Die Wertigkeit der Lymphadenektomie beim muskelinvasiven Urothelkarzinom der Harnblase – Ein Überblick über die aktuelle Datenlage

Zusammenfassung

Einleitung: Das Ausmaß der Lymphadenektomie, sowie das Vorhandensein von Lymphknotenmetastasen sind wichtige prognostische Faktoren in der Behandlung des muskelinvasiven Urothelkarzinom der Harnblase. Dennoch besteht insbesondere in Bezug des Ausmasses der Lymphadenektomie noch Diskussionsbedarf. Material und Methodik: Es erfolgte eine Literatursuche in Pubmed unter Berücksichtigung der aktuellen Behandlungsstandard des Urothelkarzinoms der Harnblase. Besonders die Operationsmethode, sowie der Nachweis von Lymphknotenmetastasen, Lymphknotenmapping, histopathologischen Nachweistechniken und das Risiko der Lymphknotenbeteiligung des Urothelkarzinoms der Harnblase wurden analysiert. Ergebnis: Die Anwesenheit von Lymphknotenmetastasen ist mit einer schlechteren Prognose assoziiert. Neben dem Wissen um Metastasierungswege ist eine ausführliche und sorgfältige pathologische Aufarbeitung der Lymphknoten sehr wichtig. Eine Hilfe können hierbei molekulare Marker sein, um Mikrometastasen zu detektieren. Im Vergleich zeigt die ausgedehnte Lymphadenektomie ein besseres Langzeit-Überleben als die limitierte Lymphadenektomie. Durch die laparoskopische und roboterassistierte Zystektomie sind zwei schonendere Operationsmethoden vorhanden, bei denen eine ausgedehnte Lymphadenektomie allerdings schwieriger durchzuführen ist. Die Evaluation bisheriger Daten erfolgte bisher meist retrospektiv. Bezüglich des Operationszuganges ist die roboterassistierte und laparoskopische Zystektomie noch mit einer verlängerten Operationsdauer assoziiert. Eine ausgedehnte Lymphadenektomie ist jedoch auch mit diesen Methoden möglich, jedoch fehlen bisher aussagekräftige Langzeitergebnisse. Schlussfolgerung: Eine ausgedehnte pelvine Lymphadenektomie zeigt in retrospektiven Serien ein erfreuliches Outcome in Patienten mit Lymphknotenmetastasen. Deshalb sollte bei Patienten mit muskelinvasiven Urothelkarzinom der Harnblase eine ausgedehnte Lymphadenektomie durchgeführt werden. 

Abstract

Introduction: The extent of the lymphadenectomy (LAE) as well as the appearance of lymph node metastasis are important prognostic factors in the treatment of the muscle invasive transitional cell carcinoma of the bladder (TCC). However there is still the need to discuss the dimension of the LAE. Material and Methods: Pubmed was searched with regard to guidelines for the treatment of muscle invasive TCC. In particular, operation techniques, the appearance of lymph node metastasis, lymph node mapping, histopathological and radiological detection methods, as well as the risk of positive lymph nodes were analysed. Results: The confirmation of lymph node metastasis is associated with a poorer outcome. Besides knowledge of metastasis pathways, an extensive and careful pathological reprocessing is one cornerstone of the procedure. Molecular markers seem to support the detection of micrometastasis. The extended LAE is associated with a better long-term survival rate compared to the limited LAE. New operation techniques such as laparoscopic or robot-assisted cystectomy are associated with lower peri- and postoperative morbidity, but the extended LAE is more challenging using these techniques. There are no long-term results available yet for these methods. Most data regarding lymphadenectomy and survival rate are based on retrospective studies thus decreasing the level of evidence. Conclusion: An extended LAE shows retrospectively a better outcome in patients with lymph node metastasis in TCC. Therefore an extended LAE should be performed in patients with muscle invasive TCC. New methods for detecting lymph node metastasis are elevating the confirmation rate. 

Schlüsselwörter

Blasenkarzinom - Lymphadenektomie - Muskelinvasion - Zystektomie

Key words

bladder cancer - lymphadenectomy - muscle invasive tumours - cystectomy

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