„Do’s and Dont’s“ bei der radikalen Zystektomie und Harnableitung: Minimierung von postoperativen Komplikationen

Zusammenfassung

Die radikale Zystektomie (RC) mit Anlage einer Harnableitung (HA) ist ein umfangreicher und anspruchsvoller abdomineller Eingriff. Es bestehen durch die Operation selbst sowie aufgrund patientenindividueller Komorbiditäten erhebliche periinterventionelle Risiken. Das mögliche Komplikationsspektrum ist groß und muss von den beteiligten Behandlern beherrscht werden. Zur Erreichung eines optimalen onkologischen und funktionellen Ergebnisses sind multiple Faktoren zu beachten. Diese „DOs“ reichen von der leitliniengerechten Indikationsstellung über möglichst standardisierte perioperative Maßnahmen bis hin zur Anwendung optimaler und etablierter chirurgischer Techniken bei der Resektion der Harnblase und der Rekonstruktion der Harnableitung. Alle Maßnahmen haben das Ziel, die Komplikationsrate der RC zu minimieren und die Rehabilitation zu beschleunigen. Wir fassen in diesem Artikel wichtige Handlungsempfehlungen sowie zu vermeidende Praktiken des perioperativen Managements („Don’ts“) bei der Zystektomie und Harnableitung zusammen.

Abstract

Radical cystectomy (RC) with urinary diversion is a challenging surgical intervention. There is significant risk of postoperative complications, particularly linked to urinary diversion and the patient’s comorbidities. The surgeon and the multidisciplinary team need to be familiar with all potential complications. In order to achieve optimal oncological and functional outcomes, multiple factors have to be considered during perioperative management, including the adherence to evidence-based guidelines, standardised concepts of enhanced recovery and best surgical practice for RC and urinary diversion. All measures should aim to minimise complication rates after RC and to accelerate recovery. We summarise essential Dos and Don’ts when performing RC with different forms of urinary diversion.

Schlüsselwörter

Harnblasenkarzinom - Tumoren des Urogenitaltraktes - Radikale Zystektomie - Harnableitung - Komplikationen

Keywords

urothelial bladder cancer - neoplasms of the urinary tract - radical cystectomy - urinary diversion - postoperative complications

Publication History

Received: 04 October 2021

Accepted after revision: 14 January 2022

Article published online:
16 February 2022

• Literatur

• 1 Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft DK, AWMF): S3-Leitlinie Früherkennung, Diagnose, Therapie und Nachsorge des Harnblasenkarzinoms, Langversion 2.0. S3-Leitlinie Früherkennung, Diagnose, Therapie und Nachsorge des Harnblasenkarzinoms; Langversion 1.1. https://www.leitlinienprogramm-onkologie.de/fileadmin/user_upload/Downloads/Leitlinien/Blasenkarzinom/Version_2.0/LL_Harnblasenkarzinom_Langversion_2.0.pdf 2020
• 2 Cerantola Y, Valerio M, Persson B. et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS((R))) society recommendations. Clin Nutr 2013; 32: 879-887 DOI: 10.1016/j.clnu.2013.09.014. (PMID: 24189391)
• 3 Frees SK, Aning J, Black P. et al. A prospective randomized pilot study evaluating an ERAS protocol versus a standard protocol for patients treated with radical cystectomy and urinary diversion for bladder cancer. World J Urol 2018; 36: 215-220 DOI: 10.1007/s00345-017-2109-2. (PMID: 29116394)
• 4 Liu B, Domes T, Jana K. Evaluation of an enhanced recovery protocol on patients having radical cystectomy for bladder cancer. Can Urol Assoc J 2018; DOI: 10.5489/cuaj.527310.5489/cuaj.5273.
• 5 Vlad O, Catalin B, Mihai H. et al. Enhanced recovery after surgery (ERAS) protocols in patients undergoing radical cystectomy with ileal urinary diversions: A randomized controlled trial. Medicine (Baltimore) 2020; 99: e20902 DOI: 10.1097/MD.0000000000020902. (PMID: 32629682)
• 6 Witjes JA, Bruins HM, Cathomas R. et al. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines. Eur Urol 2021; 79: 82-104 DOI: 10.1016/j.eururo.2020.03.055. (PMID: 32360052)
• 7 Woo S, Panebianco V, Narumi Y. et al. Diagnostic Performance of Vesical Imaging Reporting and Data System for the Prediction of Muscle-invasive Bladder Cancer: A Systematic Review and Meta-analysis. Eur Urol Oncol 2020; 3: 306-315 DOI: 10.1016/j.euo.2020.02.007. (PMID: 33575545)
• 8 Kiss B, Furrer MA, Wuethrich PY. et al. Stenting Prior to Cystectomy is an Independent Risk Factor for Upper Urinary Tract Recurrence. J Urol 2017; 198: 1263-1268 DOI: 10.1016/j.juro.2017.06.020. (PMID: 28603003)
• 9 Satkunasivam R, Hu B, Metcalfe C. et al. Utility and significance of ureteric frozen section analysis during radical cystectomy. BJU Int 2016; 117: 463-468 DOI: 10.1111/bju.13081. (PMID: 25684323)
• 10 Gschwend JE, Heck MM, Lehmann J. et al. Extended Versus Limited Lymph Node Dissection in Bladder Cancer Patients Undergoing Radical Cystectomy: Survival Results from a Prospective, Randomized Trial. Eur Urol 2019; 75: 604-611 DOI: 10.1016/j.eururo.2018.09.047. (PMID: 30337060)
• 11 Gschwend JE. Hautmann ileal neobladder. Aktuelle Urol 2009; 40: 367-382 DOI: 10.1055/s-2009-1233500. (PMID: 19899017)
• 12 Parekh DJ, Reis IM, Castle EP. et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet 2018; 391: 2525-2536 DOI: 10.1016/S0140-6736(18)30996-6. (PMID: 29976469)
• 13 Faba OR, Tyson MD, Artibani W. et al. Update of the ICUD-SIU International Consultation on Bladder Cancer 2018: urinary diversion. World J Urol 2019; 37: 85-93 DOI: 10.1007/s00345-018-2484-3. (PMID: 30238399)
• 14 Hautmann RE. Declining Use of Orthotopic Reconstruction Worldwide-What Went Wrong?. J Urol 2018; 199: 900-903 DOI: 10.1016/j.juro.2017.10.031. (PMID: 29074221)
• 15 Hautmann RE, Botto H, Studer UE. How to Obtain Good Results with Orthotopic Bladder Substitution: The 10 Commandments. Eur Urol Suppl 2009; 8: 712-717
• 16 Aboumohamed AA, Raza SJ, Al-Daghmin A. et al. Health-related quality of life outcomes after robot-assisted and open radical cystectomy using a validated bladder-specific instrument: a multi-institutional study. Urology 2014; 83: 1300-1308 DOI: 10.1016/j.urology.2014.02.024. (PMID: 24746661)
• 17 Check DK, Leo MC, Banegas MP. et al. Decision Regret Related to Urinary Diversion Choice among Patients Treated with Cystectomy. J Urol 2020; 203: 159-163 DOI: 10.1097/JU.0000000000000512. (PMID: 31441673)
• 18 Cody JD, Nabi G, Dublin N. et al. Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy. Cochrane Database Syst Rev 2012; DOI: 10.1002/14651858.CD003306.pub2. (PMID: 22336788)
• 19 Kristjansson A, Wallin L, Mansson W. Renal function up to 16 years after conduit (refluxing or anti-reflux anastomosis) or continent urinary diversion. 1. Glomerular filtration rate and patency of uretero-intestinal anastomosis. Br J Urol 1995; 76: 539-545 DOI: 10.1111/j.1464-410x.1995.tb07775.x. (PMID: 8535669)