettering Cancer Center nomogram did
not exceed 3% in the worst case and was 1–2% in all other
cases. This nomogram has proven its reliability in other
studies on large cohorts. The nomogram allowed registra-
tion of patients on the transplantation waiting list at an
earlier stage, whilst radical prostatectomy made the
decision to put the patient on the transplant list easier.
The authors reported no recurrence with a mean follow-up
of 3.2 yr, suggesting that there could be no waiting period
for transplantation in cases of cured low-risk PC .
In their study, Woodle et al (which was an update of the
PC series published by Penn in 1995 and 1997 ) included a
significant number of high-risk extraprostatic tumours.
Despite its shortcomings, this study is still unequalled for
the study of high-risk PC before transplantation
4.3.3. Urothelial carcinoma (bladder and upper urinary tract
urothelial carcinoma)
The included studies showed that UUTUC has a high risk of
recurrence. The risk of synchronous bilateral involvement is
10–16% and the risk of contralateral recurrence is 31 –39%
. For candidates for transplantation with a history
of UUTUC, two strategies are justified:
1. Systematic treatment of the contralateral upper urinary
tract and/or the bladder by nephroureterectomy and/or
even cystectomy;
2. Close monitoring of the bladder and the contralateral
upper urinary tract.
4.3.4. Testicular cancer
The level of evidence reported in this study did not allow us
to conclude on the risk of testicular tumour recurrence after
renal transplantation. The two case reports highlighted the
risk of retroperitoneal recurrence after transplantation,
even with a long waiting period ). A case-by-case
discussion is needed to decide on a period of exclusion
before transplantation.
4.4. Implications for research
Although the findings of this systematic review enabled us
to identify the prognostic factors of recurrence and to
conclude that immunosuppression did not modify the
natural history of urological cancer for selected patients,
the literature in this particular area differed according to the
type of cancer. With the exception of Tillou et al
(19 patients), we found no comparative study for PC. There
were few studies on bladder cancer, with no data
concerning the stage (tumour invading the vesical muscle
or not) and the use of adjuvant intravesical therapy.
In practice, it appears to be difficult to evaluate the
excess risk of recurrence represented by the initiation of
immunosuppressive therapy and thus the possible delete-
rious impact of transplantation on recurrence and cancer-
specific survival. Randomised controlled trials will ethically
and logistically be difficult to conduct. However, well-
designed prospective cohort studies with homogenous
type/stage of cancer and clear predefined oncological
outcomes at different time points are needed to strongly
support a reduction of the waiting period for low-risk RCC
and PC, which was a tendency suggested in this systematic
review.
4.5. Limitations of this study
This report is the first systematic review assessing and
appraising all available evidence of the risk of cancer
recurrence for CKD patients on dialysis or who have
undergone transplantation. Limitations mainly consist in
the low level of the references:
The included studies are all retrospective and most of
them are not comparative. As such, the RoB and/or
confounding is high in most studies.
Long-term follow-up is lacking. Several data were not
systematically reported: prognostic score or monograms,
duration, and type of immunosuppressive treatment,
type of recurrence (local or systemic). For PC, the
oncological results of nontransplanted patients were
based on only six patients in two studies.
For urothelial tumours, the majority of studies included
UUTUC occurring in the particular field of aristolochic
acid nephropathy.
4.6. Conclusions
Although this systematic review summarised all the
available evidence on renal transplantation and history of
cancer, it was limited by the level of evidence of the
included studies, which mainly consisted of noncompara-
tive retrospective cohort studies of preselected patients.
Acknowledging that the comparison is not free from bias,
this systematic review indicates that immunosuppression
does not seem to alter the natural history of recurrence and
mortality for low-risk renal and PC, and could lead to a
shortening of the waiting period in this specific situation.
For high-risk renal and PC, the historical Cincinnati registry
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