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
Dr. med. G. Gakis
Klinik für Urologie · Universitätsklinikum Tübingen
Hoppe-Seyler Straße 3
72076 Tübingen
Phone: 00 49 / 70 71 / 2 98 50 92
Fax: 00 49 / 70 71 / 29 50 92
Email: georgios.gakis@med.uni-tuebingen.de
