Nachsorge nach Blasenersatzoperationen

Zusammenfassung

Ein Blasenersatz wird zumeist nach radikaler Zystektomie wegen eines Urothelkarzinoms der Harnblase erforderlich. Neben der Tumornachsorge (lokales, urethrales und systemisches Rezidiv, Tumorauftreten im oberen Harntrakt) ist eine funktionelle Nachsorge der Harnableitung erforderlich. Die diesbezüglichen Leitlinienempfehlungen sind noch lückenhaft. Durch lange Kontaktzeit und große Oberfläche in kontinenten Pouches aus Darmsegmenten kann die Resorption von Harnbestandteilen zu Elektrolytstörungen und Azidosen führen. Entscheidend für die Kompensation ist die Nierenfunktion. Die Ausschaltung langstreckiger Ileumsegmente aus der Darmpassage kann zu Malabsorption von Vitamin B₁₂ und Gallensäuren führen. Jeweils bis über 30 % der Langzeitüberlebenden nach Zystektomie mit kontinenten Ersatzblasen substituieren Bicarbonat und Vitamin B₁₂. Besondere Aufmerksamkeit ist auch dem oberen Harntrakt, der Nierenfunktion und der Entwicklung von Sekundärmalignomen zu widmen. Sekundärmalignome treten gehäuft in Sigma-Rektum-Pouches, Blasenaugmentationen und Ersatzblasen mit Inkorporation von Kolonanteilen auf. In der Nachsorge ist es wichtig, die spezifischen Komplikationsmöglichkeiten der verschiedenen Harnableitungsformen zu berücksichtigen.

Abstract

Surgical replacement of the urinary bladder is usually necessary after radical cystectomy for muscle invasive bladder cancer. Besides uro-oncological follow-up (local, urethral, and systemic recurrence; tumor in the upper tract) functional follow-up of the urinary diversion is indicated. Guidelines are still scarce. Long contact time and large surface area in continent pouches made from long intestinal segments lead to absorption of contents of urine and thus to acidosis and imbalances in serum electrolytes. Compensation depends on renal function. Exclusion of long ileal segments out of the intestinal passage may lead to malabsorption of Vitamin B₁₂ and bile acids. 30 % and more of long-term survivors with continent pouches take Vitamin B₁₂ and sodium bicarbonate. Special attention has to be paid to obstruction of the upper urinary tract, total renal function and to secondary malignancy in the bladder substitute. For the latter, sigma-rectum pouches, augmentation cystoplasties and continent pouches with incorporation of colonic segments are at special risk. Functional follow-up affords good understanding of the specific complications of the different types of urinary diversions.

Schlüsselwörter

Blasenkarzinom - Harnableitung - Nachsorge - Metabolik - Azidose - Conduit - Pouch

Key words

bladder cancer - urinary diversion - follow-up - metabolism - acidosis - conduit - pouch

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