Operative Therapie des Harnblasenkarzinoms: Fortschritte der letzten 50 Jahre

Zusammenfassung

Innerhalb der letzten 5 Jahrzehnte wurden bei der operativen Therapie des Harnblasenkarzinoms enorme Behandlungsfortschritte erzielt. Diese haben die Morbidität und Mortalität der Erkrankung deutlich reduziert. Neben einem kontinuierlich zunehmenden Verständnis der Tumorbiologie trugen zu einer erfolgreicheren Behandlung viele Neuentwicklungen endoskopischer Instrumente und Methoden sowie neue chirurgische Techniken für die radikale Zystektomie (RZ) bei. Durch eine bessere klinisch-pathologische Risikostratifizierung der Patienten stehen mittlerweile unterschiedliche Behandlungspfade zur Verfügung. Diese reichen von wiederholten endoskopischen Resektionen über eine risikoadaptierte adjuvante Instillationstherapie bis hin zur RZ, die darüber hinaus Bestandteil eines multimodalen kurativen Konzeptes sein kann. Zum 50-jährigen Jubiläum der Aktuellen Urologie geben wir einen Überblick über die wichtigsten Fortschritte seit dem Jahr 1969 und die aktuellen Entwicklungen bei der operativen Therapie des Harnblasenkarzinoms. Moderne endoskopische Bildgebungsverfahren („enhanced cystoscopy“) und das molekulare Subtyping verbessern die Risikoeinschätzung. Außerdem bestehen erste Erfahrungen mit der roboterassistierten RZ, neue Tendenzen zur Standardisierung von Techniken, ein verbessertes perioperatives Management sowie Initiativen zur Qualitätsmessung von funktionellem und onkologischem Outcome. All diese Entwicklungen werden die Lebensqualität und die Heilungsraten von Patienten mit einem Harnblasenkarzinom weiter verbessern.

Abstract

The past 5 decades have seen major advances in the surgical treatment of bladder cancer, which have significantly reduced the morbidity and mortality of the disease. Enhanced understanding of tumour biology as well as a large number of newly developed endoscopic instruments and techniques have contributed to making treatment more successful. Moreover, modified and improved surgical techniques of radical cystectomy have been implemented and the clinical and pathological risk stratification of patients has been improved. Hence, patients are treated differently according to risk groups. Treatment algorithms range from repeated transurethral resections to adjuvant intravesical therapy to radical cystectomy, which may be part of a multimodal approach with curative intent. Celebrating the 50th anniversary of “Aktuelle Urologie”, we summarise the most important advances in the treatment of BC since 1969 and report some current trends. Modern endoscopic imaging techniques (“enhanced cystoscopy”) and molecular subtyping of BC may further improve risk stratification. Moreover, some initial experience has been made with robot-assisted radical cystectomy, and there are new trends for the standardisation of techniques, concepts of enhanced recovery after surgery, as well as initiatives for the measurement of surgical quality and patient-reported outcomes. We believe that all these current developments may help to further improve the quality of life and therapeutic outcome of patients with BC.

Schlüsselwörter

Harnblasenkarzinom - Urothelkarzinom - chirurgische Therapie - Tumoren des Urogenitaltraktes - Harnableitung

Keywords

bladder cancer - urothelial carcinoma - surgical treatment - neoplasms of the urinary tract - urinary diversion

• Literatur

• 1 Sylvester RJ, van der Meijden AP, Oosterlinck W. et al. Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials. Eur Urol 2006; 49: 466-465
• 2 Babjuk M, Böhle A, Burger M. et al. EAU Guidelines on Non-Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol 2017; 71: 447-461
• 3 Kriegmair M, Baumgartner R, Knuechel R. et al. Fluorescence photodetection of neoplastic urothelial lesions following intravesical instillation of 5-aminolevulinic acid. Urology 1994; 44: 836-841
• 4 Kausch I, Sommerauer M, Montorsi F. et al. Photodynamic diagnosis in non–muscle-invasive bladder cancer: a systematic review and cumulative analysis of prospective studies. Eur Urol 2010; 57: 595-606
• 5 Grossman HB, Stenzl A, Fradet Y. et al. Long-term decrease in bladder cancer recurrence with hexaminolevulinate enabled fluorescence cystoscopy. J Urol 2012; 188: 58-62
• 6 Gakis G, Fahmy O. Systematic Review and Meta-Analysis on the Impact of Hexaminolevulinate- Versus White-Light Guided Transurethral Bladder Tumor Resection on Progression in Non-Muscle Invasive Bladder Cancer. Bladder Cancer 2016; 2: 293-300
• 7 Kriegmair MC, Ritter M, Michel MS. et al. Modern endoscopic imaging tools for urothelial carcinoma of the urinary bladder. Aktuelle Urol 2017; 48: 296-305
• 8 Simon G. Über die Methoden, die weibliche Urinblase zugänglich zu machen und über die Sondierung des Harnleiters beim Weibe. Sammlung klin Vortr, Leipzig 1875; 88: 674
• 9 Iglesias JJ, Fiore G. Iglesias resectoscope with simultaneous irrigation, suction and low intravesical pressure. Eur Urol 1975; 1: 251-254
• 10 Jurewicz M, Soloway MS. Approaching the optimal transurethral resection of a bladder tumor. Turkish Journal of Urology 2014; 40: 73-77
• 11 Denholm S, Conn I, Newsam J. et al. Morbidity following cystoscopy: comparison of flexible and rigid techniques. British journal of urology 1990; 66: 152-154
• 12 Kramer MW, Altieri V, Hurle R. et al. Current Evidence of Transurethral En-bloc Resection of Nonmuscle Invasive Bladder Cancer. Eur Urol Focus 2017; 3: 567-576
• 13 Bialek L, Poletajew S, Magusiak PM. et al. Bimanual palpation for staging of bladder cancer-clinical use and its predictors. Turk J Urol 2018; 45: 22-26
• 14 Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft DK, AWMF). S3-Leitlinie Früherkennung, Diagnose, Therapie und Nachsorge des Harnblasenkarzinoms, Langversion 1.1. http://leitlinienprogramm-onkologiede/Harnblasenkarzinom920html 2016
• 15 Naselli A, Hurle R, Paparella S. et al. Role of Restaging Transurethral Resection for T1 Non-muscle invasive Bladder Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus 2018; 4: 558-567
• 16 Oosterlinck W, Kurth KH, Schröder F. et al. A prospective European Organization for Research and Treatment of Cancer Genitourinary Group randomized trial comparing transurethral resection followed by a single intravesical instillation of epirubicin or water in single stage Ta, T1 papillary carcinoma of the bladder. J Urol 1993; 149: 749-752
• 17 Sylvester RJ, Oosterlinck W, Holmang S. et al. Systematic Review and Individual Patient Data Meta-analysis of Randomized Trials Comparing a Single Immediate Instillation of Chemotherapy After Transurethral Resection with Transurethral Resection Alone in Patients with Stage pTa-pT1 Urothelial Carcinoma of the Bladder: Which Patients Benefit from the Instillation?. Eur Urol 2016; 69: 231-244
• 18 Mishina T, Oda K, Murata S. et al. Mitomycin C bladder instillation therapy for bladder tumors. J Urol 1975; 114: 217-219
• 19 Morales A, Eidinger D, Bruce AW. Intracavitary bacillus Calmette-Guerin in the treatment of superficial bladder tumors. J Urol 1976; 116: 180
• 20 Camacho FJ, Pinsky CM, Herr HW. et al. Treatment of superficial bladder cancer with intravesical BCG. Proc Am Soc Clin Oncol 1980; 21: 359
• 21 Lamm DL, Thor DE, Harris SC. et al. Bacillus Calmette-Guerin immunotherapy of superficial bladder cancer. J Urol 1980; 124: 38
• 22 Ojea A, Nogueira JL, Solsona E. et al. A multicentre, randomised prospective trial comparing three intravesical adjuvant therapies for intermediate-risk superficial bladder cancer: low-dose bacillus Calmette-Guerin (27 mg) versus very low-dose bacillus Calmette-Guerin (13.5 mg) versus mitomycin C. Eur Urol 2007; 52: 1398-1406
• 23 Smith ZL, Christodouleas JP, Keefe SM. et al. Bladder preservation in the treatment of muscle-invasive bladder cancer (MIBC): a review of the literature and a practical approach to therapy. BJU Int 2013; 112: 13-25
• 24 Shariat SF, Palapattu GS, Karakiewicz PI. et al. Discrepancy between clinical and pathologic stage: impact on prognosis after radical cystectomy. Eur Urol 2007; 51: 137-149
• 25 Skinner DG. Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J Urol 1982; 128: 34-36
• 26 Bruins HM, Veskimae E, Hernandez V. et al. The impact of the extent of lymphadenectomy on oncologic outcomes in patients undergoing radical cystectomy for bladder cancer: a systematic review. Eur Urol 2014; 66: 1065-1077
• 27 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 2018; [Epub ahead of print]
• 28 Hautmann RE, de Petriconi RC, Volkmer BG. Lessons Learned From 1,000 Neobladders: The 90-Day-Complication Rate. J Urol 2010; 184: 990-994
• 29 Hautmann RE, de Petriconi RC, Volkmer BG. 25 Years of Experience With 1,000 Neobladders: Long-Term Complications. J Urol 2011; 185: 2207-2212
• 30 Azhar RA, Bochner B, Catto J. et al. Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs. Eur Urol 2016; 70: 176-187
• 31 Maloney I, Parker DC, Cookson MS. et al. Bladder Cancer Recovery Pathways: A Systematic Review. Bladder Cancer 2017; 27: 269-281
• 32 Aziz A, May M, Burger M. et al. Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Eur Urol 2014; 66: 156-163
• 33 Waingankar N, Mallin K, Smaldone M. et al. Assessing the relative influence of hospital and surgeon volume on short-term mortality after radical cystectomy. BJU Int 2017; 120: 239-245
• 34 Kefer JC, Cherullo EE, Jones JS. et al. Prostate-sparing cystectomy: has Pandora's box been opened?. Expert Rev Anticancer Ther 2007; 7: 1003-1014
• 35 Hautmann RE, Hautmann O, Volkmer BG. et al. Nerve-sparing radical cystectomy: a new technique. Eur Urol Suppl 2010; 9: 428-432
• 36 Neulander EZ, Hawke CK, Soloway MS. Incidental appendectomy during radical cystectomy: an interdepartmental survey and review of the literature. Urology 2000; 56: 241-244
• 37 Liedberg F, Jancke G, Sörenby A. et al. Should we Refrain from Performing Oophorectomy in Conjunction with Radical Cystectomy for Bladder Cancer?. Eur Urol 2017; 71: 851-853
• 38 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
• 39 Frees S, Schenk AC, Rubenwolf P. et al. Bowel function in patients with urinary diversion: a gender-matched comparison of continent urinary diversion with the ileocecal pouch and ileal conduit. World J Urol 2017; 35: 913-919
• 40 Kramer MW, von Klot CA, Kabbani M. et al. Long-term bowel disorders following radial cystectomy: an underestimated issue?. World J Urol 2015; 33: 1373-1380
• 41 Somani BK, Kumar V, Wong S. et al. Bowel dysfunction after transposition of intestinal segments into the urinary tract: 8-year prospective cohort study. J Urol 2007; 177: 1793-1798
• 42 Messing EM. Perioperative Blood Transfusions and Bladder Cancer Outcomes. Bladder Cancer 2018; 29: 445-446
• 43 Shaaban AA, Gaballah MA, el-Diasty TA. et al. Urethral controlled bladder substitution: a comparison between the intussuscepted nipple valve and the technique of Le Duc as antireflux procedures. J Urol 1992; 148: 1156-1161
• 44 Skinner EC, Fairey AS, Groshen S. et al. Randomized Trial of Studer Pouch versus T-Pouch Orthotopic Ileal Neobladder in Patients with Bladder Cancer. J Urol 2015; 194: 433-439
• 45 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
• 46 Bochner BH, Dalbagni G, Marzouk KH. et al. Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: Oncologic Outcomes. Eur Urol 2018; 74: 465-471
• 47 Hautmann RE, Herr HW, Pruthi RS. et al. Robotic radical cystectomy – is the diversion the Achilles' heel?. J Urol 2014; 192: 1601-1603
• 48 Hautmann RE. Declining Use of Orthotopic Reconstruction Worldwide – What Went Wrong?. J Urol 2018; 199: 900-903
• 49 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
• 50 Yin M, Joshi M, Meijer RP. et al. Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer: A Systematic Review and Two-Step Meta-Analysis. Oncologist 2016; 21: 708-715
• 51 Martini T, Gilfrich C, Mayr R. et al. The Use of Neoadjuvant Chemotherapy in Patients With Urothelial Carcinoma of the Bladder: Current Practice Among Clinicians. Clin Genitourin Cancer 2017; 15: 356-362
• 52 Seiler R, Ashab HAD, Erho N. et al. Impact of Molecular Subtypes in Muscle-invasive Bladder Cancer on Predicting Response and Survival after Neoadjuvant Chemotherapy. Eur Urol 2017; 72: 544-554
• 53 Leow JJ, Martin-Doyle W, Rajagopal PS. et al. Adjuvant chemotherapy for invasive bladder cancer: a 2013 updated systematic review and meta-analysis of randomized trials. Eur Urol 2014; 66: 42-54
• 54 Hautmann RE, Egghart G, Frohneberg D. et al. The ileal neobladder. J Urol 1988; 139: 39-42
• 55 Klän R, Loy V, Huland H. Residual tumor discovered in routine second transurethral resection in patients with stage T1 transitional cell carcinoma of the bladder. J Urol 1991; 146: 316-318