Advertisement

Der Urologe

, Volume 56, Issue 3, pp 306–312 | Cite as

Harnröhrenstrikturen nach Strahlentherapie

  • C. M. Rosenbaum
  • O. Engel
  • M. Fisch
  • L. A. Kluth
Leitthema

Zusammenfassung

Strahlenbedingte Harnröhrenstrikturen treten v. a. nach Bestrahlung der Prostata beim Prostatakarzinom auf und stellen eine der häufigsten Langzeitnebenwirkungen der Strahlentherapie dar. Strikturen treten meist in den ersten 2 Jahren nach Bestrahlung auf. Die niedrigsten Strikturraten zeigen sich bei der perkutanen Radiatio, höhere Raten zeigen sich bei der Brachytherapie, die höchste Inzidenz kann bei der Kombination aus beiden Verfahren gesehen werden. Bei Weitem am häufigsten zeigen sich Strikturen im Bereich der bulbomembranösen Harnröhre. Die Diagnostik sollte neben der klinischen urologischen Untersuchung eine Sonographie, Harnstrahlmessung, Urethrozystoskopie und ein kombiniertes retrogrades und Miktionszystourethrogramm beinhalten. Endoskopische Therapien wie die Dilatation und die Harnröhrenschlitzung können bei kurzen bulbomembranösen Strikturen als primäre Therapie versucht werden, zeigen aber hohe Rezidivraten. Harnröhrenplastiken wie die End-zu-End-Anastomosierung (EPA) zeigen deutlich höhere Erfolgsraten von 70–95 %, die Inkontinenzraten liegen zwischen 7 und 40 %. Die Erfolgsraten der Harnröhrenplastik mit Mundschleimhautautotransplantat (MSH) liegen zwischen 71 und 78 %, die Inkontinenzraten zwischen 10,5 und 44 %. Eine postoperative Harninkontinenz kann in der Regel mit der Implantation eines artifiziellen Sphinkters erfolgreich und sicher behandelt werden. Insgesamt erscheint bei kürzeren Harnröhrenstrikturen die EPA das Verfahren der Wahl, während bei längeren Strikturen eine Harnröhrenplastik mit MSH angezeigt ist. Mit dem Patienten sollten alle Therapieoptionen im Hinblick auf die Strikturausdehnung, Lokalisation und eventueller postoperativer Inkontinenz diskutiert werden.

Schlüsselwörter

Harnröhrenplastik Prostatakarzinom Mundschleimhautautotransplantat Harninkontinenz, postoperative Harnröhre, bulbomembranöse 

Urethral stricture after radiation therapy

Abstract

Radiation-induced urethral stricture occurs most often due to radiation for prostate cancer. It is one of the most common side effects of radiotherapy. Stricture rates are lowest in patients undergoing external beam radiation therapy, occur more frequently in those who require brachytherapy and show highest stricture rates in patients receiving a combination of external beam radiation and brachytherapy. Strictures are mostly located at the bulbomembranous part of the urethra. Diagnostic work-up should include basic urologic work-up, ultrasound, uroflowmetric assessment, urethroscopy, retrograde urethrogram and voiding cystourethrography. Endoscopic management such as dilatation and internal urethrotomy has been proposed in short strictures. However these therapies have a high risk for recurrence. The success rate of urethroplasty is higher. Success rates of primary end-to-end anastomosis (EPA) have been reported to be 70–95 %; rates of incontinence are 7–40 %. While success rates of buccal mucosa graft urethroplasty (BMGU) range from 71–78 %, postoperative incontinence occurs in 10.5–44 %. Usually, postoperative incontinence can successfully be treated with an artificial urinary sphincter. It seems like EPA is the treatment of choice for short urethral strictures, whereas BMGU is indicated in longer, more complex strictures. Patients should be counselled with regard to length and location of strictures as well as with regard to postoperative incontinence.

Keywords

Urethroplasty Prostate cancer Buccal mucosa graft urethroplasty Urinary incontinence, postoperative Urethra, bulbomembranous 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

C. M. Rosenbaum, O. Engel, M. Fisch und L. A. Kluth geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Ahyai S, Schmid M, Kuhl M et al (2015) Outcomes of ventral Onlay Buccal Mucosa graft urethroplasty in patients after radiotherapy. J Urol. doi: 10.1016/j.juro.2015.03.116 Google Scholar
  2. 2.
    Al Hussein Al Awamlh B, Lee DJ, Nguyen DP et al (2015) Assessment of the quality-of-life and functional outcomes in patients undergoing cystectomy and urinary diversion for the management of radiation-induced refractory benign disease. Urology 85:394–400CrossRefPubMedGoogle Scholar
  3. 3.
    Bernstein EF, Sullivan FJ, Mitchell JB et al (1993) Biology of chronic radiation effect on tissues and wound healing. Clin Plast Surg 20:435–453PubMedGoogle Scholar
  4. 4.
    Bostrom PJ, Soloway MS, Manoharan M et al (2008) Bladder cancer after radiotherapy for prostate cancer: detailed analysis of pathological features and outcome after radical cystectomy. J Urol 179:91–95 (discussion 95)CrossRefPubMedGoogle Scholar
  5. 5.
    Crew JP, Jephcott CR, Reynard JM (2001) Radiation-induced haemorrhagic cystitis. Eur Urol 40:111–123CrossRefPubMedGoogle Scholar
  6. 6.
    Elliott SP, Mcaninch JW, Chi T et al (2006) Management of severe urethral complications of prostate cancer therapy. J Urol 176:2508–2513CrossRefPubMedGoogle Scholar
  7. 7.
    Elliott SP, Meng MV, Elkin EP et al (2007) Incidence of urethral stricture after primary treatment for prostate cancer: data from CaPSURE. J Urol 178:529–534 (discussion 534)CrossRefPubMedGoogle Scholar
  8. 8.
    Erickson BA, Granieri MA, Meeks JJ et al (2010) Prospective analysis of erectile dysfunction after anterior urethroplasty: incidence and recovery of function. J Urol 183:657–661CrossRefPubMedGoogle Scholar
  9. 9.
    Glass AS, Mcaninch JW, Zaid UB et al (2012) Urethroplasty after radiation therapy for prostate cancer. Urology 79:1402–1405CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Gomez-Iturriaga Pina A, Crook J, Borg J et al (2010) Median 5 year follow-up of 125iodine brachytherapy as monotherapy in men aged〈or=55 years with favorable prostate cancer. Urology 75:1412–1416CrossRefPubMedGoogle Scholar
  11. 11.
    Hei TK, Zhou H, Ivanov VN et al (2008) Mechanism of radiation-induced bystander effects: a unifying model. J Pharm Pharmacol 60:943–950CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Herschorn S, Elliott S, Coburn M et al (2014) SIU/ICUD consultation on urethral strictures: posterior urethral stenosis after treatment of prostate cancer. Urology 83:59–70CrossRefGoogle Scholar
  13. 13.
    Hindson BR, Millar JL, Matheson B (2013) Urethral strictures following high-dose-rate brachytherapy for prostate cancer: analysis of risk factors. Brachytherapy 12:50–55CrossRefPubMedGoogle Scholar
  14. 14.
    Hofer MD, Zhao LC, Morey AF et al (2014) Outcomes after urethroplasty for radiotherapy induced bulbomembranous urethral stricture disease. J Urol 191:1307–1312CrossRefPubMedGoogle Scholar
  15. 15.
    Hofer MD, Zhao LC, Morey AF et al (2014) Outcomes after Urethroplasty for radiotherapy induced Bulbomembranous urethral stricture disease. J Urol. doi: 10.1016/j.juro.2013.10.147 Google Scholar
  16. 16.
    Huang EH, Pollack A, Levy L et al (2002) Late rectal toxicity: dose-volume effects of conformal radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 54:1314–1321CrossRefPubMedGoogle Scholar
  17. 17.
    Hudak SJ, Atkinson TH, Morey AF (2012) Repeat transurethral manipulation of bulbar urethral strictures is associated with increased stricture complexity and prolonged disease duration. J Urol 187:1691–1695CrossRefPubMedGoogle Scholar
  18. 18.
    Jackson MJ, Chaudhury I, Mangera A et al (2013) A prospective patient-centred evaluation of urethroplasty for anterior urethral stricture using a validated patient-reported outcome measure. Eur Urol 64:777–782CrossRefPubMedGoogle Scholar
  19. 19.
    Jarosek SL, Virnig BA, Chu H et al (2015) Propensity-weighted long-term risk of urinary adverse events after prostate cancer surgery, radiation, or both. Eur Urol 67:273–280CrossRefPubMedGoogle Scholar
  20. 20.
    Kluth LA, Dahlem R, Becker A et al (2015) Psychometric validation of a German language version of a PROM for urethral stricture surgery and preliminary testing of supplementary ED and UI constructs. World J Urol. doi: 10.1007/s00345-015-1610-8 Google Scholar
  21. 21.
    Meeks JJ, Brandes SB, Morey AF et al (2011) Urethroplasty for radiotherapy induced bulbomembranous strictures: a multi-institutional experience. J Urol 185:1761–1765CrossRefPubMedGoogle Scholar
  22. 22.
    Merrick GS, Butler WM, Wallner KE et al (2006) Risk factors for the development of prostate brachytherapy related urethral strictures. J Urol 175:1376–1380 (discussion 1381)CrossRefPubMedGoogle Scholar
  23. 23.
    Mohammed N, Kestin L, Ghilezan M et al (2012) Comparison of acute and late toxicities for three modern high-dose radiation treatment techniques for localized prostate cancer. Int J Radiat Oncol Biol Phys 82:204–212CrossRefPubMedGoogle Scholar
  24. 24.
    Palmer DA, Buckley JC, Zinman LN et al (2015) Urethroplasty for high risk, long segment urethral strictures with ventral buccal mucosa graft and gracilis muscle flap. J Urol 193:902–905CrossRefPubMedGoogle Scholar
  25. 25.
    Sack BS, Langenstroer P, Guralnick ML et al (2016) Cystectomy and urinary diversion for the management of a devastated lower urinary tract following prostatic cryotherapy and/or radiotherapy. WMJ 115:70–73PubMedGoogle Scholar
  26. 26.
    Sullivan L, Williams SG, Tai KH et al (2009) Urethral stricture following high dose rate brachytherapy for prostate cancer. Radiother Oncol 91:232–236CrossRefPubMedGoogle Scholar
  27. 27.
    Tibbs MK (1997) Wound healing following radiation therapy: a review. Radiother Oncol 42:99–106CrossRefPubMedGoogle Scholar
  28. 28.
    Zhao W, Diz DI, Robbins ME (2007) Oxidative damage pathways in relation to normal tissue injury. Br J Radiol 80(1):23–31CrossRefGoogle Scholar
  29. 29.
    Zietman AL, Desilvio ML, Slater JD et al (2005) Comparison of conventional-dose vs high-dose conformal radiation therapy in clinically localized adenocarcinoma of the prostate: a randomized controlled trial. JAMA 294:1233–1239CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • C. M. Rosenbaum
    • 1
  • O. Engel
    • 1
  • M. Fisch
    • 1
  • L. A. Kluth
    • 1
  1. 1.Klinik und Poliklinik für UrologieUniversitätsklinikum Hamburg-EppendorfHamburgDeutschland

Personalised recommendations