Palliative chirurgische Therapieoptionen beim kastrationsresistenten Prostatakarzinom

Zusammenfassung

LHRH-Analoga oder Antagonisten stellen das Mittel der Wahl beim metastasierten Prostatakarzinom dar. Trotz anfänglich meist guten Ansprechens hat diese Therapie nur einen palliativen Charakter und führt unweigerlich nach durchschnittlich 1,5 bis 2,5 Jahren zur Entwicklung eines kastrationsresistenten Prostatakarzinoms (KRPCA). In diesem Fall stehen neben der klassischen Taxan-basierten Chemotherapie, die sekundäre Hormonablation mit Enzalutamid und Abirateron, Sipuleucel T sowie Radium 223 als neuere Therapieverfahren zur Verfügung. Aufgrund der dadurch – je nach Therapieansprechen – verlängerten Überlebenszeit gewinnen behandlungswürdige Komplikationen durch das lokal progrediente KRPCA, Lokalrezidive oder pelvine Lymphknotenmetasen 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 Ureterneoimplantation, 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

If prostate cancer recurs after primary treatment, deprivation therapy with LHRH analogues or antagonists is the treatment of choice in men with metastatic prostate cancer. However, this treatment only achieves palliative results. Median time to progression ranges between 11 and 78 months. After the introduction of Docetaxel as a first-line treatment in castration-resistant prostate cancer (CRPCA) and cabazitaxel as a second-line chemotherapy, several new drugs containing abiraterone, enzalutamide, radium 223 and sipuleucel-T have become available, which can lead to complete or partial remissions in metastasis, but do not have an effect on the prostate itself as has been shown recently. As a result of local progression of CRPCA, local complications of the urinary tract such as subvesical obstruction, recurrent gross haematuria with or without clotting, upper urinary tract dilatation, rectourethral or rectovesical fistulae and rectal obstruction will occur in about one third of all patients. Several surgical treatment options are available to manage the aforementioned complications. In patients with local progressive CRPCA and lower urinary tract symptoms, palliative TUR-P, radical prostatectomy or radical cystoprostatectomy with urinary diversion and even anterior and posterior exenteration can be performed in selected patients, requiring a preoperative multiparametric MRI of the prostate and the pelvic floor along with a laboratory examination to optimise surgical techniques and perioperative outcomes. In case of symptomatic involvement of the upper urinary tract system, the placement of endoluminal DJ stents or percutaneous nephrostomy in men with a poor performance status and a short life expectancy is the treatment of choice. In men with an ECOG performance status of 0 to 1, reconstructive surgery such as ureteral reimplantation, ileal ureteral replacement or placement of a subcutaneous pyelovesical bypass is an appropriate treatment option.

To summarise, the aforementioned palliative surgical treatment options should be provided for selected patients and performed by well-experienced urologists.

Schlüsselwörter

Prostatakarzinom - kastrationsresistentes Prostatakarzinom - radikale Prostatektomie - radikale Zystoprostatektomie - Ureterneoimplantation

Keywords

prostate cancer - radical prostatectomy - ureteral reimplantation - castration-resistant prostate cancer - radical cystoprostatectomy

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