Skip to main content
SpringerLink
Log in

Radikale Zystektomie und Harnableitung – worauf kommt es an?

Radical cystectomy and urinary diversion—what is important ?

  • Leitthema
  • Published:
Der Urologe Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Die radikale Zystektomie (rCx) stellt nach wie vor die häufigste Therapieoption beim lokal begrenzten muskelinvasiven Urothelkarzinom in Deutschland dar. Verschiedene Modifikationen in der prä-, peri- und postoperativen Phase haben zu einer deutlichen Verbesserung des Outcomes geführt.

Ziel der Arbeit

Die vorliegende Arbeit soll einen guten Überblick über die aktuelle Datenlage hinsichtlich einer optimalen Vorbereitung und Durchführung der rCx mit anschließender Harnableitung bei Patienten mit Harnblasenkarzinom geben.

Material und Methoden

Hinsichtlich der Vorbereitung, der Durchführung der rCx sowie der anschließenden Harnableitung erfolgten jeweils separate Datenanalysen.

Ergebnisse

Die Zeit von der Indikation bis zur Durchführung der rCx sollte optimal genutzt werden. Hierbei ist insbesondere auf die frühzeitige Einstellung von Komorbiditäten zu achten. Zahlreiche ERAS-(„enhanced recovery after surgery“) und Fast-track-Konzepte sollten fester Bestandteil des therapeutischen Managements sein. Bei der Durchführung der rCx mit Anlage einer Neoblase spielt der Erhalt der Kontinenz und der Erektionsfähigkeit eine besondere Rolle. Gerade die Behandlung in einem spezialisierten Zentrum mit hoher Fallzahl kann hier zu einer Verbesserung des Outcomes führen. Auch die rCx mit intra- oder extrakorporaler Harnableitung wird inzwischen in minimal-invasiver roboterassistierter Technik durchgeführt.

Diskussion

Bei der rCx mit folgender Harnableitung ist es sinnvoll und notwendig nach neuen Möglichkeiten zur weiteren Reduktion von Komplikationen zu suchen und damit einhergehend eine Verbesserung des Outcomes sowie der Lebensqualität unserer Patienten zu erreichen.

Abstract

Background

In Germany, radical cystectomy with urinary diversion is the primary therapeutic option for localized muscle invasive urothelial bladder cancer. Modifications in the pre-, peri-, and postoperative phase have significantly improved outcomes.

Objectives

Different factors and parameters are directly associated with patients’ outcome. An overview on how to best approach this procedure is provided in this article.

Materials and methods

The data regarding preparation and the procedure for the radical cystectomy followed by urinary diversion are separately analyzed.

Results

During the preoperative phase, Fast Track and ERAS (Enhanced Recovery after Surgery) concepts should be an integral part of therapeutic management. Different aspects of such models are presented and discussed. Comorbidities such as diabetes mellitus, hypertension, malnutrition or anemia should also be treated early. In the perioperative phase, optimized fluid management and close interaction with the anesthesiologist are needed. Use of vasopressors during surgery and controlled hypotension (about 80 mm Hg) help reduce perioperative blood loss. Blood product use should be minimized. The use of epidural anesthesia to improve the stress reaction of the body improves pain management and functional recovery. Radical cystectomy is associated with the best oncological outcome, preserving functional structures to maintain a good quality of life. Nerve-sparing procedures in men and women should be used where appropriate. The use of robotic assisted radical cystectomy (RARC) is also discussed.

Conclusion

The ileum conduit is still the most common urinary diversion worldwide. However, numerous other urinary diversions to provide patients with the highest quality of life are available. Centers with a high case load seem to be associated with an improved outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  1. Ahmadi H, Lee CT (2015) Health-related quality of life with urinary diversion. Curr Opin Urol 25:562–569

    Article  PubMed  Google Scholar 

  2. Ali AS, Hayes MC, Birch B et al (2015) Health related quality of life (HRQoL) after cystectomy: comparison between orthotopic neobladder and ileal conduit diversion. Eur J Surg Oncol 41:295–299

    Article  PubMed  CAS  Google Scholar 

  3. Aziz A, May M, Burger M et al (2014) Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Eur Urol 66:156–163

    Article  PubMed  Google Scholar 

  4. Berger I, Wehrberger C, Ponholzer A et al (2015) Impact of the use of bowel for urinary diversion on perioperative complications and 90-day mortality in patients aged 75 years or older. Urol Int 94:394–400

    Article  PubMed  Google Scholar 

  5. Bochner BH, Sjoberg DD, Laudone VP et al (2014) A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med 371:389–390

    Article  PubMed  CAS  Google Scholar 

  6. Buchner A, Grimm T, Schneevoigt BS et al (2017) Dramatic impact of blood transfusion on cancer-specific survival after radical cystectomy irrespective of tumor stage. Scand J Urol 51:130–136

    Article  PubMed  Google Scholar 

  7. Carli F, Kehlet H, Baldini G et al (2011) Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med 36:63–72

    Article  PubMed  CAS  Google Scholar 

  8. Cody JD, Nabi G, Dublin N et al (2012) Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD003306.pub2

    Article  PubMed  Google Scholar 

  9. Collins JW, Hosseini A, Adding C et al (2017) Early recurrence patterns following totally Intracorporeal robot-assisted radical cystectomy: results from the EAU Robotic urology section (ERUS) scientific working group. Eur Urol 71:723–726

    Article  PubMed  Google Scholar 

  10. Colombo R, Pellucchi F, Moschini M et al (2015) Fifteen-year single-centre experience with three different surgical procedures of nerve-sparing cystectomy in selected organ-confined bladder cancer patients. World J Urol 33:1389–1395

    Article  PubMed  CAS  Google Scholar 

  11. Davis NF, Burke JP, Mcdermott T et al (2015) Bricker versus Wallace anastomosis: a meta-analysis of ureteroenteric stricture rates after ileal conduit urinary diversion. Can Urol Assoc J 9:E284–E290

    Article  PubMed  PubMed Central  Google Scholar 

  12. Deliveliotis C, Papatsoris A, Chrisofos M et al (2005) Urinary diversion in high-risk elderly patients: modified cutaneous ureterostomy or ileal conduit? Urology 66:299–304

    Article  PubMed  CAS  Google Scholar 

  13. Geschwend JE, Heck MM, Lehmann J et al (2016) Limited versus extended pelvic lymphadenectomyin patients with bladder cancer undergoing radical cystectomy: survival results from randomized trail (LEA AUO AB 25/02, NCTO1215071). JCO 34(suppl):abstr 4503

    Article  Google Scholar 

  14. Gierth M, Mayr R, Aziz A et al (2015) Preoperative anemia is associated with adverse outcome in patients with urothelial carcinoma of the bladder following radical cystectomy. J Cancer Res Clin Oncol 141:1819–1826

    Article  PubMed  CAS  Google Scholar 

  15. Goossens-Laan CA, Leliveld AM, Verhoeven RH et al (2014) Effects of age and comorbidity on treatment and survival of patients with muscle-invasive bladder cancer. Int J Cancer 135:905–912

    Article  PubMed  CAS  Google Scholar 

  16. Gschwend J, Retz M, Kuebler H (2010) Indications and oncological outcome of radical cystectomy for urothelial bladder cancer. Eur Urol 9:10–18

    Article  Google Scholar 

  17. Hollenbeck BK, Miller DC, Taub D et al (2004) Aggressive treatment for bladder cancer is associated with improved overall survival among patients 80 years old or older. Urology 64:292–297

    Article  PubMed  Google Scholar 

  18. Johnson EU, Singh G (2013) Long-term outcomes of urinary tract reconstruction in patients with neurogenic urinary tract dysfunction. Indian J Urol 29:328–337

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  19. Karl A, Rittler P, Buchner A et al (2009) Prospective assessment of malnutrition in urologic patients. Urology 73:1072–1076

    Article  PubMed  Google Scholar 

  20. Karl A, Buchner A, Becker A et al (2014) A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study. J Urol 191:335–340

    Article  PubMed  CAS  Google Scholar 

  21. Kim SP, Boorjian SA, Shah ND et al (2012) Contemporary trends of in-hospital complications and mortality for radical cystectomy. BJU Int 110:1163–1168

    Article  PubMed  Google Scholar 

  22. Leissner J, Hohenfellner R, Thuroff JW et al (2000) Lymphadenectomy in patients with transitional cell carcinoma of the urinary bladder; significance for staging and prognosis. BJU Int 85:817–823

    Article  PubMed  CAS  Google Scholar 

  23. Maffezzini M, Campodonico F, Capponi G et al (2012) Fast-track surgery and technical nuances to reduce complications after radical cystectomy and intestinal urinary diversion with the modified Indiana pouch. Surg Oncol 21:191–195

    Article  PubMed  Google Scholar 

  24. Nygren J, Thacker J, Carli F et al (2013) Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced Recovery After Surgery (ERAS((R))) Society recommendations. World J Surg 37:285–305

    Article  PubMed  CAS  Google Scholar 

  25. Pang KH, Groves R, Venugopal S et al (2017) Prospective implementation of enhanced recovery after surgery protocols to radical cystectomy. Eur Urol pii:S0302-2838(17)30660-7. https://doi.org/10.1016/j.eururo.2017.07.031

    Article  Google Scholar 

  26. Pillai P, Mceleavy I, Gaughan M et al (2011) A double-blind randomized controlled clinical trial to assess the effect of Doppler optimized intraoperative fluid management on outcome following radical cystectomy. J Urol 186:2201–2206

    Article  PubMed  Google Scholar 

  27. Pycha A, Comploj E, Martini T et al (2008) Comparison of complications in three incontinent urinary diversions. Eur Urol 54:825–832

    Article  PubMed  Google Scholar 

  28. Rodriguez AR, Lockhart A, King J et al (2011) Cutaneous ureterostomy technique for adults and effects of ureteral stenting: an alternative to the ileal conduit. J Urol 186:1939–1943

    Article  PubMed  Google Scholar 

  29. Roghmann F, Ravi P, Hanske J et al (2015) Perioperative outcomes after radical cystectomy at NCI-designated centres: are they any better? Can Urol Assoc J 9:207–212

    Article  PubMed  PubMed Central  Google Scholar 

  30. Tyritzis SI, Wiklund NP (2018) Is the open cystectomy era over? An update on the available evidence. Int J Urol 25(3):187. https://doi.org/10.1111/iju.13497

    Article  PubMed  Google Scholar 

  31. Tyson MD, Chang SS (2016) Enhanced recovery pathways versus standard care after cystectomy: a meta-analysis of the effect on perioperative outcomes. Eur Urol 70:995–1003

    Article  PubMed  PubMed Central  Google Scholar 

  32. Udovicich C, Perera M, Huq M et al (2017) Hospital volume and perioperative outcomes for radical cystectomy: a population study. BJU Int 119(Suppl 5):26–32

    Article  PubMed  Google Scholar 

  33. Walsh PC, Marschke P, Ricker D et al (2000) Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 55:58–61

    Article  PubMed  CAS  Google Scholar 

  34. Witjes AJ, Lebret T, Comperat EM et al (2017) Updated 2016 EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Urol 71:462–475

    Article  Google Scholar 

  35. Xia L, Guzzo TJ (2017) Preoperative anemia and low hemoglobin level are associated with worse clinical outcomes in patients with bladder cancer undergoing radical cystectomy: a Meta-analysis. Clin Genitourin Cancer 15:263–272.e4

    Article  PubMed  Google Scholar 

  36. Yuh B, Wilson T, Bochner B et al (2015) Systematic review and cumulative analysis of oncologic and functional outcomes after robot-assisted radical cystectomy. Eur Urol 67:402–422

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Urologische Universitätsklinik, Marien Hospital Herne, Ruhr-Universität Bochum, Herne, Deutschland

    J. Noldus

  2. Klinik für Urologie, Medizinische Fakultät, Heinrich-Heine-Universität, Düsseldorf, Deutschland

    G. Niegisch

  3. Urologische Abteilung, Landeskrankenhaus Bozen, Bozen, Italien

    A. Pycha

  4. Medizinische Fakultät, Sigmund Freud Privatuniversität, Wien, Österreich

    A. Pycha

  5. Urologische Klinik und Poliklinik, Blasentumorklinik, Ludwig-Maximilians-Universität-München, Campus Großhadern, LMU, Marchioninistr. 15, 81377, München, Deutschland

    A. Karl

Authors
  1. J. Noldus
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. G. Niegisch
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. A. Pycha
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Karl
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to A. Karl.

Ethics declarations

Interessenkonflikt

J. Noldus, G. Niegisch, A. Pycha und A. Karl geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Noldus, J., Niegisch, G., Pycha, A. et al. Radikale Zystektomie und Harnableitung – worauf kommt es an?. Urologe 57, 673–678 (2018). https://doi.org/10.1007/s00120-018-0648-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00120-018-0648-9

Schlüsselwörter

Keywords

Search

Navigation