Palliative Urologische Chirurgie des metastasierten Prostatakarzinoms: was müssen wir zukünftig berücksichtigen?

Zusammenfassung

Die kombinierte Androgendeprivation mit einem neuen Androgenrezeptor-Biosyntheseinhibitor, dem Zytostatikum Docetaxel oder der Kombination mit Abirateron/Prednison plus Docetaxel bzw. Darolutamid plus Docetaxel stellen die Therapie der Wahl des metastasierten hormonsensitiven Prostatakarzinoms (mHSPC) dar. Trotz des meist guten Ansprechens hat diese Therapie nur einen palliativen Charakter und führt unweigerlich nach durchschnittlich 2,5–4 Jahren zur Entwicklung eines kastrationsresistenten Prostatakarzinoms (CRPC). In diesem Fall stehen neben der klassischen taxanbasierten Chemotherapie, die sekundäre Hormonablation, die Radionuklidtherapie mit Radium 223 oder 177Lu-PSMA als neuere Therapieverfahren zur Verfügung. Aufgrund der dadurch – je nach Therapieansprechen – verlängerten Überlebenszeit gewinnen behandlungswürdige Komplikationen durch das lokal progrediente CRPC, Lokalrezidive oder pelvine Lymphknotenmetastasen zunehmend an Bedeutung.

Treten Komplikationen des unteren Harntrakts wie rezidivierende transfusionspflichtige Makrohämaturien mit oder ohne Blasentamponade, eine subvesikale Obstruktion mit der Notwendigkeit einer Harnableitung oder rektourethrale/rektovesikale Fisteln auf, stehen als palliative chirurgische Therapieoptionen die palliative TUR-P, die radikale (Zysto-)Prostatektomie mit entsprechender Harnableitung sowie die posteriore Exenteration bei rektaler Infiltration zur Verfügung. Bei Harnstauungsnieren aufgrund einer supravesikalen Obstruktion stehen je nach Erlebenserwartung und Allgemeinzustand des Patienten die Anlage einer endoluminalen Ureterschiene oder perkutanen Nephrostomie sowie chirurgisch rekonstruktive Maßnahmen wie die Ureterneuimplantation, Ureter-Ileum-Interponat oder Implantation eines Detour-Systems als Therapieoptionen zur Verfügung.

Letztlich stellt die palliative Tumorchirurgie ein individuelles Therapiekonzept dar, welches bei sorgfältiger Patientenselektion und adäquater chirurgischer Expertise zu einer Verbesserung der Lebensqualität und lokalen Tumorkontrolle führen kann.

Abstract

Androgen deprivation in combination with novel hormonal agents, docetaxel or the combination of abiraterone/prednisone plus docetaxel or darolutamide plus docetaxel represent the standard therapeutic approach in metastatic hormone-sensitive prostate cancer (mHSPC). Patients with low-risk prostate cancer also benefit from additional radiation therapy or radical prostatectomy in terms of progression-free and overall survival. Despite favourable response rates, basically all patients will develop castration-resistant prostate cancer (CRPC) within 2.5 to 4 years. Systemic chemotherapy, second-line hormonal treatment or systemic application of radionuclides such as Radium-223 or 177Lu-PSMA represent salvage management options. As the new medical treatment options have led to an improved oncological outcome with significantly prolonged survival times, about 50% to 65% of patients will develop symptoms due to local progression of prostate cancer. The management of such symptomatic local progression will become more important in upcoming years, which means that all uro-oncologists need to be aware of the various surgical management options.

If complications of the lower urogenital tract occur, for example repetitive gross haematuria with or without bladder clotting and with the necessity for red blood cell transfusions, subvesical obstruction, acute urinary retention or rectourethral or rectovesical fistulas, these may be managed by palliative surgery such as palliative TURP, radical cystectomy, radical cystoprostatectomy with urinary diversion, and pelvic exenteration. Symptomatic or asymptomatic obstruction of the upper urinary tract can be managed by endoluminal or percutaneous urinary diversion, ureteral reimplantation, ileal ureter replacement, or implantation of a Detour system.

However, an individualised and risk-adapted treatment strategy needs to be developed for each single patient to achieve an optimal therapeutic outcome with improvement of both symptoms and quality of life. In specific clinical situations, best supportive care may be an adequate option.

Schlüsselwörter

hormonsensitives Prostatakarzinom - kastrationsresistentes Prostatakarzinom - radikale Zystoprostatektomie - Ureterneuimplantation - Detour – System

Keywords

radical cystoprostatectomy - ureteral reimplantation - Detour system - ureter ileum interposition - castration-resistant prostate cancer

Publication History

Received: 14 November 2023

Accepted: 29 November 2023

Article published online:
17 January 2024

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