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Massive Electrocoagulation of Deeply Infiltrating Bladder Tumors Combined With Ligation of the Vena Cava for Prevention of Pulmonary Embolism
THE JOURNAL OF UROLOGY
Vol. 70, No. 3, September 1953 Printed in U.S.A.
MASSIVE ELECTROCOAGULATION OF DEEPLY INFILTRATING BLADDER TUMORS COMBINED WITH LIGATION OF THE VENA CAVA FOR PREVENTION OF PULMONARY EMBOLISM FREDERIC E. B. FOLEY, EDWARD J. RICHARDSON, WILLIAM P. MULVANEY AND IRVING VICTOR
Bladder tumors have ·wide ranges of character in respect of different features, The surgical problem posed by bladder tumors is defined by the character of the neoplasm with respect to: 1) cytologic type, 2) extent of surface area involvement, 3) depth of invasion and 4) metastatic involvement. A very simple surgical problem is posed by the benign bladder tumor with small surface area of involvement, without invasion beyond the mucosa and without metastasis. There is general agreement among urologic surgeons concerning management of such tumors. The surgical principles of general agreement encompass a variety of methods giving excellent results with tumors of this character and others subBtantially less innocent. The surgical problem becomes more formidable and difficult in proportion to lack of cell differentiation, the extent of surface area involvement, depth of invasion and metastatic extension. Decrease in the percentage of surgical cures parallels the character of the tumor as indicated by the grades of these features. There is general disagreement concerning the surgical management of highly malignant, extensive and deeply invading bladder tumors. During the past 10 years improvement of the surgical treatment of tumors of this character has been a chief concern of clinical research in urology. The new conceptions, tireless effort and devotion of many workers during this period have not only failed to compose the divergence of opinion but actually have increased it. Moreover, the results currently obtained are not substantially better than former results. The considerations here presented are strictly limited to very bad bladder tumors: malignant, extensive and deeply infiltrating. It is believed that among the cases of bladder tumor here reported there would be no two year survivors by any former method of surgical treatment. The safeguards of modern surgery: multiple transfusions, improved anesthesia, sulfonamides, antibiotics, improved techniques and other advances have permitted total cystectomy with bilateral ureterosigmoidostomy to become a routine procedure. ViThen total cystectomy came into vogue it was widely regarded as promise of a new era in the surgical treatment of vicious bladder tumors. There was reason to believe this was an ill-founded hope. A deeply invading growth which has gone beyond the bladder wall will not be completely eradicated by total cystectomy. Yet this is the type of growth for which cystectomy has been most enthusiastically urged and most widely employed. A tumor of such character has extended across the cleavage plane in which the bladder would be enucleated by total cystectomy. It is inevitable that total cystectomy, as now practiced, Read before the Section on Urology, American Medical Association meeting, Chicago, June 1952. 456
TR1£AT:'vmN"T OF DEEPLY INFILTRATIKG BLADDER Tl:MORS
457
,,·ill not completely erndicate such a neoplasm. Total cystectomy by section through structures peripheral to the bladder has not been and would be beset by graTe technical difficulties. There is uo analogy between total as nm,· practiced, ancl Halstecl's emminently sur:c(1ssful total ma8tectomy. The latter the neoplasm a wide berth. The total ~u,,,r,nn, tlrn bladder tumor which has extended wall less than no lwrth at all. The plane of dissection is directly across the avenue of ir1Yas1011. of this difference between the radical for breast, cancer and total cystectomy for bladder cancer probably accounts fm· misplaeiug hope in the avenue of invasion of a bladder tumor is relafrFely narrow, btlt, often it extends far ont into the pelvis from its comparatively limited area of origin in the bladder. Destruction of the neoplasm to the far end of it:c, avenue of inntsion is necessary for cure. If there is extension beyond the bladder wall this will not be cystectomy. Nioreover, there is no need for remoYal of bladder wall far peripheral to the tumor bearing surface area in tbe bladder from the center of which the outward invasion extends. Electrocoagulation is capable of destructive heat penetration outward into surrounding structnre,~ from the surface area of bladder involvement to almost any desired extent---far bey011cl any sharp dissection ,vhich may be made. In the long of one of ns (FEBF), cutting current excision followed by deep electroeoagulation of the area of deepest invasion has given far the best results of any method employed against deeply infiltrating bladder tumors. Former use of the method was conditioned by fear of postoperative embolism due to heat coagulation of blood in the comparati,-ely large ttnd neighboring ,·eins. The extent of heat penetration was deliberately limited to an>id this effect. In of that precaution fatal pulmonary embolism occurred in ;3 cases amI dictated still more eautious use of the agent.. It has been l011g known that the vena eava may be ligated anywhere between the iliac bifmcatio11 aud the renal veins with only temporary iil effects in the form of lmrer edema. lll recent years, deliberate and purposeful ca,·,J, ligation has been in the trnatrnent of thrombophlebitis of the lmrnr extremities and by gynecologists in connection with extensive pelvic operatious. These deliberate use,; of can1 li 6ation suggested its employment as a measure against pulmonary embolism in connection 11·ith mas,~ive tion of deeply infiltrating bladder tumors. It appeared that prevention of embolisrn in this way would permit much more extensive heat destruction of oiadder tumors than had heen pre,·iously permissa.ble and would make feasible eradication of invasions of surrounding structures not removablf; dissection and not. the limited applicatio11 of e1ectrocoagulatwn formerly employed. lVIETHOD
should be sharply distinguished from fulvuratfrm J). Both of them are effected high frequency current. In the case of fnlgurnJion
458
FOLEY, RICHARDSON, MULVANEY AND VICTOR
the active electrode is held a short distance from the tissue. The current is made to arc from the active electrode to the tissue. The effect is superficial burning with carbonization. Nearly all of the energy is spent on the surface area struck by the arc and there is no significant heat penetration. In the case of electrocoagulation (diathermy, dialectric heating), the energy is applied in a different way. The active electrode is held in contact with the tissue. The tissue (dialectric) between the active and inactive electrodes is heated. The area of heat is in the form of a cone with the apex at the active electrode within the bladder and base at the inactive electrode over the patient's buttocks. Temperature elevation over any cross section area of the cone will be approximately in inverse proportion to the area of the conical section. What may be the temperature elevation of Elcctrocoagulation
Futguration
. /'--<;·:~J''~c:
__________ Active _________ _
'
_::;i::~oed-e--
·'"'_°"'_""_""'_~_.. __""'_ --
A
__
=--
- - - - - -i - - - - - -
_-_-_-:-_!-_-::
';.__,Jndiffczrcnt ///
electrode
/
I
I
Cone of heat penetration
FIG. 1. Fulguration. Small, active electrode is held close to, but not in contact with, tissue. Current arcs from electrode to tissue. Nearly all of energy is spent on surface area struck by the arc. There is intense surface heat with carbonization, but no significant heat penetration. Electrocoagulation. Comparatively large active electrode is held in contact with tissue. Energy is spent in gradual heating of the tissue (dialectric) between active and inactive electrodes. Area of dialectric heating is in the form of a cone, with apex at the active electrode and base at the inactive electrode. Temperature elevation over any cross section of cone will be approximately in inverse proportion to area of section.
the tissue is evident from the fact that dialectric heaters or stoves with large electrodes of equal size will heat a large roast of meat to comparatively even coagulating temperature from surface to surface. Such temperature is lethal for the cells of both normal and neoplastic tissue. Histologic examination shows that the thermal trauma of electrocoagulation extends beyond the area of local tissue coagulation. It extends through the venous, arterial and lymphatic channels. These are the avenues of extension of neoplasm. The fact that dialectric heating follows the same avenues may be significant. CLINICAL APPLICATION OF METHOD
It has been determined from the cystoscopy, biopsy and rectal examination, with finding of a palpable mass, that the bladder tumor is 1) malignant, 2) extensive and 3) deeply infiltrating.
TREATMENT OF DEEPLY INFILTRATING BLADDER TUMORS
45\f
The peritoneal cavity is opened by median incision from the pubic arch upward beyond the umbilicus. The peritonealized surface of the bladder is palpated to determine the extent and direction of neoplastic invasion. Palpation is made along the iliac vessels and cava to determine if metastatic lymph nodes are present and the liver is palpated. If there is no evidence of metastasis the contemplated procedure is carried out. The posterior parietal peritoneum over the vena cava is incised. The cava immediately above its iliac bifurcation is bluntly separated from surrounding structures around its whole circumference and is ligated with umbilical tape. The inspection and palpation have determined if there is invasion extending to the peritonealized surface of bladder wall. If such extension of the neoplasm
Fm. 2. Electrodes: A, cutting current loop. B, fulgurating point. C, fulgurating ball. D, coagulating stamp. E, coagulating spike.
is present the area of involvement is extraperitonealized by circular incision of the peritoneum peripheral to the area of involvement, dissecting up a peripheral flap of peritoneum and bringing its edges together by suture, thus extraperitonealizing the surface of involvement. If the tumor involves peritonealized portions of bladder without extension through the bladder wall, the peritoneum is only stripped away from the bladder without extraperitonealizing any part of its serosal surface. The peritoneal cavity is closed and the bladder is opened. The presenting tumor is excised with the cutting current loop (fig. 2, A) carrying the excision deeply into the bladder wall. Around the periphery of the denuded area the excision will expose normal appearing muscle bundles. At the center of the denuded area the excision will not have reached through the central part of the invading growth. It is not important that the core of invading growth be excised. After control of bleeding by fulguration, the whole denuded area is subjected
460
FOLEY, RICHARDSON, MULVANEY AND VICTOR
to massive electrocoagulation -with a stamp electrode (fig. 3, a). Following that a spike electrode is plunged deeply into the core of the invading growth for a distance of two to three centimeters and is held in place while the coagulating current is supplied to the electrode (fig. 3, b). Arcing indicates that tissue in contact -with the electrode has been carbonized and that maximal electrocoagulation of tissue peripheral to the electrode has been obtained. Closely spaced applications of this sort completely coagulate tissue far beyond the bladder wall over the ,vhole area of involvement. During electrocoagulation of posterior wall tumors a gauze pack is placed between the bladder wall and the peritoneum which has been separated from it (fig. 4).
/
Fw. 3. Massive electrocoagulation of deeply infiltrating bladder tumor. a, Comparativel:v superficial electrocoagulation is effected by application of current with large surface area stamp electrode. Well below surface there is only dialectric heating without coagulation. b, Deep electrocoagulation is effected by application of current with a spike electrode inserted deeply into tissue. Well below surface there is complete coagulation including coagulation of blood in adjacent vessels whereas with more superficial coagulation effected by stamp electrode, c, "coagulation thrombi" are not formed in these vessels.
The coagulation of tissue and blood vessels far beyond the bladder wall, as described, would almost inevitably cause pulmonary embolism were it not for the cava ligation. The destruction of tissue thus accomplished extends far beyond the tissue removal which may be accomplished by cystectomy or any presently practiced sharp dissection. If the ureteral orifices and terminal portions of the ureters are in or close to the area of involvement they are included in the cutting current excision and electrocoagulation. Ten bladder tumors without demonstrable evidence of metastasis have been subjected to the above described method of surgical treatment (table 1). All of these grmYths were regarded as inoperable by previous methods and beyond hope of complete eradication by cystectomy. All of the tumors were deeply infiltrating, undifferentiated squamous cell carcinomas of the bladder of large area. All of them belong to the class of bladder tumors, which according to the consensus of opinion are the most malignant and most nearly hopeless. Among the 10 cases there were 9 males and 1 female. The ages were GO years
461
TREATMENT OF DEEPLY INFILTRATING BLADDER TUMORS
to 72 years. All of the tumors covered comparatively large surface areas. Eight of the tumors had extended through and beyond the bladder wall and belonged to Group C of the Jewett classification. 1 Two of the growths extended deeply into Pcritornzum peeled
from blad?e,r wa I I
~===-
FIG. 4. Peritoneum is stripped away from tumor-bearing areas of bladder wall. Gauze pack interposed between bladder and peritoneum protects latter from destructive heat. 1. Ten cases of malignant squamous cell carcinomas of bladder, extensive and deeply infiltrating treated by massive electrocoagulation and caval ligation for prevention of fatal pulmonary embolism
TABLE
TIME SINCE OPERATION
INFILTRATION
CASE NUMBER
AGE
AREA CMS.
1 2 3 4 5 Female 6 7
74 67 50 72 61 69 67
6x8 4X 5 4x4 4x4 Right half of bladder 4 X 6 5 X 5
8 9 10
61 68 69
3X 5 4x6 7X 7
Thru wall
I Jewett class
Yes Yes Yes No Yes
C C C
Yes No
C
B2
15 Seeds No
Yes Yes Yes
C C C
No No No
B2 C
TUMOR
RADON
PRESENT
Alive
16 Seeds No 10 Seeds 10 Seeds 8 Seeds
Dead
5 Months 7 Months
-
3 Years
0 0 0
8 Months 1 Year 7 Months 11 Months
-
1 Year 4 Months 1 Year 5½ Months
0
3 Months
1
0 (?) 0 0
the bladder wall, but without gross evidence of perivesical involvement and belonged to Group B 2 of the Jewett classification. Of the 10 patients, six survive and four have died. The time interval between operation and the most recent cystoscopy or death were: 4 patients dead 5 months, 7 months, 8 months and 11 months after operation; 6 patients alive 3 years, 19 months, 16 months, 12 1 Jewett, H.J.: Carcinoma of the bladder: Influence of depth of infiltration on the 5 year results following complete extirpation of the primary growth. J. Urol., 67: 672-676, 1952.
462
FOLEY, RICHARDSON, MULVANEY AND VICTOR
months, 5½ months and 3 months after operation. In three of the fatal cases there was recurrent or persisting neoplasm. In 1 case, No. 4, death due to sepsis occurred 8 months following operation and the autopsy found no evidence of persisting or recurrent neoplasm. The six surviving patients are well without evidence of neoplasm as determined by cystoscopy. However, one of these patients, case 8, now has unilateral exophthalmus which eventually may prove to be due to metastasis to the orbit. In 5 cases radon seeds were implanted over the area of excision and coagulation. The number of cases is too small to permit purposeful comparison of results between the radiated and nonradiated tumors. In one of the cases of longest survival, No. 3, radiation was employed. In 3 cases of death since operation, radiation was also employed. A notable occurrence was wound dehiscence in 3 cases. It seems reasonable to attribute this to the disturbance of circulation made by the cava ligation. In all of these cases resuture of the wound with wire stay sutures was followed by healing and recovery. The experience indicates that in all cases of cava ligation, wound closure should be made with stay sutures. In none of the cases was there history of lower extremity thrombophlebitis prior to operation. Following the cava ligation there was temporary edema of the lower extremities in most cases. This largely disappeared postoperatively and is not a serious consideration which would not be the case had there been thrombophlebitis prior to operation. COMMENT
r
Total cystectomy for carcinoma of the bladder has not increased the percentage of permanent cures. Ureterosigmoidostomy leaves many of the patients "electrolytic invalids." Cutaneous ureterostomy avoids electrolytic imbalance, but is of itself a considerable affliction. The number of cures of deeply infiltrating bladder carcinoma by all surgical methods heretofore employed is discouragingly small. The same is true of radiation treatment. Evidence is accumulating which indicates that the percentage of cures by total cystectomy is no higher than by less radical procedures and indeed may be lower. Colby and Kerr2 compared the results of cystectomy with those obtained by other less radical methods. In 82 cases of tumors of this sort, treated by means other than cystectomy, there were 9 five year survivors or 11 per cent. In 25 cases treated by total cystectomy, there were 2 survivors or 8 per cent. Jewett 1 reports that only 2 of 61 patients (3.3 per cent) with deeply infiltrating bladder tumors treated either by total cystectomy or segmental resection survived five years. There was one survival among 13 cases in group B 2 and one survival among 48 cases in group C. It may be presumed that the tumors covered by Jewett's report were more vicious than those covered by the Colby and Kerr report. It is impossible to know from such reports just what may have been the exact character of the tumors 2 Colby, F. H. and Kerr, W. S., Jr.: Carcinoma of bladder: Evaluation of total cystectomy and other methods of treatment. New Eng. J. Med., 244: 504-506, 1951.
TREATMENT OF DEEPLY INFILTRATING BLADDER TUMORS
463
with which they are concerned. It may be said that in a general way the results reported in these two papers are representative of general experience in dealing with bad bladder tumors: the comparatively bad and the very bad. Results of exteneration operations are not available. They will contain a much higher operative mortality and morbidity than goes with the procedure here described. So-called "artificial bladders" made with segments of bowel have not avoided electrolyte imbalance, and from the standpoint of tumor extirpation are, of course, subject to the same faults as cystectomy with ureterosigmoidostomy. The most desirable surgical treatment of infiltrating carcinoma of the bladder should eradicate the neoplasm and preserve normal bladder function as nearly as possible. Vena cava ligation is not new. Some of the earliest ligations were made incident to its injury during nephrectomy. Pleasants,3 in a lengthy review of 8 cases of caval ligation or excision made previous to 1911, stated that death resulted in only two of the patients. Vena cava ligation is now commonplace in the modern treatment of thrombo-embolic disease. The truly massive electrocoagulation permitted by cava ligation accomplishes much more than can be accomplished by any form of extirpation presently feasible by dissection, and at the same time preserves vesical function-which is lost by cystectomy. The results obtained by the method described are encouraging in these cases of heretofore practically inoperable neoplasm. SUMMARY
A method of surgical treatment of deeply infiltrating, extensive and malignant bladder tumors by massive electrocoagulation combined with ligation of the vena cava as a prophylactic measure to prevent pulmonary embolism is described. The results to date in 10 cases of such neoplasms subjected to this form of treatment are described. PURPOSE AND CONCLUSION
The purpose of this presentation rests upon the character of the neoplasm in these ten cases. All of them were of the most vicious sort. In none of them, subjected to former methods of operation, would there have been prospect of anything but fatal outcome within a year or so. The number of cases and duration of time since operation are entirely too limited to warrant a secure appraisal. A long period of time would be required for us alone to accomplish that and even then conclusions would be based on a not convincing number of cases. We present at this time a new departure, and possibly a new hope, in this most disillusioning field of urologic effort for the purpose of prompting others to put it to trial to the end that with the least possible delay its merit may be accurately appraised by large experience.
228 Lowry Bldg., St. Paul, Minn. (F.E.B.F.; E.J.R.) Union Central Bldg., Cincinnati, 0. (W.P.M.) Savannah, Ga. (I.V.) 3 Pleasants, J. H.: Obstruction of inferior vena cava with a report of eighteen cases. Johns Hop. Hosp. Rep., 16: 363-548, 1911.
Vol. 70, No. 3, September 1953 Printed in U.S.A.
MASSIVE ELECTROCOAGULATION OF DEEPLY INFILTRATING BLADDER TUMORS COMBINED WITH LIGATION OF THE VENA CAVA FOR PREVENTION OF PULMONARY EMBOLISM FREDERIC E. B. FOLEY, EDWARD J. RICHARDSON, WILLIAM P. MULVANEY AND IRVING VICTOR
Bladder tumors have ·wide ranges of character in respect of different features, The surgical problem posed by bladder tumors is defined by the character of the neoplasm with respect to: 1) cytologic type, 2) extent of surface area involvement, 3) depth of invasion and 4) metastatic involvement. A very simple surgical problem is posed by the benign bladder tumor with small surface area of involvement, without invasion beyond the mucosa and without metastasis. There is general agreement among urologic surgeons concerning management of such tumors. The surgical principles of general agreement encompass a variety of methods giving excellent results with tumors of this character and others subBtantially less innocent. The surgical problem becomes more formidable and difficult in proportion to lack of cell differentiation, the extent of surface area involvement, depth of invasion and metastatic extension. Decrease in the percentage of surgical cures parallels the character of the tumor as indicated by the grades of these features. There is general disagreement concerning the surgical management of highly malignant, extensive and deeply invading bladder tumors. During the past 10 years improvement of the surgical treatment of tumors of this character has been a chief concern of clinical research in urology. The new conceptions, tireless effort and devotion of many workers during this period have not only failed to compose the divergence of opinion but actually have increased it. Moreover, the results currently obtained are not substantially better than former results. The considerations here presented are strictly limited to very bad bladder tumors: malignant, extensive and deeply infiltrating. It is believed that among the cases of bladder tumor here reported there would be no two year survivors by any former method of surgical treatment. The safeguards of modern surgery: multiple transfusions, improved anesthesia, sulfonamides, antibiotics, improved techniques and other advances have permitted total cystectomy with bilateral ureterosigmoidostomy to become a routine procedure. ViThen total cystectomy came into vogue it was widely regarded as promise of a new era in the surgical treatment of vicious bladder tumors. There was reason to believe this was an ill-founded hope. A deeply invading growth which has gone beyond the bladder wall will not be completely eradicated by total cystectomy. Yet this is the type of growth for which cystectomy has been most enthusiastically urged and most widely employed. A tumor of such character has extended across the cleavage plane in which the bladder would be enucleated by total cystectomy. It is inevitable that total cystectomy, as now practiced, Read before the Section on Urology, American Medical Association meeting, Chicago, June 1952. 456
TR1£AT:'vmN"T OF DEEPLY INFILTRATIKG BLADDER Tl:MORS
457
,,·ill not completely erndicate such a neoplasm. Total cystectomy by section through structures peripheral to the bladder has not been and would be beset by graTe technical difficulties. There is uo analogy between total as nm,· practiced, ancl Halstecl's emminently sur:c(1ssful total ma8tectomy. The latter the neoplasm a wide berth. The total ~u,,,r,nn, tlrn bladder tumor which has extended wall less than no lwrth at all. The plane of dissection is directly across the avenue of ir1Yas1011. of this difference between the radical for breast, cancer and total cystectomy for bladder cancer probably accounts fm· misplaeiug hope in the avenue of invasion of a bladder tumor is relafrFely narrow, btlt, often it extends far ont into the pelvis from its comparatively limited area of origin in the bladder. Destruction of the neoplasm to the far end of it:c, avenue of inntsion is necessary for cure. If there is extension beyond the bladder wall this will not be cystectomy. Nioreover, there is no need for remoYal of bladder wall far peripheral to the tumor bearing surface area in tbe bladder from the center of which the outward invasion extends. Electrocoagulation is capable of destructive heat penetration outward into surrounding structnre,~ from the surface area of bladder involvement to almost any desired extent---far bey011cl any sharp dissection ,vhich may be made. In the long of one of ns (FEBF), cutting current excision followed by deep electroeoagulation of the area of deepest invasion has given far the best results of any method employed against deeply infiltrating bladder tumors. Former use of the method was conditioned by fear of postoperative embolism due to heat coagulation of blood in the comparati,-ely large ttnd neighboring ,·eins. The extent of heat penetration was deliberately limited to an>id this effect. In of that precaution fatal pulmonary embolism occurred in ;3 cases amI dictated still more eautious use of the agent.. It has been l011g known that the vena eava may be ligated anywhere between the iliac bifmcatio11 aud the renal veins with only temporary iil effects in the form of lmrer edema. lll recent years, deliberate and purposeful ca,·,J, ligation has been in the trnatrnent of thrombophlebitis of the lmrnr extremities and by gynecologists in connection with extensive pelvic operatious. These deliberate use,; of can1 li 6ation suggested its employment as a measure against pulmonary embolism in connection 11·ith mas,~ive tion of deeply infiltrating bladder tumors. It appeared that prevention of embolisrn in this way would permit much more extensive heat destruction of oiadder tumors than had heen pre,·iously permissa.ble and would make feasible eradication of invasions of surrounding structures not removablf; dissection and not. the limited applicatio11 of e1ectrocoagulatwn formerly employed. lVIETHOD
should be sharply distinguished from fulvuratfrm J). Both of them are effected high frequency current. In the case of fnlgurnJion
458
FOLEY, RICHARDSON, MULVANEY AND VICTOR
the active electrode is held a short distance from the tissue. The current is made to arc from the active electrode to the tissue. The effect is superficial burning with carbonization. Nearly all of the energy is spent on the surface area struck by the arc and there is no significant heat penetration. In the case of electrocoagulation (diathermy, dialectric heating), the energy is applied in a different way. The active electrode is held in contact with the tissue. The tissue (dialectric) between the active and inactive electrodes is heated. The area of heat is in the form of a cone with the apex at the active electrode within the bladder and base at the inactive electrode over the patient's buttocks. Temperature elevation over any cross section area of the cone will be approximately in inverse proportion to the area of the conical section. What may be the temperature elevation of Elcctrocoagulation
Futguration
. /'--<;·:~J''~c:
__________ Active _________ _
'
_::;i::~oed-e--
·'"'_°"'_""_""'_~_.. __""'_ --
A
__
=--
- - - - - -i - - - - - -
_-_-_-:-_!-_-::
';.__,Jndiffczrcnt ///
electrode
/
I
I
Cone of heat penetration
FIG. 1. Fulguration. Small, active electrode is held close to, but not in contact with, tissue. Current arcs from electrode to tissue. Nearly all of energy is spent on surface area struck by the arc. There is intense surface heat with carbonization, but no significant heat penetration. Electrocoagulation. Comparatively large active electrode is held in contact with tissue. Energy is spent in gradual heating of the tissue (dialectric) between active and inactive electrodes. Area of dialectric heating is in the form of a cone, with apex at the active electrode and base at the inactive electrode. Temperature elevation over any cross section of cone will be approximately in inverse proportion to area of section.
the tissue is evident from the fact that dialectric heaters or stoves with large electrodes of equal size will heat a large roast of meat to comparatively even coagulating temperature from surface to surface. Such temperature is lethal for the cells of both normal and neoplastic tissue. Histologic examination shows that the thermal trauma of electrocoagulation extends beyond the area of local tissue coagulation. It extends through the venous, arterial and lymphatic channels. These are the avenues of extension of neoplasm. The fact that dialectric heating follows the same avenues may be significant. CLINICAL APPLICATION OF METHOD
It has been determined from the cystoscopy, biopsy and rectal examination, with finding of a palpable mass, that the bladder tumor is 1) malignant, 2) extensive and 3) deeply infiltrating.
TREATMENT OF DEEPLY INFILTRATING BLADDER TUMORS
45\f
The peritoneal cavity is opened by median incision from the pubic arch upward beyond the umbilicus. The peritonealized surface of the bladder is palpated to determine the extent and direction of neoplastic invasion. Palpation is made along the iliac vessels and cava to determine if metastatic lymph nodes are present and the liver is palpated. If there is no evidence of metastasis the contemplated procedure is carried out. The posterior parietal peritoneum over the vena cava is incised. The cava immediately above its iliac bifurcation is bluntly separated from surrounding structures around its whole circumference and is ligated with umbilical tape. The inspection and palpation have determined if there is invasion extending to the peritonealized surface of bladder wall. If such extension of the neoplasm
Fm. 2. Electrodes: A, cutting current loop. B, fulgurating point. C, fulgurating ball. D, coagulating stamp. E, coagulating spike.
is present the area of involvement is extraperitonealized by circular incision of the peritoneum peripheral to the area of involvement, dissecting up a peripheral flap of peritoneum and bringing its edges together by suture, thus extraperitonealizing the surface of involvement. If the tumor involves peritonealized portions of bladder without extension through the bladder wall, the peritoneum is only stripped away from the bladder without extraperitonealizing any part of its serosal surface. The peritoneal cavity is closed and the bladder is opened. The presenting tumor is excised with the cutting current loop (fig. 2, A) carrying the excision deeply into the bladder wall. Around the periphery of the denuded area the excision will expose normal appearing muscle bundles. At the center of the denuded area the excision will not have reached through the central part of the invading growth. It is not important that the core of invading growth be excised. After control of bleeding by fulguration, the whole denuded area is subjected
460
FOLEY, RICHARDSON, MULVANEY AND VICTOR
to massive electrocoagulation -with a stamp electrode (fig. 3, a). Following that a spike electrode is plunged deeply into the core of the invading growth for a distance of two to three centimeters and is held in place while the coagulating current is supplied to the electrode (fig. 3, b). Arcing indicates that tissue in contact -with the electrode has been carbonized and that maximal electrocoagulation of tissue peripheral to the electrode has been obtained. Closely spaced applications of this sort completely coagulate tissue far beyond the bladder wall over the ,vhole area of involvement. During electrocoagulation of posterior wall tumors a gauze pack is placed between the bladder wall and the peritoneum which has been separated from it (fig. 4).
/
Fw. 3. Massive electrocoagulation of deeply infiltrating bladder tumor. a, Comparativel:v superficial electrocoagulation is effected by application of current with large surface area stamp electrode. Well below surface there is only dialectric heating without coagulation. b, Deep electrocoagulation is effected by application of current with a spike electrode inserted deeply into tissue. Well below surface there is complete coagulation including coagulation of blood in adjacent vessels whereas with more superficial coagulation effected by stamp electrode, c, "coagulation thrombi" are not formed in these vessels.
The coagulation of tissue and blood vessels far beyond the bladder wall, as described, would almost inevitably cause pulmonary embolism were it not for the cava ligation. The destruction of tissue thus accomplished extends far beyond the tissue removal which may be accomplished by cystectomy or any presently practiced sharp dissection. If the ureteral orifices and terminal portions of the ureters are in or close to the area of involvement they are included in the cutting current excision and electrocoagulation. Ten bladder tumors without demonstrable evidence of metastasis have been subjected to the above described method of surgical treatment (table 1). All of these grmYths were regarded as inoperable by previous methods and beyond hope of complete eradication by cystectomy. All of the tumors were deeply infiltrating, undifferentiated squamous cell carcinomas of the bladder of large area. All of them belong to the class of bladder tumors, which according to the consensus of opinion are the most malignant and most nearly hopeless. Among the 10 cases there were 9 males and 1 female. The ages were GO years
461
TREATMENT OF DEEPLY INFILTRATING BLADDER TUMORS
to 72 years. All of the tumors covered comparatively large surface areas. Eight of the tumors had extended through and beyond the bladder wall and belonged to Group C of the Jewett classification. 1 Two of the growths extended deeply into Pcritornzum peeled
from blad?e,r wa I I
~===-
FIG. 4. Peritoneum is stripped away from tumor-bearing areas of bladder wall. Gauze pack interposed between bladder and peritoneum protects latter from destructive heat. 1. Ten cases of malignant squamous cell carcinomas of bladder, extensive and deeply infiltrating treated by massive electrocoagulation and caval ligation for prevention of fatal pulmonary embolism
TABLE
TIME SINCE OPERATION
INFILTRATION
CASE NUMBER
AGE
AREA CMS.
1 2 3 4 5 Female 6 7
74 67 50 72 61 69 67
6x8 4X 5 4x4 4x4 Right half of bladder 4 X 6 5 X 5
8 9 10
61 68 69
3X 5 4x6 7X 7
Thru wall
I Jewett class
Yes Yes Yes No Yes
C C C
Yes No
C
B2
15 Seeds No
Yes Yes Yes
C C C
No No No
B2 C
TUMOR
RADON
PRESENT
Alive
16 Seeds No 10 Seeds 10 Seeds 8 Seeds
Dead
5 Months 7 Months
-
3 Years
0 0 0
8 Months 1 Year 7 Months 11 Months
-
1 Year 4 Months 1 Year 5½ Months
0
3 Months
1
0 (?) 0 0
the bladder wall, but without gross evidence of perivesical involvement and belonged to Group B 2 of the Jewett classification. Of the 10 patients, six survive and four have died. The time interval between operation and the most recent cystoscopy or death were: 4 patients dead 5 months, 7 months, 8 months and 11 months after operation; 6 patients alive 3 years, 19 months, 16 months, 12 1 Jewett, H.J.: Carcinoma of the bladder: Influence of depth of infiltration on the 5 year results following complete extirpation of the primary growth. J. Urol., 67: 672-676, 1952.
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months, 5½ months and 3 months after operation. In three of the fatal cases there was recurrent or persisting neoplasm. In 1 case, No. 4, death due to sepsis occurred 8 months following operation and the autopsy found no evidence of persisting or recurrent neoplasm. The six surviving patients are well without evidence of neoplasm as determined by cystoscopy. However, one of these patients, case 8, now has unilateral exophthalmus which eventually may prove to be due to metastasis to the orbit. In 5 cases radon seeds were implanted over the area of excision and coagulation. The number of cases is too small to permit purposeful comparison of results between the radiated and nonradiated tumors. In one of the cases of longest survival, No. 3, radiation was employed. In 3 cases of death since operation, radiation was also employed. A notable occurrence was wound dehiscence in 3 cases. It seems reasonable to attribute this to the disturbance of circulation made by the cava ligation. In all of these cases resuture of the wound with wire stay sutures was followed by healing and recovery. The experience indicates that in all cases of cava ligation, wound closure should be made with stay sutures. In none of the cases was there history of lower extremity thrombophlebitis prior to operation. Following the cava ligation there was temporary edema of the lower extremities in most cases. This largely disappeared postoperatively and is not a serious consideration which would not be the case had there been thrombophlebitis prior to operation. COMMENT
r
Total cystectomy for carcinoma of the bladder has not increased the percentage of permanent cures. Ureterosigmoidostomy leaves many of the patients "electrolytic invalids." Cutaneous ureterostomy avoids electrolytic imbalance, but is of itself a considerable affliction. The number of cures of deeply infiltrating bladder carcinoma by all surgical methods heretofore employed is discouragingly small. The same is true of radiation treatment. Evidence is accumulating which indicates that the percentage of cures by total cystectomy is no higher than by less radical procedures and indeed may be lower. Colby and Kerr2 compared the results of cystectomy with those obtained by other less radical methods. In 82 cases of tumors of this sort, treated by means other than cystectomy, there were 9 five year survivors or 11 per cent. In 25 cases treated by total cystectomy, there were 2 survivors or 8 per cent. Jewett 1 reports that only 2 of 61 patients (3.3 per cent) with deeply infiltrating bladder tumors treated either by total cystectomy or segmental resection survived five years. There was one survival among 13 cases in group B 2 and one survival among 48 cases in group C. It may be presumed that the tumors covered by Jewett's report were more vicious than those covered by the Colby and Kerr report. It is impossible to know from such reports just what may have been the exact character of the tumors 2 Colby, F. H. and Kerr, W. S., Jr.: Carcinoma of bladder: Evaluation of total cystectomy and other methods of treatment. New Eng. J. Med., 244: 504-506, 1951.
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with which they are concerned. It may be said that in a general way the results reported in these two papers are representative of general experience in dealing with bad bladder tumors: the comparatively bad and the very bad. Results of exteneration operations are not available. They will contain a much higher operative mortality and morbidity than goes with the procedure here described. So-called "artificial bladders" made with segments of bowel have not avoided electrolyte imbalance, and from the standpoint of tumor extirpation are, of course, subject to the same faults as cystectomy with ureterosigmoidostomy. The most desirable surgical treatment of infiltrating carcinoma of the bladder should eradicate the neoplasm and preserve normal bladder function as nearly as possible. Vena cava ligation is not new. Some of the earliest ligations were made incident to its injury during nephrectomy. Pleasants,3 in a lengthy review of 8 cases of caval ligation or excision made previous to 1911, stated that death resulted in only two of the patients. Vena cava ligation is now commonplace in the modern treatment of thrombo-embolic disease. The truly massive electrocoagulation permitted by cava ligation accomplishes much more than can be accomplished by any form of extirpation presently feasible by dissection, and at the same time preserves vesical function-which is lost by cystectomy. The results obtained by the method described are encouraging in these cases of heretofore practically inoperable neoplasm. SUMMARY
A method of surgical treatment of deeply infiltrating, extensive and malignant bladder tumors by massive electrocoagulation combined with ligation of the vena cava as a prophylactic measure to prevent pulmonary embolism is described. The results to date in 10 cases of such neoplasms subjected to this form of treatment are described. PURPOSE AND CONCLUSION
The purpose of this presentation rests upon the character of the neoplasm in these ten cases. All of them were of the most vicious sort. In none of them, subjected to former methods of operation, would there have been prospect of anything but fatal outcome within a year or so. The number of cases and duration of time since operation are entirely too limited to warrant a secure appraisal. A long period of time would be required for us alone to accomplish that and even then conclusions would be based on a not convincing number of cases. We present at this time a new departure, and possibly a new hope, in this most disillusioning field of urologic effort for the purpose of prompting others to put it to trial to the end that with the least possible delay its merit may be accurately appraised by large experience.
228 Lowry Bldg., St. Paul, Minn. (F.E.B.F.; E.J.R.) Union Central Bldg., Cincinnati, 0. (W.P.M.) Savannah, Ga. (I.V.) 3 Pleasants, J. H.: Obstruction of inferior vena cava with a report of eighteen cases. Johns Hop. Hosp. Rep., 16: 363-548, 1911.