Zusammenfassung
Neben der radikalen Nephroureterektomie mit Entfernung einer Blasenmanschette, die immer noch den Goldstandard in der Therapie des Urothelkarzinoms des oberen Harntraktes darstellt, haben sich aufgrund technischer Verbesserungen in der Endoskopie verschiedene perkutane und transurethrale endoskopische Methoden zur organerhaltenden Therapie etabliert. Während sie anfangs nur bei selektierten Indikationen eingesetzt wurden, wenn die Nephroureterektomie mit einer nicht zumutbaren postoperativen Morbidität verbunden gewesen wäre (z. B. Dialysepflichtigkeit bei Entfernung einer karzinomtragenden Einzelniere), wird heute zunehmend auch bei erweiterter Indikationsstellung zum organerhaltenden Therapieversuch geraten. Eine Analyse der aktuellen Literatur zeigt, dass v. a. bei kleinen (<1,5 cm) solitären Urothelkarzinomen von niedrigem Malignitätsgrad und ohne muskelinvasives Wachstum eine Organerhaltung angestrebt werden kann. Während das tumorspezifische Überleben mit 69 bis 100% vergleichbar gut wie die Nephroureterektomie ist, zeigen sich nach organerhaltender Therapie mehr Tumorrezidive (Rezidivrate 23–90%). Diese Daten sind jedoch mit Vorsicht zu interpretieren, da sie retrospektiven unizentrischen Studien mit niedrigen Patientenzahlen, sehr unterschiedlichen Patientenkollektiven und meist relativ kurzen Nachsorgezeiträumen entstammen. Prospektive randomisierte Multicenterstudien mit großen Patientenkollektiven und langem Follow-up sind im Moment nicht verfügbar. Wichtig ist nach organerhaltender Therapie des Urothelkarzinoms des oberen Harntraktes eine lebenslange Nachsorge mittels Bildgebung und Endoskopie, um im Falle eines Rezidivs eine frühzeitige Zweittherapie einleiten zu können.
Abstract
In addition to radical nephrourterectomy with removal of the bladder cuff, which is still the gold standard in the therapy of urothelial tumors of the upper urinary tract, various percutaneous and transurethral endoscopic methods are now well established for organ-sparing therapies due to technical improvements in endoscopy. Although these were originally only used with selective indications, if radical nephrourterectomy were not coupled with an unreasonable postoperative morbidity (e.g. dialysis-dependence after removal of a tumor-carrying single kidney), organ-sparing therapy attempts are increasingly more recommended, even by extended indications. Analysis of the current literature shows that organ-sparing is strived for, especially with small (<1.5 cm) solitary urothelial tumors with low grade malignancy and without muscle invading growth. Although tumor-specific survival with 69–100% is comparable to nephrourterectomy, organ-sparing treatment appears more inclined to tumor recurrence (relapse rate 23–90%). These data must, however, be interpreted with caution because they originate from retrospective single center studies with low patient numbers, very different patient collectives and mostly relatively short follow-up time periods. Prospective randomized multicenter studies with large patient collectives and long follow-up times are not yet available. After organ-sparing therapy of urothelial tumors of the upper urinary tract, it is important to have life-long follow-up with imaging and endoscopy, in order to initiate an early second therapy in the case of a relapse.
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Hruza, M., Stock, C., Teber, D. et al. Endoskopische organerhaltende Therapie von Urotheltumoren des oberen Harntraktes. Urologe 47, 830–837 (2008). https://doi.org/10.1007/s00120-008-1714-5
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DOI: https://doi.org/10.1007/s00120-008-1714-5