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Lumbar Fossa Evisceration for Large Flank Tumors
THE .JOURNAL OF UROLOGY
Vol. 81, No. 5, May 1959 Printed h1 U.S.A.
LUMBAR FOSSA EVISCERATION FOR LARGE FLANK TUMORS JAMES J. DIAMOND From the Tumor Service, St.Joseph's Hospital, Reading, Pa.
Occasionally the urologist or general surgeon is faced ,vith the problem of removing large tumors of the flank region which involve more than one organ. Such tumors may arise in the colon, kidney, adrenal or retroperitoneal mesenchyme, and spread to contiguous structures. Such large masses are removed only with considerable difficulty through a standard flank nephrectomy incision, and may be erroneously termed inoperable due to the spatial inadequacy of the incision. The intent of this paper is to describe an approach which in the opinion of the author will satisfy the anatomical, technical and oncological requirements of a proper surgical attack on these otherwise difficult situations. PREVIOUSLY SUGGESTED APPROACHES TO THE PROBLEM
When renal cancer spreads locally, it may invade the adrenal, pancreatic tail, spleen or left colon on the left side, while on the right it may spread to the duodenum, adrenal or right colon. Similar patterns of spread may occur in cancer of the right or left colon, and the surgery proper to the curative removal of these multivisceral tumors must be tailored to the dimensions suggested in this report, i.e., evisceration of the lumbar fossa in en bloc continuity with a hemicolectomy. Various approaches have been devised by urologists to facilitate the removal of such masses. :VIortensen described a thoracoabdominal approach through the bed of the tenth left rib; he resected the spleen and distal pancreas with a large renal mass previously declared inoperable by the flank route. Sweetser utilizes a large anterolateral flap to gain access to large renal tumors. Chute and his associates use a thoracoabdominal incision through the bed of the eleventh rib to expose the renal mass. Recently, Clarke, Rudy and Leadbetter have reported a large experience with the thoracoabdominal approach to the operative area, including many multivisceral resections as well as several cases Accepted for publication October 20, 1958. 624
previously attacked in vain by the flank approach. The dorsolumbar flap incision devised by N agama tsu is familiar to most cancer surgeons, but we arc unable to convert it comfortably to our needs when the enormous resection here described is indicated. Since we are in full sympathy with any aggressive philosophy of cancer surgery, we wish to describe the total evisceration of the lumbar fossa as a radical attack on renal cancer, and the en bloc evisceration and hemicolcctomy as a logical attack on cancer that has invaded both colon and kidney, regardless of the primary origin. vV e have now performed the latter procedure three times by way of the thoracoabdominal route, once for right colon cancer invading the kidney, once for right kidney adenocarcinoma invading the right colon, and lastly for a recurrent descending colon cancer involving the left kidney. 'l'Hic OPERATION AS AN EN BLOC PROCEDURE
The lumbar fossa extends from the vertebral column to the lateral muscular parietes, from the diaphragm to the pelvic aditus. Anteriorly it is limited by the posterior peritoneum, posteriorly by the diaphragm, quadratus lumborum, psoas and iliacus muscles. It contains the kidney and ureter, adrenal, perirenal fat as contained within Gerota's fascial envelope, the ovarian or spermatic vessels, the para-aortic or paracaval nodes, and three nerves, i.e., the iliohypogastric, ilioinguinal and genitofemoral. The duodenum and tail of the pancreas are intimately associated with the fossae. Operative exposure of the fossa is obtained in this manner: A rectus incision into the peritoneal cavity is made from a point halfway between the umbilicus and symphysis pubis up to the costal margin, then turned out into the ninth interspace to the midaxillary line. The diaphragm is divided radially to the vertebral column and then appropriate retractors are utilized to spread the ribs and abdominal portion of the incision. On the right side, the right
LUMBAR FOSSA EVISCERATION FOR LARGE TUMORS
colon, duodenum and liver are reflected medially by cutting their loose attachments to the parietal peritoneum. On the left side, the spleen, pancreatic tail and colon are reflected in like manner. The exposure of the mass is naturally altered to meet the exigencies of the situation, and the spleen or pancreatic tail may be left attached to the mass if the thoroughness of the operation would be compromised by leaving these structures behind. If hemicolectomy is to be done because of joint involvement of kidney and colon, the transverse colon is divided in the midline as well as its mesocolon down to the aorta. Pari passu, the terminal ileum or sigmoid colon is divided in like manner. Division of the gastrocolic and lienocolic ligaments will then permit the hemicolon to be left attached to the contents of the fossa. The posterior peritoneum is then incised for the length of the abdominal cavity in the midline, from the diaphragm to the bifurcation of the aorta and then along the iliac vessels to the bifurcation of the iliacs. The celiac axis and superior mesenteric arteries are skirted. The renal vein and artery in order are divided; then, depending on the side, the adrenal, spermatic or ovarian and inferior mesenteric vessels are divided. If a suitable safety margin is available on the left side, only the left colic branch of the inferior mesenteric artery is divided. By elevating or incising the pelvic peritoneum it is possible to divide the ureter at the base of the bladder. If indicated, total ureterectomy and segmental resection of the bladder around the ureteral orifice are achieved by extending the abdominal incision down to the symphysis pubis. Lymphadenectomy is then accomplished from the diaphragm to the bifurcation of the iliac vessels. This will bare the entire abdominal sympathetic chain, the vertebrae and great vessels. The posterior peritoneum is then incised from the crus of the diaphragm to the tip of the eleventh rib, then downward in the mid-sagittal line to join the peritoneal incision over the bifurcation of the common iliac on that side. When the hemicolon is to be removed in continuity with the lumbar fossa contents, it is necessary to incise the peritoneum anterior to the colonic attachments along the lateral wall of the peritoneal cavity. Vii'hen the peritoneal circumcision has been completed, the spermatic
625
or ovarian vessels are divided at the pelvic brim, and the entire specimen is separated from the posterior muscles in an avascular plane. If simple fossa evisceration has been performed for renal cancer, the fossa is easily reperitonealized by replacing the colon into its original position and tacking it to the cut edge of the lateral peritoneum. If hemicolectomy has been performed also, the fossa is reperitonealized by swinging the remaining omentum over into the fossa and tacking it in place, after the bowel anastomosis has been completed. The specimen thus contains the peritoneum, kidney and ureter, adrenal, nodes and perirenal fat, with or without hemicolon and wide wedge of mesentery. We have not yet resected spleen or pancreatic tail, but will not hesitate to do so if the need should arise. It should be emphasized that this specimen is removed in an inviolate state, after preliminary isolation of all channels communicating between the tumor mass and the rest of the body prior to manipulation of the tumor. The only breach of this technique occurs when frozen section is necessary to establish diagnosis prior to actual ablation. The procedure as accomplished combines the accepted principles of minimal handling of tumor, preliminary isolation and en bloc continuity of resection. No surgeon familiar with modern cancer surgery precepts will challenge the integrity of this philosophy, regardless of the salvage rates obtained by such a procedure. ANCILLARY CONSIDERATIONS
After considerable chagrin early in our experience, we now obtain excretory urograms in all cases of bowel cancer where there is the remotest possibility of retroperitoneal involvement. Naturally, a barium enema is part of the workup of any renal tumor. Preoperative preparation includes vigorous saline catharsis and ample bowel sterilization; the operative exposure is considerably enhanced by collapse of the loops of small bowel. Blood loss is between one and two pints of blood if the operator is deliberate, although such a painstaking technique may extend operating time to five or six hours. There is little difficulty in obtaining wide exposure, and the pertinent retraction is not arduous for the assistant, which factor is not unimportant in lengthy operations. Postoperative ileus may last five days; we
626
JAMES J, DIAMOND
rely on a nasogastric tube and intravenous fluids until peristalsis is audible and flatus is passed. The chest catheter is removed at 48 hours. Temporary postoperative adrenal hypofunction may occur and should be recognized and treated promptly, but we have not seen it yet. Personal evaluation of the procedure. Although we are quite familiar with the techniques of radical nephrectomy suggested by N agamatsu, Sweetser, Foley and others, we believe that there is indication that the described procedure may enjoy certain advantages which may or may not obtain in the conventional approaches to renal tumors: 1) Any renal tumor curable by simple nephrectomy without node dissection is curable by radical nephrectomy. 2) Renal tumors pronounced inoperable by the flank route are often quite readily delivered by the thoracoabdominal route. 3) The renal vein is ligated safely under clear visualization prior to any manipulation of the tumor. 4) Similar early isolation of the bowel segment by mesenteric ligation is achieved prior to handling of the tumor. 5) The vena cava may be repaired if damaged, or resected if necessary, under direct close vision. 6) If indicated, total ureterect.omy is readily performed by a simple downward extension of the abdominal incision. 7) The liver and ipsilateral lung and mediastinum are accessible, which factor is of use in determining operability and prognosis. 8) When contiguous intra-abdominal viscera require resection, the abdominal exposure is unexcelled for gaining access to the pPrtinent node areas. 9) Oxygenation of the patient is readily maintained in those patients with a marginal pulmonary function reserve. The oxygenation of such risky patients is not without difficulty when they are submitted to lengthy procedures which involve an open thorax while lying on their side. Objections to the procedure. Why do a radical nephrectomy when its superiority over simple nephrectomy is not yet proven? It is true that there is no published evidence of the superiority of radical nephrectomy as defined by Foley. Moreover, it is unlikely that any such evidence
will be forthcoming in the next 20 years, due to the prolonged natural history of renal cancer. In addition, there is no control node study against which to pitch the information now being obtained by histologic study of regional nodes removed in the radical procedure. However, since radical nephrectomy in the hands of competent surgeons does not appreciably alter the morbidity and mortality over that encountered in simple nephrectomy, we see no objection to instituting the policy of radical nephrectomy at the present time. If after 20 years the procedure proves worthless, there will have been nothing lost, while a number of lives may be saved currently if the future followup studies do reveal a significant improvement in salvage rates. Beyond the considerations of salvage, it is important to remember that the increase in local resectability achieved by extended procedures will result in control of the local tumor in more patients, and thus will spare them the ordeal of flank pain, bowel obstruction and the sequelae of massive tumor growth, tumor necrosis, hemorrhage and infection. Such gains are in themselves adequate indication to attack these tumors by whichever method will secure local removal in the en bloc type of resection. When considering the fruitfulness of the extensive retroperitoneal lymph node excision, one naturally meets objec.:tions from those who point out the incidence of renal vein invasion by the tumor, and the resultant pulmonary spread. This commonly accepted situation may or may not deserve all of the ominous import now credited to it. It is currently recognized that many tumors invade veins, notably cancers of the thyroid and colon, but the presence of this invasion does not denote incurability but merely decreased curability. If tumor cells are constantly exfoliated into the circulation, it does not matter whether the cells are from tumor in tiny venules in the renal parenchyma or from tumor in the main renal vein. Consequently, it may well be a defeatist attitude to omit lymphadenectomy when tumor thrombus is in the vein, for in all probability the cell exfoliation has been going on for many months, and the absence of pulmonary metastases may denote that the exfoliated cells are lodging in tissue hostile to the independent survival of these cells. It remains to be proven that there is not a stage at which renal cancers are localized to the
LUMBAR FOSSA EVISCERATION FOR LARGE TUMORS
kidney and regional nodes, and thus curable by radical nephrectomy with regional lymphadenectomy. Studies on autopsy material reveal only the terminal state of affairs in renal cancer, not the conditions present in the early stages of the tumor. Consequently, such studies should not be held as incontrovertible evidence that lymphadenectomy is a futile adjunct to nephrectomy. Such evidence in order to be unassailable must arise from carefully controlled long term comparisons of survival obtained by standard nephrectomy and by radical nephrectomy. There is bound to be an increase in morbidity and mortality in any series of extended procedures, for there is an inherent morbidity in any series of bowel resections or thoracotomies. In current surgical practice, the urologist as well as the general surgeon must be proficient in the thoracoabdominal approach to flank tumors, and the diaphragm cannot constitute a barrier to the attack. The thoracic portion of the incision is not developed until the local resectability of the lesion is established, and the extended resection is not begun until manual examination of the mediastinal nodes and lung has been accomplished. By following this order of procedure, no patients will be subjected to any unnecessary extended procedure. Needless to say, the urologist must be familiar with the technique of bowel resection and with the scope of resection required by cancer in the various segments of colon. If a renal cancer has invaded mesentery or colon, the same wide resection of bowel and mesenteric node areas is indicated as in cases of primary cancer of the colon. The described operative approach renders such wide en bloc resection quite simple. Why is such a wide area of peritoneum removed? Aside from the fact that it simplifies the procedure, we believe that the wide resection of the peritoneal covering of the fossa contents has considerable merit. We are frnnk to admit that we are not always able to obtain a good line of cleavage between Gerota's fascia and the peritoneum. This is particularly true when the presence of a tumor has created a pseudo-inflammatory reaction in the surrounding tissues, or where prior surgery has been attempted. If the tumor has crossed from kidney through Gerota's fascia to the mesentery or bowel, wide resection of the peritoneum becomes
627
quite mandatory, for we just don't know where the tiny lymphatic channels of Gerota's fascia stop and those of the subserous peritoneal plexus start. Even when a renal cancer is still limited to the kidney and perirenal fat, the additional layer of overlying peritoneum should be widely ablated in continuity with the contents of the fossa. If it is good cancer surgery to stay one plane away from the tumor, it might well be better to stay two planes away in these cases. It has been shown by Beare and McDonald that cancers of the renal parenchyma which have invaded the capsule and perirenal fat are associated with a decreased survival. Since cancer does appear to be an exfoliative growth, one might ask, "Where do tumor cells go when they are exfoliated into the perirenal fat?" Certainly fat is no barrier to cells floating free in the tissue spaces between the fat cells, and when tumor extensions are demonstrable in the fat one must remember that the tumor crossed intercellular fluid spaces to get into the perirenal fat. Such free-floating cells may die without implanting, or they may drain to regional nodes where they may either live or die. vVe can see no objection born of either practical experience or proven observation that would countermand the suggested plan of utilizing wide removal of the peritoneum as an additional margin of safety anterior to the fossa contents. Such an additional margin does not exist along the other borders of the lumbar fossa. Local irrigation with ethyleneimines or other tumoricidal cytotoxins, as is currently proposed in tumor surgery of the head and neck or of the pelvis, may prove to be a fruitful investigational field for those actively interested in tracking down all conceivable leads to an improved salvage rate in renal cancer. In a similar vein, systemic chemotherapy to attempt destruction of any viable exfoliated cells in the blood or in subclinical metastatic deposits might add to the salvage rate. It is not in keeping with the dignity of those charged with the treatment of cancer patients that they should seek out ephemeral or illproven reasons why they should not extend every plausible and feasible adjunct to the therapy of cancer. In this field of endeavor as in others, it is better to have tried and failed than never to have tried at all.
628
JAMES J. DIAMOND
CASE REPORT
A 63-year-old white woman was admitted with pain in the left groin and hip 18 months in duration. She had undergone a limited segmental resection of the upper portion of the descending colon for carcinoma 32 months earlier. For the past year and a half, she had sought relief from pain radiating from the lumbar area into the groin and hip, and had lost 35 pounds. No dysfunction of the bowel or kidney was noted. Her stool and urine contained no blood. A barium enema was negative. Intravenous pyelography revealed a filling defect between the middle and lower calyces of the left kidney. No distant metastases were demonstrable by roentgen ray studies or by marrow puncture smears. A diagnosis was made of recurrent carcinoma of the colon in the left lumbar fossa structures, probably inoperable. A laparotomy was performed and a large monobloc mass found in the left lumbar fossa involving the kidney and mesocolon; large nodes were palpable in the mesentery and in the hilar region of the kidney. To obtain exposure, the incision was extended up to the costal margin, then out into the ninth interspace, and the diaphragm incised to lay open the fossa. A left lumbar fossa evisceration was then performed including an en bloc left hemicolectomy, nephro-ureterectomy, adrenalectomy, retroperitoneal lymphaclenectomy from diaphragm to iliac bifurcation and a transverse to sigmoid colocolostomy. It was necessary to resect both the iliohypogastric and ilioinguinal nerves because they passed through tumor. The fossa was reperitonealized by flipping over the remaining omentum and suturing it to the cut edge of peritoneum on the lateral parietes. The patient was discharged on the twelfth postoperative clay, free of all preoperative or any other pain. Pathology report: A.denocarcinoma of the colon, recurrent, involving the mesenteric nodes, kidney, hilar nodes, one inferior paraaortic node and two periureteral nodes. No tumor was found in bowel mucosa or musculature. We have also performed a practically identical procedure for carcinoma of the right colon invading the right kidney, and for adenocarcinoma of the right kidney involving the right colon. The monobloc resection of the hemicolon with
the entire contents of the lumbar fossa has been achieved with ease in each case, due to the unexcelled exposure, distinctness of landmarks and easily followed planes. We have not yet encountered any undue morbidity, but naturally we anticipate it in each case due to the enormity of the procedure. All three patients are living and well, from three to 11 months postoperatively. SUMMARY A technique of monobloc excision of the contents of the lumbar fossa has been presented as an operative attack on large flank tumors. One of three cases is cited in some detail. I ts a pplicability to large multivisceral flank tumors of bowel or retroperitoneal origin is demonstrated, and the rationale of such a wide ablative procedure is discussed. It is felt that it is the operation of choice for multivisceral involvement by renal or colon cancers, and the technique of hemicolectomy in continuitv with lumbar fossa evisceration is described. It is also suggested that simple fossa evisceration with wide resection of the posterior peritoneum be considered as an approach to large renal cancers which are still limited to the contents of Gerota's fascia grossly. The rationale of coincident regional lymphaclenectomy pertinent to kidney and/or colon is also presented. Although the long-term fruitfulness of such extended procedures is still in doubt, it is suggested that the benefit of the doubt be extended to the patient rather than to the cancer until such time as this philosophy be proven unrealistic. REFERENCES BEARE, J.B. AND JVIcDoNALD, J. R.: Involvement of the renal capsule in surgically removed hypernephroma: A gross and histologic study. J. Urol., 61: 857-861, 1949. · CHUTE, R. AND SAUTTER, L.: Thoraco-abdominal nephrectomy for renal tumors. J. U rol. 61: 688-696, 1949.
CLARKE, B. W. F. : surgery plasms. 1958.
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G., RunY, H. A. AND LEADBETTER The thoracoabdominal incision f oi of renal, adrenal and testicular neoSurg., Gynec. & Obst. 106: 363-367 '
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MoRTENSEN, H. Transthoracic nephrectomy. J. Urol., 60: 855-858, 1948. . NAGAMATSU, G. R., LERMAN, P.H. AND BERMAN M .. H.: The dorsolumbar flap incision in uro~ logic surgery. J. Urol., 67: 787-803, 1952. SWEETSER, T. H.: The surgical approach to renal and other retroperitoneal tumors. J. Urol. 57: 651-661, 1947.
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Vol. 81, No. 5, May 1959 Printed h1 U.S.A.
LUMBAR FOSSA EVISCERATION FOR LARGE FLANK TUMORS JAMES J. DIAMOND From the Tumor Service, St.Joseph's Hospital, Reading, Pa.
Occasionally the urologist or general surgeon is faced ,vith the problem of removing large tumors of the flank region which involve more than one organ. Such tumors may arise in the colon, kidney, adrenal or retroperitoneal mesenchyme, and spread to contiguous structures. Such large masses are removed only with considerable difficulty through a standard flank nephrectomy incision, and may be erroneously termed inoperable due to the spatial inadequacy of the incision. The intent of this paper is to describe an approach which in the opinion of the author will satisfy the anatomical, technical and oncological requirements of a proper surgical attack on these otherwise difficult situations. PREVIOUSLY SUGGESTED APPROACHES TO THE PROBLEM
When renal cancer spreads locally, it may invade the adrenal, pancreatic tail, spleen or left colon on the left side, while on the right it may spread to the duodenum, adrenal or right colon. Similar patterns of spread may occur in cancer of the right or left colon, and the surgery proper to the curative removal of these multivisceral tumors must be tailored to the dimensions suggested in this report, i.e., evisceration of the lumbar fossa in en bloc continuity with a hemicolectomy. Various approaches have been devised by urologists to facilitate the removal of such masses. :VIortensen described a thoracoabdominal approach through the bed of the tenth left rib; he resected the spleen and distal pancreas with a large renal mass previously declared inoperable by the flank route. Sweetser utilizes a large anterolateral flap to gain access to large renal tumors. Chute and his associates use a thoracoabdominal incision through the bed of the eleventh rib to expose the renal mass. Recently, Clarke, Rudy and Leadbetter have reported a large experience with the thoracoabdominal approach to the operative area, including many multivisceral resections as well as several cases Accepted for publication October 20, 1958. 624
previously attacked in vain by the flank approach. The dorsolumbar flap incision devised by N agama tsu is familiar to most cancer surgeons, but we arc unable to convert it comfortably to our needs when the enormous resection here described is indicated. Since we are in full sympathy with any aggressive philosophy of cancer surgery, we wish to describe the total evisceration of the lumbar fossa as a radical attack on renal cancer, and the en bloc evisceration and hemicolcctomy as a logical attack on cancer that has invaded both colon and kidney, regardless of the primary origin. vV e have now performed the latter procedure three times by way of the thoracoabdominal route, once for right colon cancer invading the kidney, once for right kidney adenocarcinoma invading the right colon, and lastly for a recurrent descending colon cancer involving the left kidney. 'l'Hic OPERATION AS AN EN BLOC PROCEDURE
The lumbar fossa extends from the vertebral column to the lateral muscular parietes, from the diaphragm to the pelvic aditus. Anteriorly it is limited by the posterior peritoneum, posteriorly by the diaphragm, quadratus lumborum, psoas and iliacus muscles. It contains the kidney and ureter, adrenal, perirenal fat as contained within Gerota's fascial envelope, the ovarian or spermatic vessels, the para-aortic or paracaval nodes, and three nerves, i.e., the iliohypogastric, ilioinguinal and genitofemoral. The duodenum and tail of the pancreas are intimately associated with the fossae. Operative exposure of the fossa is obtained in this manner: A rectus incision into the peritoneal cavity is made from a point halfway between the umbilicus and symphysis pubis up to the costal margin, then turned out into the ninth interspace to the midaxillary line. The diaphragm is divided radially to the vertebral column and then appropriate retractors are utilized to spread the ribs and abdominal portion of the incision. On the right side, the right
LUMBAR FOSSA EVISCERATION FOR LARGE TUMORS
colon, duodenum and liver are reflected medially by cutting their loose attachments to the parietal peritoneum. On the left side, the spleen, pancreatic tail and colon are reflected in like manner. The exposure of the mass is naturally altered to meet the exigencies of the situation, and the spleen or pancreatic tail may be left attached to the mass if the thoroughness of the operation would be compromised by leaving these structures behind. If hemicolectomy is to be done because of joint involvement of kidney and colon, the transverse colon is divided in the midline as well as its mesocolon down to the aorta. Pari passu, the terminal ileum or sigmoid colon is divided in like manner. Division of the gastrocolic and lienocolic ligaments will then permit the hemicolon to be left attached to the contents of the fossa. The posterior peritoneum is then incised for the length of the abdominal cavity in the midline, from the diaphragm to the bifurcation of the aorta and then along the iliac vessels to the bifurcation of the iliacs. The celiac axis and superior mesenteric arteries are skirted. The renal vein and artery in order are divided; then, depending on the side, the adrenal, spermatic or ovarian and inferior mesenteric vessels are divided. If a suitable safety margin is available on the left side, only the left colic branch of the inferior mesenteric artery is divided. By elevating or incising the pelvic peritoneum it is possible to divide the ureter at the base of the bladder. If indicated, total ureterectomy and segmental resection of the bladder around the ureteral orifice are achieved by extending the abdominal incision down to the symphysis pubis. Lymphadenectomy is then accomplished from the diaphragm to the bifurcation of the iliac vessels. This will bare the entire abdominal sympathetic chain, the vertebrae and great vessels. The posterior peritoneum is then incised from the crus of the diaphragm to the tip of the eleventh rib, then downward in the mid-sagittal line to join the peritoneal incision over the bifurcation of the common iliac on that side. When the hemicolon is to be removed in continuity with the lumbar fossa contents, it is necessary to incise the peritoneum anterior to the colonic attachments along the lateral wall of the peritoneal cavity. Vii'hen the peritoneal circumcision has been completed, the spermatic
625
or ovarian vessels are divided at the pelvic brim, and the entire specimen is separated from the posterior muscles in an avascular plane. If simple fossa evisceration has been performed for renal cancer, the fossa is easily reperitonealized by replacing the colon into its original position and tacking it to the cut edge of the lateral peritoneum. If hemicolectomy has been performed also, the fossa is reperitonealized by swinging the remaining omentum over into the fossa and tacking it in place, after the bowel anastomosis has been completed. The specimen thus contains the peritoneum, kidney and ureter, adrenal, nodes and perirenal fat, with or without hemicolon and wide wedge of mesentery. We have not yet resected spleen or pancreatic tail, but will not hesitate to do so if the need should arise. It should be emphasized that this specimen is removed in an inviolate state, after preliminary isolation of all channels communicating between the tumor mass and the rest of the body prior to manipulation of the tumor. The only breach of this technique occurs when frozen section is necessary to establish diagnosis prior to actual ablation. The procedure as accomplished combines the accepted principles of minimal handling of tumor, preliminary isolation and en bloc continuity of resection. No surgeon familiar with modern cancer surgery precepts will challenge the integrity of this philosophy, regardless of the salvage rates obtained by such a procedure. ANCILLARY CONSIDERATIONS
After considerable chagrin early in our experience, we now obtain excretory urograms in all cases of bowel cancer where there is the remotest possibility of retroperitoneal involvement. Naturally, a barium enema is part of the workup of any renal tumor. Preoperative preparation includes vigorous saline catharsis and ample bowel sterilization; the operative exposure is considerably enhanced by collapse of the loops of small bowel. Blood loss is between one and two pints of blood if the operator is deliberate, although such a painstaking technique may extend operating time to five or six hours. There is little difficulty in obtaining wide exposure, and the pertinent retraction is not arduous for the assistant, which factor is not unimportant in lengthy operations. Postoperative ileus may last five days; we
626
JAMES J, DIAMOND
rely on a nasogastric tube and intravenous fluids until peristalsis is audible and flatus is passed. The chest catheter is removed at 48 hours. Temporary postoperative adrenal hypofunction may occur and should be recognized and treated promptly, but we have not seen it yet. Personal evaluation of the procedure. Although we are quite familiar with the techniques of radical nephrectomy suggested by N agamatsu, Sweetser, Foley and others, we believe that there is indication that the described procedure may enjoy certain advantages which may or may not obtain in the conventional approaches to renal tumors: 1) Any renal tumor curable by simple nephrectomy without node dissection is curable by radical nephrectomy. 2) Renal tumors pronounced inoperable by the flank route are often quite readily delivered by the thoracoabdominal route. 3) The renal vein is ligated safely under clear visualization prior to any manipulation of the tumor. 4) Similar early isolation of the bowel segment by mesenteric ligation is achieved prior to handling of the tumor. 5) The vena cava may be repaired if damaged, or resected if necessary, under direct close vision. 6) If indicated, total ureterect.omy is readily performed by a simple downward extension of the abdominal incision. 7) The liver and ipsilateral lung and mediastinum are accessible, which factor is of use in determining operability and prognosis. 8) When contiguous intra-abdominal viscera require resection, the abdominal exposure is unexcelled for gaining access to the pPrtinent node areas. 9) Oxygenation of the patient is readily maintained in those patients with a marginal pulmonary function reserve. The oxygenation of such risky patients is not without difficulty when they are submitted to lengthy procedures which involve an open thorax while lying on their side. Objections to the procedure. Why do a radical nephrectomy when its superiority over simple nephrectomy is not yet proven? It is true that there is no published evidence of the superiority of radical nephrectomy as defined by Foley. Moreover, it is unlikely that any such evidence
will be forthcoming in the next 20 years, due to the prolonged natural history of renal cancer. In addition, there is no control node study against which to pitch the information now being obtained by histologic study of regional nodes removed in the radical procedure. However, since radical nephrectomy in the hands of competent surgeons does not appreciably alter the morbidity and mortality over that encountered in simple nephrectomy, we see no objection to instituting the policy of radical nephrectomy at the present time. If after 20 years the procedure proves worthless, there will have been nothing lost, while a number of lives may be saved currently if the future followup studies do reveal a significant improvement in salvage rates. Beyond the considerations of salvage, it is important to remember that the increase in local resectability achieved by extended procedures will result in control of the local tumor in more patients, and thus will spare them the ordeal of flank pain, bowel obstruction and the sequelae of massive tumor growth, tumor necrosis, hemorrhage and infection. Such gains are in themselves adequate indication to attack these tumors by whichever method will secure local removal in the en bloc type of resection. When considering the fruitfulness of the extensive retroperitoneal lymph node excision, one naturally meets objec.:tions from those who point out the incidence of renal vein invasion by the tumor, and the resultant pulmonary spread. This commonly accepted situation may or may not deserve all of the ominous import now credited to it. It is currently recognized that many tumors invade veins, notably cancers of the thyroid and colon, but the presence of this invasion does not denote incurability but merely decreased curability. If tumor cells are constantly exfoliated into the circulation, it does not matter whether the cells are from tumor in tiny venules in the renal parenchyma or from tumor in the main renal vein. Consequently, it may well be a defeatist attitude to omit lymphadenectomy when tumor thrombus is in the vein, for in all probability the cell exfoliation has been going on for many months, and the absence of pulmonary metastases may denote that the exfoliated cells are lodging in tissue hostile to the independent survival of these cells. It remains to be proven that there is not a stage at which renal cancers are localized to the
LUMBAR FOSSA EVISCERATION FOR LARGE TUMORS
kidney and regional nodes, and thus curable by radical nephrectomy with regional lymphadenectomy. Studies on autopsy material reveal only the terminal state of affairs in renal cancer, not the conditions present in the early stages of the tumor. Consequently, such studies should not be held as incontrovertible evidence that lymphadenectomy is a futile adjunct to nephrectomy. Such evidence in order to be unassailable must arise from carefully controlled long term comparisons of survival obtained by standard nephrectomy and by radical nephrectomy. There is bound to be an increase in morbidity and mortality in any series of extended procedures, for there is an inherent morbidity in any series of bowel resections or thoracotomies. In current surgical practice, the urologist as well as the general surgeon must be proficient in the thoracoabdominal approach to flank tumors, and the diaphragm cannot constitute a barrier to the attack. The thoracic portion of the incision is not developed until the local resectability of the lesion is established, and the extended resection is not begun until manual examination of the mediastinal nodes and lung has been accomplished. By following this order of procedure, no patients will be subjected to any unnecessary extended procedure. Needless to say, the urologist must be familiar with the technique of bowel resection and with the scope of resection required by cancer in the various segments of colon. If a renal cancer has invaded mesentery or colon, the same wide resection of bowel and mesenteric node areas is indicated as in cases of primary cancer of the colon. The described operative approach renders such wide en bloc resection quite simple. Why is such a wide area of peritoneum removed? Aside from the fact that it simplifies the procedure, we believe that the wide resection of the peritoneal covering of the fossa contents has considerable merit. We are frnnk to admit that we are not always able to obtain a good line of cleavage between Gerota's fascia and the peritoneum. This is particularly true when the presence of a tumor has created a pseudo-inflammatory reaction in the surrounding tissues, or where prior surgery has been attempted. If the tumor has crossed from kidney through Gerota's fascia to the mesentery or bowel, wide resection of the peritoneum becomes
627
quite mandatory, for we just don't know where the tiny lymphatic channels of Gerota's fascia stop and those of the subserous peritoneal plexus start. Even when a renal cancer is still limited to the kidney and perirenal fat, the additional layer of overlying peritoneum should be widely ablated in continuity with the contents of the fossa. If it is good cancer surgery to stay one plane away from the tumor, it might well be better to stay two planes away in these cases. It has been shown by Beare and McDonald that cancers of the renal parenchyma which have invaded the capsule and perirenal fat are associated with a decreased survival. Since cancer does appear to be an exfoliative growth, one might ask, "Where do tumor cells go when they are exfoliated into the perirenal fat?" Certainly fat is no barrier to cells floating free in the tissue spaces between the fat cells, and when tumor extensions are demonstrable in the fat one must remember that the tumor crossed intercellular fluid spaces to get into the perirenal fat. Such free-floating cells may die without implanting, or they may drain to regional nodes where they may either live or die. vVe can see no objection born of either practical experience or proven observation that would countermand the suggested plan of utilizing wide removal of the peritoneum as an additional margin of safety anterior to the fossa contents. Such an additional margin does not exist along the other borders of the lumbar fossa. Local irrigation with ethyleneimines or other tumoricidal cytotoxins, as is currently proposed in tumor surgery of the head and neck or of the pelvis, may prove to be a fruitful investigational field for those actively interested in tracking down all conceivable leads to an improved salvage rate in renal cancer. In a similar vein, systemic chemotherapy to attempt destruction of any viable exfoliated cells in the blood or in subclinical metastatic deposits might add to the salvage rate. It is not in keeping with the dignity of those charged with the treatment of cancer patients that they should seek out ephemeral or illproven reasons why they should not extend every plausible and feasible adjunct to the therapy of cancer. In this field of endeavor as in others, it is better to have tried and failed than never to have tried at all.
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JAMES J. DIAMOND
CASE REPORT
A 63-year-old white woman was admitted with pain in the left groin and hip 18 months in duration. She had undergone a limited segmental resection of the upper portion of the descending colon for carcinoma 32 months earlier. For the past year and a half, she had sought relief from pain radiating from the lumbar area into the groin and hip, and had lost 35 pounds. No dysfunction of the bowel or kidney was noted. Her stool and urine contained no blood. A barium enema was negative. Intravenous pyelography revealed a filling defect between the middle and lower calyces of the left kidney. No distant metastases were demonstrable by roentgen ray studies or by marrow puncture smears. A diagnosis was made of recurrent carcinoma of the colon in the left lumbar fossa structures, probably inoperable. A laparotomy was performed and a large monobloc mass found in the left lumbar fossa involving the kidney and mesocolon; large nodes were palpable in the mesentery and in the hilar region of the kidney. To obtain exposure, the incision was extended up to the costal margin, then out into the ninth interspace, and the diaphragm incised to lay open the fossa. A left lumbar fossa evisceration was then performed including an en bloc left hemicolectomy, nephro-ureterectomy, adrenalectomy, retroperitoneal lymphaclenectomy from diaphragm to iliac bifurcation and a transverse to sigmoid colocolostomy. It was necessary to resect both the iliohypogastric and ilioinguinal nerves because they passed through tumor. The fossa was reperitonealized by flipping over the remaining omentum and suturing it to the cut edge of peritoneum on the lateral parietes. The patient was discharged on the twelfth postoperative clay, free of all preoperative or any other pain. Pathology report: A.denocarcinoma of the colon, recurrent, involving the mesenteric nodes, kidney, hilar nodes, one inferior paraaortic node and two periureteral nodes. No tumor was found in bowel mucosa or musculature. We have also performed a practically identical procedure for carcinoma of the right colon invading the right kidney, and for adenocarcinoma of the right kidney involving the right colon. The monobloc resection of the hemicolon with
the entire contents of the lumbar fossa has been achieved with ease in each case, due to the unexcelled exposure, distinctness of landmarks and easily followed planes. We have not yet encountered any undue morbidity, but naturally we anticipate it in each case due to the enormity of the procedure. All three patients are living and well, from three to 11 months postoperatively. SUMMARY A technique of monobloc excision of the contents of the lumbar fossa has been presented as an operative attack on large flank tumors. One of three cases is cited in some detail. I ts a pplicability to large multivisceral flank tumors of bowel or retroperitoneal origin is demonstrated, and the rationale of such a wide ablative procedure is discussed. It is felt that it is the operation of choice for multivisceral involvement by renal or colon cancers, and the technique of hemicolectomy in continuitv with lumbar fossa evisceration is described. It is also suggested that simple fossa evisceration with wide resection of the posterior peritoneum be considered as an approach to large renal cancers which are still limited to the contents of Gerota's fascia grossly. The rationale of coincident regional lymphaclenectomy pertinent to kidney and/or colon is also presented. Although the long-term fruitfulness of such extended procedures is still in doubt, it is suggested that the benefit of the doubt be extended to the patient rather than to the cancer until such time as this philosophy be proven unrealistic. REFERENCES BEARE, J.B. AND JVIcDoNALD, J. R.: Involvement of the renal capsule in surgically removed hypernephroma: A gross and histologic study. J. Urol., 61: 857-861, 1949. · CHUTE, R. AND SAUTTER, L.: Thoraco-abdominal nephrectomy for renal tumors. J. U rol. 61: 688-696, 1949.
CLARKE, B. W. F. : surgery plasms. 1958.
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G., RunY, H. A. AND LEADBETTER The thoracoabdominal incision f oi of renal, adrenal and testicular neoSurg., Gynec. & Obst. 106: 363-367 '
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MoRTENSEN, H. Transthoracic nephrectomy. J. Urol., 60: 855-858, 1948. . NAGAMATSU, G. R., LERMAN, P.H. AND BERMAN M .. H.: The dorsolumbar flap incision in uro~ logic surgery. J. Urol., 67: 787-803, 1952. SWEETSER, T. H.: The surgical approach to renal and other retroperitoneal tumors. J. Urol. 57: 651-661, 1947.
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