Systematische Übersichtsarbeit: aortale Komplikationen nach intravesikaler Bacillus Calmette-Guérin-Behandlung

Zusammenfassung

Hintergrund Aortale Pathologien nach intravesikaler BCG-Applikation (BCG: Bacillus Calmette-Guérin) stellen eine seltene Komplikation nach der Behandlung von nicht muskelinvasiven Harnblasentumoren dar. Das Ziel dieser Studie war es, eine deskriptive Analyse der bisher publizierten Studien im Rahmen einer systematischen Übersichtsarbeit durchzuführen und die besonderen Herausforderungen der Diagnosestellung und Behandlung dieser seltenen Komplikation zu diskutieren.

Material und Methode Es erfolgte eine Literaturrecherche in den Datenbanken PubMed (1949–2021) und Web of Science (1900–2021) mit den Suchtermini „mycobacterium“ OR „bovis“ OR „BCG“ AND „aorta“ OR „aneurysm“. In einem stufenweisen Bewertungsverfahren wurden Publikationen mit folgenden Einschlusskriterien in die finale Datenauswertung eingeschlossen: Originalarbeit, Volltextverfügbarkeit in englischer oder deutscher Sprache und aortale Komplikation nach intravesikaler BCG-Instillation.

Ergebnisse In 55 publizierten Arbeiten wurden insgesamt 60 Einzelfälle beschrieben. BCG-induzierte, mykotische Aortenaneurysmen können in allen Segmenten der Aorta auftreten, wobei das infrarenale Aortensegment am häufigsten betroffen war (65% aller Fälle). Häufig handelte es sich um sakkuläre (65%) Aussackungen mit (28%) oder ohne Aortenruptur (63%). Begleitinfektionen in anderweitigen Geweben waren typisch (65%). Die Diagnose beruhte auf der Kombination aus pathologischen und mikrobiologischen Analysemethoden. Ein gängiger Therapiealgorithmus war die chirurgische Infektsanierung (85%) und die antimykobakterielle Therapie (83%). Gleichzeitig durchgeführt führten sie zu einem Langzeitüberleben von 81%. Eine Protheseninfektion nach initialem Aortenrepair mit alloplastischem Material (n = 40) entwickelte sich im Verlauf bei 10 Patienten (25%).

Diskussion Die Diagnosestellung beruht auf der Probengewinnung jeglichen infizierten Gewebes und der Kombination aus passender Anamnese, Klinik und Laboranalysen. Die Kombination aus chirurgischer Infektsanierung und pharmakologischer Begleittherapie scheint die besten Ergebnisse zu erzielen. Bereits bei der Initialoperation sollte die Möglichkeit eines autologen oder allogenen Aortenersatzes evaluiert werden, da das Risiko eines Protheseninfektes nach Verwendung alloplastischer Materialien hoch ist.

Abstract

Background Aortic complications after intravesical Bacillus Calmette-Guérin (BCG) application are a rare complication of the treatment of non-muscle invasive bladder cancer. The aim of this systematic review was to perform a descriptive analysis of previously published studies and to discuss the particular challenges of diagnosis and treatment of this rare complication.

Material and Methods A literature search was performed in PubMed (1949–2021) and Web of Science (1900–2021) using the search terms “mycobacterium” OR “bovis” OR “BCG” AND “aorta” OR “aneurysm”. In a staged review process, publications with the following inclusion criteria were included in data analysis: original paper, full-text availability in English or German and aortic complication after intravesical BCG instillation. We focused on the analysis of BCG-specific medical history data as well as treatment strategies in relation to patient outcome and the occurrence of graft infections during follow-up.

Results A total of 60 individual cases were described in 55 published articles. BCG-induced mycotic aortic aneurysms can occur in all segments of the thoracoabdominal aorta, but the infrarenal aortic segment was most commonly affected (65% of cases). The most common configuration was saccular outpouchings (65%). Concomitant infections in other tissues were typical (65%). Patients with mycotic aneurysm presented with or without consecutive aortic rupture in 28% and 63%, respectively. Diagnosis was based on a combination of pathological and microbiological examinations. A common treatment algorithm was surgical infection treatment (85%) and antitubercular therapy (83%). Performed simultaneously, they resulted in a long-term survival of 81%. Graft infection after initial aortic repair with alloplastic material (n = 40) developed in ten patients (25%) during follow-up.

Discussion Diagnosis of mycotic aneurysms or vascular complications after intravesical BCG application is exceptionally challenging and a high level of suspicion is required. Diagnosis is based on obtaining sample material of affected regions and the combination of patient’s history, clinical presentation and pathological or microbiological examinations. Currently, no consensus guideline for optimal medical treatment options of aortic complications secondary to BCG instillation exists. The combination of surgical treatment and supportive antitubercular therapy seems to achieve the best results. Since the risk of prosthetic infection after the use of alloplastic materials remains high (25%), we strongly suggest evaluating autologous or allogenic aortic replacement during initial aortic repair.

Schlüsselwörter

Aortenaneurysma - mykotisches Aortenaneurysma - Mycobacterium bovis - BCG - Harnblasenkarzinom - systematische Übersichtsarbeit

Keywords

mycotic aneurysm - mycobacterium bovis - BCG - bladder cancer - systematic review - Aortic aneurysm

Publication History

Received: 23 May 2021

Accepted after revision: 08 August 2021

Article published online:
19 October 2021

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