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Pelvine Lymphadenektomie und radikale Prostatektomie

Empfehlungen der S3-Leitlinie

Pelvic lymphadenectomy and radical prostatectomy

Recommendations of the German S3 guideline

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Zusammenfassung

Die radikale Prostatektomie (RP) ist die am häufigsten eingesetzte Therapie beim lokalisierten Prostatakarzinom. Im Gegensatz zu anderen Verfahren ist der Wert der RP beim lokal begrenzten Prostatakarzinom durch eine prospektiv randomisierte Studie (im Vergleich zu „watchful waiting“) untermauert; über die Ergebnisse dieser Studie sollen Patienten laut S3-Leitlinie vor einer Therapieentscheidung aufgeklärt werden. Als Ziele der Operation und damit Qualitätsindikatoren werden – in Anlehnung an die Vorgaben der Deutschen Krebsgesellschaft für die Zertifizierung von Prostatakarzinomzentren – die Rate an R0-Resektion und der Erhalt der Harnkontinenz sowie Potenz herausgestellt.

Bei Patienten mit „Low-risk-Tumoren“ (nach D’Amico-Kriterien) kann auf eine pelvine Lymphadenektomie verzichtet werden. Wird eine Lymphadenektomie durchgeführt, so sollten zumindest 10 Lymphknoten entnommen werden. Bei lokal fortgeschrittenen Tumoren sollte eine extendierte Lymphadenektomie empfohlen werden.

Auch für das lokal fortgeschrittene Prostatakarzinom stellt die RP eine Option dar. Bei Tumoren mit einem Gleason-Score ≥8 bzw. im klinischen Stadium cT3/4 sollte vor einer Therapieentscheidung allerdings eine Kernspintomographie des Beckens erfolgen. Praktisch keinen Stellenwert hat die (neo)adjuvante Therapie bei der RP (Ausnahme: adjuvante Therapie bei Lymphknotenmetastasen).

Erstmalig werden durch die deutsche S3-Leitlinie mit dem Ziel der Qualitätssicherung Mindestmengen festgelegt. Die RP soll nur unter der Leitung eines erfahrenen Operateurs durchgeführt werden. Dies beinhaltet die Durchführung von mindestens 50 Prostatektomien in einer Einrichtung pro Jahr sowie mindestens 25 pro Operateur pro Jahr sowie ein entsprechendes Ausbildungsprogramm.

Abstract

Radical prostatectomy is the most frequently used treatment for localized prostate cancer. In contrast to other strategies radical prostatectomy has been shown to be superior to watchful waiting in a prospective randomized trial. According to the German S3 guideline patients have to be informed about the results of this trial prior to treatment decision. The aims and quality indicators of radical prostatectomy include—as has also been defined by the German Cancer Society for certified prostate cancer centers—complete removal of the prostate with negative surgical margins (R0) and preservation of continence as well as potency.

In low-risk disease (according to D’Amico criteria) pelvic lymph node dissection may be abandoned. If lymphadenectomy is performed a minimum number of ten nodes should be obtained. An extended lymphadenectomy is recommended in locally advanced disease.

Radical prostatectomy is a valid treatment option in locally advanced prostate cancer. In cases with Gleason score ≥ 8 or clinical stage cT3/4 magnetic resonance imaging of the pelvis should be performed prior to treatment decision making. In patients undergoing radical prostatectomy (neo) adjuvant treatment should not be used (exception: adjuvant treatment for lymph node metastases).

For the first time the German S3 guideline determines minimum surgery volumes aimed at quality assurance. Radical prostatectomy has to be performed under the supervision of an experienced surgeon. This includes the number of 50 prostatectomies per year and institution, 25 prostatectomies per surgeon, and an appropriate training program.

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Authors and Affiliations

  1. Klinik und Poliklinik für Urologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland

    M.-O. Grimm, M. Fröhner & M. Wirth

  2. Urologische Klinik und Poliklinik, Johannes Gutenberg-Universität, Mainz, Deutschland

    C. Thomas & J.W. Thüroff

  3. Klinik für Strahlentherapie und Radioonkologie, Universitätsklinik Ulm, Ulm, Deutschland

    T. Wiegel

  4. Klinik für Urologie, Universitätsklinik Aachen, Aachen, Deutschland

    A. Heidenreich

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  1. M.-O. Grimm
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  2. C. Thomas
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  3. M. Fröhner
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  4. T. Wiegel
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  5. A. Heidenreich
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  6. J.W. Thüroff
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  7. M. Wirth
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Correspondence to M.-O. Grimm.

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Grimm, MO., Thomas, C., Fröhner, M. et al. Pelvine Lymphadenektomie und radikale Prostatektomie. Urologe 49, 206–210 (2010). https://doi.org/10.1007/s00120-010-2237-4

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  • DOI: https://doi.org/10.1007/s00120-010-2237-4

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