Nutzen und Risiko des orthotopen Harnblasenersatzes bei Frauen

Zusammenfassung

Die Anlage eines orthotopen Harnblasenersatzes nach radikaler Zystektomie ist eine gängige Therapieoption bei Patientinnen mit invasiven Harnblasenkarzinom. Langzeitdaten belegen die onkologische Sicherheit sowohl im lokal begrenzten als auch im lokal-fortgeschrittenen Tumorstadium. Durch den zusätzlichen Einsatz nerverhaltender Verfahren kann nach aktuellen Studien im lokal begrenzten Tumorstadium eine signifikante Verbesserung der postoperativen Kontinenz und sexuellen Funktion ohne Einschränkungen in der onkologischen Sicherheit erzielt werden. Als eine der wichtigsten Kontraindikation für die Durchführung eines orthotopen Harnblasenersatzes gilt das Vorhandensein eines positiven intraoperativen Schnellschnittbefundes der distalen Urethraabsetzung. Das Risiko für ein urethrales Rezidiv nach Neoblasenanlage bei negativem intraoperativen Schnellschnittergebnis liegt bei ≤ 1 % und kann aufgrund veränderter Lymphabflusswege nach Neoblasenanlage frühzeitig in Form einer inguinalen Lymphknotenmetastasierung klinisch apparent werden. Nach aktuellen Arbeiten liegt das 5-Jahres rezidivfreie Überleben bei Patientinnen mit nodal-negativen, lokal begrenzten oder lokal-fortgeschrittenen Harnblasenkarzinom nach orthotopen Harnblasenersatz bei 75 % und 71 % und unterscheidet sich auch lymphknotenmetastasierten Stadium bei Patientinnen mit Neoblase nicht signifikant zu Patientinnen mit einer kutanen Harnableitungsform. Die Kontinenzraten bei Frauen mit orthotopen Blasenersatz werden tagsüber zwischen 82–96 % und nachts zwischen 57–72 % berichtet. Inwieweit durch den Einsatz roboterassistierter Verfahren eine Verbesserung der funktionellen Ergebnisse nach offener Zystektomie erzielt werden kann, bleibt insbesondere bei noch ausstehenden onkologischen Langzeitergebnissen abzuwarten und sollte im Rahmen prospektiver Studien weiter untersucht werden. 

Abstract

Orthotopic neobladder reconstruction is an established treatment option in female patients undergoing radical cystectomy for invasive bladder cancer. Long-term results have proven its oncological safety and functional efficacy in both organ-confined and locally advanced disease. The use of nerve-sparing procedures has the potential to further improve the functional results in terms of postoperative continence and sexual function as long as we adhere to basic oncological principles. One important contraindication for performing neobladder reconstruction in female patients with bladder cancer is a positive urethral margin at radical cystectomy. In this respect, frozen section analysis is associated with a high sensitivity and specificity for the detection of positive urethral margins. The risk of urethral recurrence at 5 years in patients with negative urethral margins at cystectomy is ≤ 1 % and may become clinically apparent as inguinal lymphadenopathy due to changes of the lymphatic drainge after neobladder reconstruction. The 5-year recurrence-free survival after neobladder reconstruction in female patients with organ-confined bladder cancer ranges between 63 and 75 %. In female patients with locally advanced node-negative disease (≥ pT3a–4a, pN0) who underwent an orthotopic neobladder the recurrence free survival at 5 years is 71 % and so does not significantly differ from that of female patients with node-positive disease treated with an cutaneous diversion. Whether robotic cystectomy has the potential to further improve the functional outcome after neobladder reconstruction in female patients and achieve oncological long-term results comparable to those of open series is still under investigation should further be evaluated in prospective trials. 

Schlüsselwörter

Neoblase - Frau - onkologisch - funktionell - Langzeitergebnisse

Key words

neobladder - female - functional results - oncological results - long-term results

Literatur

• 1 Stenzl A, Cowan N C, De Santis M et al. The updated EAU guidelines on muscle-invasive and metastatic bladder cancer.  Eur Urol. 2009;  55 815-825
• 2 Gakis G, Stenzl A. Ileal neobladder and its variants.  Eur Urol Suppl. DOI: 10.1016/J.eursup.2010.10.001
• 3 Le Duc A, Camey M. A procedure for avoiding reflux in uretero-ileal implantations during enterocystoplasty.  J Urol Nephrol (Paris). 1979;  85 449-454
• 4 Gerber W L. Is urethral sparing at cystectomy a safe procedure?.  Urology. 1990;  36 303-304
• 5 Stenzl A, Colleselli K, Poisel S. Rationale and technique of nerve sparing radical cystectomy before an orthotopic neobladder procedure in women.  J Urol. 1995;  154 2044-2049
• 6 Stenzl A, Colleselli K, Poisel S et al. The use of neobladders in women undergoing cystectomy for transitional-cell cancer.  World J Urol. 1996;  14 15-21
• 7 Stein J P, Cote R J, Freeman J A et al. Indications for lower urinary tract reconstruction in women after cystectomy for bladder cancer: a pathological review of female cystectomy specimens.  J Urol. 1995;  154 1329-1333
• 8 Chen M E, Pisters L L, Malpica A et al. Risk of urethral, vaginal and cervical involvement in patients undergoing radical cystectomy for bladder cancer: results of a contemporary cystectomy series from M. D. Anderson Cancer Center.  J Urol. 1997;  157 2120-2123
• 9 Chang S S, Hassan J M, Cookson M S et al. Delaying radical cystectomy for muscle invasive bladder cancer results in worse pathological stage.  J Urol. 2003;  170 1085-1087
• 10 Hautmann R E, Paiss T. Does the option of the ileal neobladder stimulate patient and physician decision toward earlier cystectomy?.  J Urol. 1998;  159 1845-1850
• 11 Schilling D, Horstmann M, Nagele U et al. Cystectomy in women.  BJU Int. 2008;  102 1289-1295
• 12 Stenzl A, Colleselli K, Bartsch G. Update of urethra-sparing approaches in cystectomy in women.  World J Urol. 1997;  15 134-138
• 13 Stein J P, Penson D F, Wu S D et al. Pathological guidelines for orthotopic urinary diversion in women with bladder cancer: a review of the literature.  J Urol. 2007;  178 756-760
• 14 Stein J P, Esrig D, Freeman J A et al. Prospective pathologic analysis of female cystectomy specimens: risk factors for orthotopic diversion in women.  Urology. 1998;  51 951-955
• 15 Stenzl A, Draxl H, Posch B et al. The risk of urethral tumors in female bladder cancer: can the urethra be used for orthotopic reconstruction of the lower urinary tract?.  J Urol. 1995;  153 950-955
• 16 Akkad T, Gozzi C, Deibl M et al. Tumor recurrence in the remnant urothelium of females undergoing radical cystectomy for transitional cell carcinoma of the bladder: long-term results from a single center.  J Urol. 2006;  175 1268-1271
• 17 Stenzl A, Jarolim L, Coloby P et al. Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors.  Cancer. 2001;  92 1864-1871
• 18 Yamashita S, Hoshi S, Ohyama C et al. Urethral recurrence following neobladder in bladder cancer patients.  Tohoku J Exp Med. 2003;  199 197-203
• 19 Stein J P, Penson D F, Lee C et al. Long-term oncological outcomes in women undergoing radical cystectomy and orthotopic diversion for bladder cancer.  J Urol. 2009;  181 2052-2058
• 20 Colleselli K, Stenzl A, Eder R et al. The female urethral sphincter: a morphological and topographical study.  J Urol. 1998;  160 49-54
• 21 Stenzl A, Colleselli K, Poisel S et al. Anterior exenteration with subsequent ureteroileal urethrostomy in females. Anatomy, risk of urethral recurrence, surgical technique, and results.  Eur Urol. 1998;  33 18-20
• 22 Arai Y, Okubo K, Konami T et al. Voiding function of orthotopic ileal neobladder in women.  Urology. 1999;  54 44-49
• 23 Stenzl A, Sherif H, Kuczyk M. Radical cystectomy with orthotopic neobladder for invasive bladder cancer: a critical analysis of long term oncological, functional and quality of life results.  Int Braz J Urol. 2010;  36 537-547
• 24 Meyer J P, Blick C, Arumainayagam N et al. A three-centre experience of orthotopic neobladder reconstruction after radical cystectomy: revisiting the initial experience, and results in 104 patients.  BJU Int. 2009;  103 680-683
• 25 Granberg C F, Boorjian S A, Crispen P L et al. Functional and oncological outcomes after orthotopic neobladder reconstruction in women.  BJU Int. 2008;  102 1551-1555
• 26 Hautmann R E, Paiss T, de Petriconi R. The ileal neobladder in women: 9 years of experience with 18 patients.  J Urol. 1996;  155 76-81
• 27 Stein J P, Dunn M D, Quek M L et al. The orthotopic T pouch ileal neobladder: experience with 209 patients.  J Urol. 2004;  172 584-587
• 28 Bhatt A, Nandipati K, Dhar N et al. Neurovascular preservation in orthotopic cystectomy: impact on female sexual function.  Urology. 2006;  67 742-745
• 29 Chiva L M, Lapuente F, Núñez C et al. Ileal orthotopic neobladder after pelvic exenteration for cervical cancer.  Gynecol Oncol. 2009;  113 47-51
• 30 Hautmann R E, de Petriconi R, Volkmer B G. Neobladder formation after pelvic irradiation.  World J Urol. 2009;  27 57-62
• 31 Stolzenburg J U, Schwalenberg T, Liatsikos E N et al. Colon pouch (Mainz III) for continent urinary diversion.  BJU Int. 2007;  99 1473-1477
• 32 Minervini A, Boni G, Salinitri G et al. Evaluation of renal function and upper urinary tract morphology in the ileal orthotopic neobladder with no antireflux mechanism.  J Urol. 2005;  173 144-147
• 33 Stenzl A, Hobisch A, Strasser H et al. Ureteroileal anastomosis in orthotopic urinary diversion: how much or how little is necessary?.  Tech Urol. 2001;  7 188-195
• 34 Skinner E C, Skinner D. Does reflux in orthotopic diversion matter? A randomized prospective comparison of the Studer and T-pouch ileal neobladders.  World J Urol. 2009;  27 51-55
• 35 Dindo D, Demartines N, Clavien P A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6 336 patients and results of a survey.  Ann Surg. 2004;  240 205-213
• 36 Hautmann R E, de Petriconi R, Volkmer B G. Lessons learned from 1000 neobladders: the 90-day complication rate.  J Urol. 2010;  184 990-994
• 37 Novara G, De Marco V, Aragona M et al. Complications and mortality after radical cystectomy for bladder transitional cell cancer.  J Urol. 2009;  182 914-921
• 38 Eisenberg M S, Dorin R P, Bartsch G et al. Early complications of cystectomy after high dose pelvic radiation.  J Urol. 2010;  184 2264-2269
• 39 Nix J, Smith A, Kurpad R et al. Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results.  Eur Urol. 2010;  57 196-201
• 40 Pruthi R S, Nielsen M E, Nix J et al. Robotic radical cystectomy for bladder cancer: surgical and pathological outcomes in 100 consecutive cases.  J Urol. 2010;  183 510-514
• 41 Ng C K, Kauffman E C, Lee M M et al. A comparison of postoperative complications in open versus robotic cystectomy.  Eur Urol. 2010;  57 274-281
• 42 Haber G P, Crouzet S, Gill I S. Laparoscopic and robotic assisted radical cystectomy for bladder cancer: a critical analysis.  Eur Urol. 2008;  54 54-62
• 43 Gakis G, Stenzl A. Editorial comment on: a comparison of postoperative complications in open versus robotic cystectomy.  Eur Urol. 2010;  57 281-282
• 44 Berger A, Aron M. Laparoscopic radical cystectomy: long-term outcomes.  Curr Opin Urol. 2008;  18 167-172
• 45 Hautmann R E. The oncologic results of laparoscopic radical cystectomy are not (yet) equivalent to open cystectomy.  Curr Opin Urol. 2009;  19 522-526
• 46 Kauffman E C, Ng C K, Lee M M et al. Early oncologic outcomes for bladder urothelial carcinoma patients treated with robotic-assisted radical cystectomy.  BJU Int. DOI: 10.1111/j.1464–410X.2010.09577.x.
• 47 Hobisch A, Tosun K, Kinzl J et al. Life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion.  Semin Urol Oncol. 2001;  19 18-23
• 48 Porter M P, Penson D F. Health related quality of life after radical cystectomy and urinary diversion for bladder cancer: a systematic review and critical analysis of the literature.  J Urol. 2005;  173 1318-1322
• 49 Large M C, Katz M H, Shikanov S et al. Orthotopic neobladder versus Indiana pouch in women: a comparison of health related quality of life outcomes.  J Urol. 2010;  183 201-206
• 50 Somani B K, Gimlin D, Fayers P et al. Quality of life and body image for bladder cancer patients undergoing radical cystectomy and urinary diversion – a prospective cohort study with a systematic review of literature.  Urology. 2009;  74 1138-1143