Control of Bladder Tumors by Endoscopic Surgery

Vol. 97, May

THE JOURNAL OF UROLOGY

Copyright © 1967 by The Williams & Wilkins Co.

Printed in U.S.A.

CONTROL OF BLADDER TUMORS BY ENDOSCOPIC SURGERY ROGER W. BARNES, R. THEODORE BERGMAN, HENRY L. HADLEY AND DAVID LOVE From the Department of Urology, School of Medicine, Loma Linda University, Loma Linda; and the White Memorial Medical Center, Los Angeles, California

The only way to be certain of a cure in a patient with a bladder tumor is by autopsy and thorough search for tumor in the bladder and for metastases to lymph glands and other structures. A 5, 10 or even 15-year followup showing no clinical evidence of tumor does not necessarily indicate a cure. One of our patients died of metastases from a bladder tumor 15 years after segmental resection; there had been no recurrence in the bladder. An evaluation of the effectiveness of treatment can be made by a determination of the survival rate. The recurrence rate is also significant, but is of less importance than the survival rate when evaluating the efficacy of treatment. Four-fifths of all bladder tumors can be controlled better by adequate endoscopic surgery and persistent followup care than by any other method of therapy. Of 505 patients with bladder tumors, followed 5 years or longer, 410 (81 per cent) were treated by endoscopic surgery. The remainder were treated by open surgery. The 5-year gross survival of all grades and depths of invasion treated by endoscopic surgery was 53 per cent (table 1). The 10-year survival of 305 patients was 32 per cent, and the 15-year survival of 206 cases was 18 per cent. The 5-year survival is significantly better with endoscopic surgery than it is with Accepted for publication June 30, 1966. Read at annual meeting of the Western Section, American Urological Association, Inc., Portland, Oregon, April 17-21, 1966. 1 Whitmore, W. F., Jr. and Marshall, V. F.: Radical total cystectomy for cancer of the bladder: 230 consecutive cases five years later. J. Urol., 87: 853, 1962. 2 Green, J. L. and Whitmore, W. F., Jr.: Experience with simple cystectomy in treatment of carcinoma of bladder. New York J. Med., 54: 3215, 1954. 3 Riches, E. W.: Place of total cystectomy in treatment of bladder growths. Ann. Roy. Coll. Surg., 18: 178, 1956. 4 Thompson, G. J.: Cystoscopic control of tumors of the urinary bladder. In: Treatment of Cancer and Allied Diseases, edited by G. T. Pack and I. M. Ariel, New York: Harper & Row, 1962, pp. 189-201.

cystectomy, as reported by others (table 2). Comparison of the survival rates reported at the 1964 Congress of the International Society of Urology in London by different authors and various methods of treatment also shows a better 5-year survival by endoscopic surgery (table 3). 5 SURVIVAL ACCORDING TO GRADE

The lower the grade of malignancy (Broders' classification) the better was the survival rate (table 4). Our pathologist classifies all papillomas as grade 1 tumors. In our series there is a 65 per cent, 5-year survival in grades 1 and 2 and 19 per cent in grades 3 and 4. Jewett has reported 5-year survivals of 37 per cent in low grade tumors and 21 per cent in high grade tumors in patients having either partial or total cystectomy. 6 SURVIVAL ACCORDING TO

STAGE

OR DEPTH OF

INVASION

There are several classifications of stage or depth of invasion. These are compared in table 5. When removing tumors endoscopically it is not possible to designate the invasion more accurately than the 4 stages: A) mucosa and submucosa; B) into muscle; C) through muscle and D) metastases. Patients with superficially invasive tumors have a higher survival rate than those with more deeply invasive growths (table 6). There is evidence that endoscopic surgery is preferable to open surgery in patients whose tumor has not extended through the bladder wall (table 7). In reports by Jewett6 and also by Whitmore and Marshall1 the 5-year survival of patients with tumors invading through the blad5 XIII Congres de la Societe Internationale d'Urologie. Edited by F. D. Fergusson, London: E. & S. Livingstone Ltd., vol. 1, pp. 121-245; vol. 2, 101-·240, 1964. 6 Jewett, H. J.: Prognosis of bladder tumors based on anatomical and pathological study. In: XIII Congres de la Societe Internationale d'Urologie, edited by F. D. Fergusson, London: E. & S. Livingstone Ltd., vol. 1, p. 138, 1964.

864

865

CONTROL OF BLADDER TUMORS BY ENDOSCOPIC' SURGERY TABLE

1. Survival rates-all grades and stages, all patientJ with proven bladder tumors treated by endoscopic surgery

+

5-Yr. Survival

Original no. of pts. at beginning of period Lost to followup

Net no. of pts. Number survived Per cent survival Died of cancer Died of other causes

410

Not included in original number 410 219 53% 0-4 yrs. 91 (22%) 101 (25%)

2. Comparison of survival following open surgical procedures with that following endoscopic surgical treatment

TABLE

5-Yr. Survival Author

No. Cases

Treatment

No Cases

%

-- -

Whitmore and MarshalP Green and Whitmore 2 Riches 3

230

Rad. total cystectomy

49

21

65

12

18

8

12

Thompson• Barnes

490 410

Simple cystectomy Simple cystectomy Endoscopic. Endoscopic

280 219

57 53

6.5

der wall was considerably better following open surgery than was ours following endoscopic removal of the tumor. However, in our cases treated by endoscopic surgery, the survival of patients whose tumor did not extend through the bladder wall was significantly better than was those with similar invasion treated by open surgery. 9 Only 14 per cent of our patients had tumors in C and D stages. 7 Union Internationale Cantre le Cancer, Research Commission, Committee on Clinical Stage Classification and Applied Statistics, Report of 1963-1964. 8 Jewett, H.J.: Carcinoma of the bladder: Development and evaluation of current concepts of therapy. J. Ural., 82: 92, 1959. 9 Barnes, R. W., Bergman, R. T., Hadley, H. L. and Love, D.: The results of endoscopic surgical treatment of bladder tumors. In: XIII Congres de la Societe Internationale d'Urologie, edited by F. D. Fergusson, London: E. & S. Livingstone Ltd., vol. 2, p. 122, 1964.

+

10-Yr. Survival

+

15-Yr. Survival

350

269

45

63

305 98 32% 0-9 yrs. 89 (29%) 118 (39%)

206 38 18% 0-14 yrs. 68 (33%) 100 (49%)

SURVIVAL IN RELATION TO SIZE

Patients with small tumors survive longer than those with larger growths (table 8). The survival is in reverse ratio to the size of the tumor when it is first removed by endoscopic surgery. Recurrence following endoscopic removal. Nearly 60 per cent of our cases had one or more repeat endoscopic procedures for removal of recurrent tumors (table 9). However, there were 110 patients (27 per cent) who had only one procedure and no recurrence for 5 years (table 10). Fortysix out of 353 (13 per cent) had no recurrence for 10 years after the first procedure and 15 out of 270 (5.5 per cent) lived 15 years or longer after the initial endoscopic removal without recurrence. There were 28 patients who had multiple procedures for recurrent tumors then lived 5 years or longer without another recurrence. Fifteen lived 10 years and 4 lived 15 years or longer without a recurrence after having had multiple procedures. This phenomenon might indicate that these patients acquired an immunity to the tumor. Small tumors are less likely to recur than large ones (table 11). Sixty-five per cent of tumors 1 cm. or less in diameter did not recur in 5 years. The larger the tumor the less likely it was to be controlled by one endoscopic removal. FACTORS INFLUENCING CONTROL

Adequate removal of the tumor by endoscopic surgery and persistent followup are the most important factors influencing control. The appearance of tumor tissue, as the tumor is being removed endoscopically, is different from bladder muscle (fig.). It is important to recognize this difference and to remove all of the tumor tissue

TABLE 3. Results of treatment of bladder tumors reported at the Congress of the International Society of Urology 5 Survival

Author

Treatment

No. Cases

Jewett

204

Barnes and associates

401

Ravasini and Cavazzana Tuoveinen and Paalanen de Campos Freire and Menezes de Goes Poole-Wilson and Pointon

147

Yrs. Surv.

Cystectomy tot. and part. Endoscopic Open surg. + radiothermy All treatment 60% open Supervolt. X-ray

100 163

Cystectomy and neo-rectal bladder

11

No. Cases

%

5 yrs. without c.a.

51

25

5 yrs. including recurrences 5 yrs.

212

53

60

41

Av. 3½ yrs. followup

64

64

3 yrs.

55

30

2 yrs.

4

36

TABLE 4. Survival according to grade of malignancy (cases lost to followup are eliminated) 5-Yr.

Malignancy (Cell Structure)

'

+ Survival

185 99 81 43

Grade 1 Grade 2 Grade 3 and 4 No grades recorded

10-Yr.

Survival

No. Cases

145 39 15 19

+ Survival

No. Cases

(80%) (39%) (19%) (44%)

125 76 68 34

Survival

69 13 5 10

15-Yr.

+ Survival Survival

No. Cases

(54%) (17%) (8%) (29%)

79

27 (3fl%) 7 (14%) 1 (2%) 3 (11%)

50

50 27

TABLE 5. Stage (infiltration, invasion, extent of tumor) Staging in This Report

Union Internationale Coutre le Cancer T.N.Nm. Histopathological Classification'

A. Invasion of epithelial and subepithelial tissues

Papilloma (so-called benign) T. 1 and P. 1 infiltration of subepithelial tissue

A.O, A

B. Invasion of muscle

T. 2 and P. 2 infiltration less than half way through muscle T. 3 and P. 3 infiltration half way or more through muscle

B-1, B-2

C. Invasion through muscle involving perivesical tissues

T. 4 and P. 3 infiltration into perivesical structures

C-1, C-2

D. Demonstrable metastases

N. and M. Node involvement and distant metastases

May occur in

Jewett'

B-1, B-2, Cl, C-2

TABLE 6. Survival according to depth of infiltration (cases lost to followup are eliminated) Depth of Infiltration

A. Mucosa and submucosa B. Into muscle C. Through muscle D. Demonstrable metastases No stage recorded

5-Yr. No. Cases

+ Survival Survival

233 114 37 20

146 46 2 1

5

0

(63%) (40%) (5%) (5%)

10-Yr. No. Cases

158 91 33 20 3

866

+ Survival

15-Yr.

+ Survival

Survival

No. Cases

Survival

81 (51%) 16 (18%) 1 (3%) 0

103 57 28 15

34 (33%) 4 (7%) 0 0

0

3

0

867

CONTROL OF BLADDER 'l'UiVIORS BY ENDOSCOPIC SURGERY

7. 5-Year survival according to depth of infiltration

TABLE

Author

Treatment

A-Mucosa and Submucosa

B-Into :i\1uscle

C and D Through Muscle aIJd/or Metastases

Jewett, 1964 (survival without cancer)

Cystectomy complete or partiaJ

21/38 (53%)

1.5/53 (28%)

16/113 (14%)

Whitmore and Marshall, 1962

Cystectomy complete or partial

A and B1 100/207 (48%)

(B2)

4/23 (17%)

7/53 (13%)

Barnes, 1964 (some with recurrence)

Endoscopic

140/227 (61%)

3/57

45/111 (41%)

(5%)

- - - - - - - - - - - ------TABLE

8. Survival in relation lo size of orig1:nal tumor 5-Yr.

Diameter of Tumor

+ Survival

No. Cases

Less than 1 cm. 1-3 cm. 3-6 cm. >6 cm.

38 189 88 58

TABLE

+ Survival

No. Cases

(80%) (59%) (44%) (31%)

23 143 63 48

19 (56%)

26

30 112 39 18

34

Not recorded

10-Yr.

Survived

15-Yr. T Survival ·---------

No. Cases

Survived

Survived -------------

17 (18%)

15 (24%)

15 95 44

10 (21%)

3/i

3 (9%)

8 (30%)

17

12 (52%)

52 (36%)

7 (·16%)

7

(29%)

9. Number of endoscopic procedures performed on each palicnl (401 paticnls)

Number of Endoscopic Procedures

3

>0

4

-------

:'\fo. patients

(;io of total patients

TABLE

169 41%

107 26%

23 6%

16

4c10

2:3

9 2c· IC

6%

10. Recurrence of bladder tumors after encloscovic removal, all cases

No recnrrence in pt's. surviving Recurrence but still living Multiple proced. but no recur. aHer last proced. Lost to followup

5 Yrs.

10 Yrs.

15 Yrs.

110 (27%) 113 (27%) 28

46 (13%) 54 (1.5%)

]5 (:3.:3%) :2:3 (8 ..sr7;)

15

.J.R 414

Total

TABLE

63 15%

4

(14%)

353

6.j (24%) 270

11. Recurrence of bladder tumors af lu encloscovic removal in relation to size of iunwr 5-yca r follow tlp (Si.ze not recorclecl in 3'l cases)

No recurrence Recurrence Died

1 cm.

1-3 cm.

3-6 cm.

20 (6.,<;;J) .'5 (16%) .'5 (19%)

63 (31r;;J) :i8 (29%) 79 (20%)

J6 (1SC;1c;l 23 (16%,) 49 UW7~)

>

(i

cm.

4 (7(;{)

J+ c23':'"c > 40 (70'7~ ;, --------·-

Total

31

200

88

.i8

868

BARNES AND ASSOCIATES

Partially resected bladder tumor shows different appearance of tumor tissue and bladder muscle and to continue resecting for approximately 1 cm. deep to the tumor and on all sides lateral to the tumor. This is done even though the resection is continued entirely through the bladder wall. When an isotonic solution is used for inflow during the operation, and free drainage through the catheter is maintained postoperatively, there are usually no serious complications from a perforation of the bladder wall. Saving a few pieces of tissue for biopsy from the bladder wall lateral to and deep to the tumor helps to determine whether the entire tumor has been removed. Followup cystoscopic examination is made every 3 months following removal of the tumor. If there is a recurrence, it is removed endoscopically. When there is no recurrence for 9 months the interval of followup cystoscopy is increased to 6 months and when there is none in a year a followup cystoscopy is repeated once a year for the remainder of the patient's life.

SUMMARY

Eighty per cent of bladder tumors can be controlled better by adequate endoscopic surgery and persistent followup than by any other method. There is a significant correlation between survival rate and the three factors, grade of malignancy, depth of invasion and size of the tumor. Patients with tumors of low grade malignancy, shallow invasion and small size have longer survival than those with tumors of high grade malignancy, deep invasion and large size. Removal of all tumor tissue, including bladder wall 1 cm. beyond the tumor, and followup cystoscopy at 3-month to 1-year intervals are the chief factors in control of bladder tumors by endoscopic surgery. 1700 Brooklyn Avenue, Los Angeles, California 90033 (R. W. B.)