Zusammenfassung
Fragestellung
Wir untersuchten die Rate harnableitungsspezifischer Komplikationen nach radikaler Zystektomie (RC) und Ileumconduitanlage (IC-Anlage).
Patienten und Methoden
305 Blasentumorpatienten nach RC und IC-Anlage konnten eingeschlossen werden (06/2003–12/2010). IC-Komplikationen (parastomale Hernien, Ureterimplantations- und IC-Stenosen, IC-Blutungen, Urolithiasis, fieberhafte Harnwegsinfekte, Niereninsuffizienz) wurden nach Clavien-Dindo (CDC) erfasst. Kaplan-Meier-Kurven wurden berechnet. Uni- und multivariable Cox’sche Regressionsanalysen mit rückwärtsgerichteter Selektion testeten den Effekt von Alter, abdomineller/pelviner Radiatio oder Voroperation vor RC, Adipositas, Komorbiditäten und fortgeschrittenem Tumorstadium auf das Auftreten einer hochgradigen IC-Komplikation (CDC ≥ III) sowie die Durchführung einer IC-Revision.
Ergebnisse
32,7 und 13,4 % unserer Patienten entwickelten eine IC-Komplikation (CDC ≥ I) und eine hochgradige IC-Komplikation (CDC ≥ III). 14,8 %, 4,6 % und 4,3 % entwickelten eine parastomale Hernie, eine Ureterimplantations- oder eine IC-Stenose. 10,5 % der Patienten mussten sich einer IC-Revision unterziehen (medianes Follow-up 19,5 Monate, IQA 7-47). Die geschätzte IC-Komplikationsrate nach 5 Jahren lag bei 52 % (CDC ≥ I) und 22 % (CDC ≥ III). Die multivariable Analyse zeigte, dass vorbestrahlte (HR 4,33) adipöse (HR 2,24) Patienten nach längerer RC-Dauer (HR 1,01), einem Risiko für eine IC-Revision ausgesetzt sind. Adipositas (HR 2,49; alle p < 0,05) war ein Risikofaktor für hochgradige Komplikationen.
Diskussion
Das Risiko für eine hochgradige IC-Komplikation oder eine IC-Revision ist moderat. Vorbestrahlte, komorbide und adipöse Patienten haben ein erhöhtes Risiko für eine IC-Revison. Adipositas stellt zudem einen Risikofaktor für hochgradige IC-Komplikationen dar.
Abstract
Background
We analyzed complications associated with urinary diversion after radical cystectomy (RC) and ileal conduit (IC) for bladder cancer (BCa).
Patients and methods
A total of 305 BCa patients after RC with IC were included in the study (June 2003–December 2010). IC complications (peristomal hernia, IC stenosis, stenosis of the ureteral anastomosis, IC bleeding, urolithiasis, urinary infections, and renal insufficiency) were identified according to the Clavien–Dindo classification (CDC). Kaplan–Meier plots were generated. Uni- and multivariable Cox regression analyses with backward selection for prediction of high-grade complications (CDC ≥ III) and IC revision surgery were conducted; covariates included age, previous abdominal/pelvic radiation, body mass index (BMI), previous abdominal/pelvic surgery, comorbidities, and advanced tumor stage.
Results
An IC complication (CDC ≥ I) or a high-grade IC complication (CDC ≥ III) was experienced by 32.7 and 13.4 % of our cohort: 14.8 %, 4.3 %, 4.6 % developed a peristomal hernia, IC stenosis, stenosis of the ureteral anastomosis, respectively. IC revision was required by 10.5 % of patients (median follow-up 19.5 months, IQR 7–47 months). The estimated rate of IC complications at 5 years was 52 % (CDC ≥ I) and 22 % (CDC ≥ III). The final model of the multivariable analysis showed that patients with a history of previous radiation (HR 4.33), a BMI ≥ 30 (HR 2.24), or longer duration of surgery (HR 1.01; all p < 0.05) were at higher risk for IC revision surgery. A BMI ≥ 30 (HR 2.49, p = 0.011) was a risk factor for high-grade complications.
Conclusion
The risk of experiencing a high-grade IC complication is moderate. Previous radiation, obesity, and comorbidities represent risk factors for IC revision surgery. Moreover, obesity is a risk factor for high-grade complications.
Abbreviations
- AIC:
-
Aikaike Information Criterion
- ASA:
-
American Society of Anesthesiologists Score
- BMI:
-
Body-Mass-Index
- CCI:
-
Charlson-Komorbiditätsindex
- CDC:
-
Clavien-Dindo-Klassifikation
- CI:
-
Konfidenzintervall
- HR:
-
Hazard Ratio
- HWI:
-
Harnwegsinfekte
- IC:
-
Ileumconduit
- ICU:
-
Intensive Care Unit
- IMC:
-
Intermediate Care Unit
- IQA:
-
Interquartilenabstand
- NB:
-
Orthotope Neoblase
- RC:
-
Radikale Zystektomie
- Ref.:
-
Referenz
Literatur
Hautmann RE, Abol-Enein H, Hafez K et al (2007) Urinary diversion. Urology 69(1 Suppl):17–49 (Epub 2007/02/07)
Stein JP, Lieskovsky G, Groshen S et al (2001) Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol 19:666–675
Bricker EM (1950) Bladder substitution after pelvic evisceration. Surg Clin North Am 30(5):1511–1521 (Epub 1950/10/01)
Witjes JA, Comperat E, Cowan NC et al (2014) EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines. Eur Urol 65(4):778–792 (Epub 2014/01/01)
Roghmann F, Becker A, Trinh QD et al (2013) Updated assessment of neobladder utilization and morbidity according to urinary diversion after radical cystectomy: a contemporary US-population-based cohort. Can Urol Assoc J 7(9–10):E552–E560 (Epub 2013/09/27)
Shabsigh A, Korets R, Vora KC et al (2009) Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 55(1):164–176
Novara G, De Marco V, Aragona M et al (2009) Complications and mortality after radical cystectomy for bladder transitional cell cancer. JURO 182(3):914–921
Novotny V, Hakenberg OW, Wiessner D et al (2007) Perioperative complications of radical cystectomy in a contemporary series. Eur Urol 51(2):397–402
Chang SS, Cookson MS, Baumgartner RG et al (2002) Analysis of early complications after radical cystectomy: results of a collaborative care pathway. J Urol 167:2012–2016
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(1):156–163 (Epub 2014/01/07)
Autorino R, Quarto G, Di Lorenzo G et al (2009) Health related quality of life after radical cystectomy: comparison of ileal conduit to continent orthotopic neobladder. Eur J Surg Oncol 35(8):858–864 (Epub 2008/10/01)
Frich PS, Kvestad CA, Angelsen A (2009) Outcome and quality of life in patients operated on with radical cystectomy and three different urinary diversion techniques. Scand J Urol Nephrol 43(1):37–41 (Epub 2008/10/25)
Tanaka T, Kitamura H, Takahashi A et al (2005) Long-term functional outcome and late complications of Studer’s ileal neobladder. Jpn J Clin Oncol 35(7):391–394 (Epub 2005/06/25)
Roghmann F, Trinh QD, Braun K et al (2014) Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy. Int J Urol 21(2):143–149 (Epub 2013/08/03)
Wittekind C, Hutter R et al (2007) TNM atlas: ilustrated guide to the TNM/pTNM classification of malignat tumors. Springer, Heidelberg
Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications. Ann Surg 240(2):205–213
Hens N, Aerts M, Molenberghs G (2006) Model selection for incomplete and design-based samples. Stat Med 25(14):2502–2520 (Epub 2006/04/06)
Shimko MS, Tollefson MK, Umbreit EC et al (2011) Long-term complications of conduit urinary diversion. J Urol 185(2):562–567 (Epub 2010/12/21)
Bartsch G, Gust K, Vallo S et al (2013) Cystectomy in the elderly patient. Urologe A 52(6):821–826 (Epub 2013/04/23. Zystektomie im Alter)
Roghmann F, Sukumar S, Ravi P et al (2013) Radical cystectomy in the elderly: national trends and disparities in perioperative outcomes and quality of care. Urol Int 92(1):27–34
Gore JL, Yu H-Y, Setodji C et al (2010) Urinary diversion and morbidity after radical cystectomy for bladder cancer. Cancer 116(2):331–339
Madersbacher S, Schmidt J, Eberle JM et al (2003) Long-term outcome of ileal conduit diversion. J Urol 169(3):985–990 (Epub 2003/02/11)
Nastro P, Knowles CH, McGrath A et al (2010) Complications of intestinal stomas. Br J Surg 97(12):1885–1889 (Epub 2010/09/28)
Klinge U, Si ZY, Zheng H et al (2000) Abnormal collagen I to III distribution in the skin of patients with incisional hernia. Eur Surg Res 32(1):43–48 (Epub 2000/03/18)
Bodman CBM von, Roghmann F, Eggert T et al (2012) 1170 parastomal hernia repair follwing ileal conduit urinary diversion using a novel funnel mesh implant. J Urol 187(4):e474
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Interessenkonflikt. F. Roghmann, M. Gockel, J. Schmidt, J. Hanske, N. von Landenberg, B. Löppenberg, K. Braun, C. von Bodman, J. Pastor, J. Palisaar, J. Noldus und M. Brock geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Roghmann, F., Gockel, M., Schmidt, J. et al. Komplikationen nach Ileumconduitanlage. Urologe 54, 533–541 (2015). https://doi.org/10.1007/s00120-015-3812-5
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DOI: https://doi.org/10.1007/s00120-015-3812-5