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Management of Abdominal Aortic Aneurysm and Invasive Transitional Cell Carcinoma of Bladder
0022-534 7/93/1493-04 76$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 149, 476-479, March 1993
Printed in U.S.A.
MANAGEMENT OF ABDOMINAL AORTIC ANEURYSM AND INVASIVE TRANSITIONAL CELL CARCINOMA OF BLADDER MARK F. LIERZ, BRADLEY E. DAVIS,* MARK J. NOBLE,t SCOTT P. WATTENHOFER AND JAMES H. THOMAS From the Department of Surgery, Sections of Vascular Surgery and Urology, University of Kansas Medical Center, and Kansas City Veterans Administration Hospital, Kansas City, Kansas
ABSTRACT
Between Januarv 1980 and June 1990 we treated 21 patients with invasive carcinoma of the bladder and abdo~inal aortic aneurysm. Three distinct gioups of patients were identified. Group 1 comprised 8 patients who were initially diagnosed with invasive bladder cancer and during cancer staging a concomitant abdominal aortic aneurysm was found. Group 2 consisted of 10 patients previously treated for invasive bladder cancer who had aneurysmal disease at a later date. Group 3 included 3 patients who underwent a previous aneurysm repair and subsequently had invasive carcinoma of the bladder. Total survival was 9 of 21 patients (43%) with a mean of 84 months of followup after initial diagnosis. This finding is comparable to long-term (greater than 5 years) survival in patients with invasive carcinoma of the bladder alone. In fact, none of the 21 patients studied experienced rupture of the aneurysm and/or died of aneurysmal disease. We found that patients with abdominal aortic aneurysm and invasive bladder cancer have a poor overall prognosis. Although aneurysm repair presents technical challenges, mortality is dependent upon the carcinoma and other vascular or medical diseases, and does not bear direct relationship to abdominal aortic aneurysm. KEY WORDS: bladder neoplasms; aorta; aneurysm; carcinoma, transitional cell
It had been estimated that there would be approximately 51,600 newly diagnosed cases of bladder cancer in the United States in 1992 and that bladder cancer would account for approximately 9,500 cancer deaths. 1• 2 Several series have placed the incidence of abdominal aortic aneurysm at 1.8 to 6.6%. 3• 4 It is generally accepted that the potential risk of rupture of an abdominal aortic aneurysm increases proportionally with the size of the aneurysm. Aneurysms 5 cm. or larger ih diameter have a significantly increased risk of spontaneous rupture, averaging approximately 10% per year. 5 Aneurysms that are symptomatic and less than 5 cm. in diameter are manageable nonoperatively (by serial radiological or sonographic evaluation).4-6 Smaller (less than 5 cm.) aneurysms have a significantly lower spontaneous rupture rate than larger aneurysms (greater than 5 cm.), although the rate is not insignificant. 7 While the management of abdominal aortic aneurysm in association with other abdominal pathology has been reviewed in the literature, it is unclear how best to manage patients with concomitant abdominal aortic aneurysm and invasive bladder cancer. 8 • 9 In an effort to clarify this problem, we reviewed patients with both disorders who were treated at our institution and we report our findings. MATERIALS AND METHODS
Between January 1980 and June 1990, 21 patients presented with a diagnosis of invasive bladder cancer and abdominal aortic aneurysm, either concurrently or consecutively. Patient age ranged from 65 to 83 years (mean 70.1). All 20 men and 1 woman were white. Inpatient and outpatient hospital records were identified by computer search of patients with aortic aneurysm and bladder cancer. Those satisfying the search were reviewed for patient Accepted for publication July 31, 1992. Read at annual meeting of South Central Section, American Urological Association, Santa Fe, New Mexico, October 13-17, 1990. * Current address: Urology Services, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, New York 10021. t Requests for reprints: Urology, Kansas University Medical Center, 39th St. and Rainbow Blvd., Kansas City, Kansas 66103. 476
age, sex, smoking history, stage and grade of the bladder cancer, size of the aneurysm, type of graft, surgical management plan, operative morbidity and mortality, postoperative followup and long-term mortality. Patient followup from the time of diagnosis and treatment ranged from 4 to 184 months (mean 59.2) and was gathered by telephone conversation, chart review or personal interview. RESULTS
After analysis of the 21 patients in this study 3 distinct groups were identified. Group 1 consisted of 8 patients with a concomitant diagnosis of abdominal aortic aneurysm and transitional cell carcinoma of the bladder requiring treatment planning for both diseases (table 1). All group 1 patients presented with urinary symptoms (that is hematuria, dysuria and so forth) and were subsequently diagnosed with invasive transitional cell carcinoma of the bladder by either transurethral resection of the bladder tumor (7 patients) or cold-cup biopsy and transurethral resection of the bladder tumor (1). The diagnosis of aneurysmal disease was made during a staging evaluation of the bladder cancer with computerized tomography (CT) of the abdomen and pelvis in all 8 patients. Aneurysm size in greatest diameter ranged from 3.7 to 7.7 cm. (mean 5.4). Four patients underwent primary abdominal aortic aneurysm repair with simultaneous pelvic lymphadenectomy. Two patients then had cystectomy and urinary diversion at a mean delay of 44 days. Two patients refused surgical cancer intervention after abdominal aortic aneurysm repair: 1 chose radiation therapy and 1 underwent an intravesical chemotherapy regimen. Patients 5 and 6 in group 1 underwent primary cystectomy with subsequent abdominal aortic aneurysm repair 40 and 93 days later, respectively. One patient with a 3.7 cm. aneurysm who underwent initial cystectomy and urinary diversion subsequently had metastatic disease 3 months postoperatively and the aneurysm was not repaired. After a pathological diagnosis was obtained by transurethral resection of bladder tumor 1 individual did not undergo further treatment of either entity
477
ABDON!II'
Group 1 outcomes Transitional Cell Ca
Abdon1.inal Aortic Aneurysm
Pt. No.
Outcome (mos.)
Size (cm.)
Repair
7.7
Y es/polytetrafluorethylene
T2
II
External radiation
4.7 5.0
Yes/polytetrafluorethylene Yes/polytetraf!uorethylene
T2 T2
III II
4
3.6
5
5.1
Not done Not done
T3-A T3-B
III III
6
6.0 5.2 5.6
Yes/polytetraf!uorethylene Yes/polytetrafluorethylene Yes/polytetraf!uorethylene
T3-A T2 T2
II/Ca in situ III/Ca in situ II
Cystectomy Transurethral resection of bladder tumor, thiotepa Cystectomy Transurethral resection of bladder tumor Cystectomy Cystectomy Cystectomy
2 3
7 8
Stage
Grade
Treatment No clinical evidence of disease (27) Dead (60)* Dead (10)* Dead (6) Dead (4) Dead (24) Dead (51) Dead (42)*
* Death from causes other than transitional cell carcinoma or abdominal aortic aneurysm.
because of poor medical condition (Goldman class 4). No patient died of a ruptured aneurysm and there was no surgical mortality. Of the 8 patients 4 died of metastatic transitional cell carcinoma of the bladder at a mean interval of 35.5 months (range 6 to 60). Three patients died of cardiac related problems (mean 18.6 months) and 1 was alive at 24 months with no clinical evidence of disease. All abdominal aortic aneurysm repairs in group 1 were done with polytetrafluorethylene. Group 2 included 10 patients with an initial diagnosis of transitional cell carcinoma of the bladder and later development of an abdominal aortic aneurysm (table 2). The interval between treatment of the bladder cancer and diagnosis of aneurysmal disease ranged from 13 to 138 months (mean 50.7). Initial diagnosis of abdominal aortic aneurysm was made sonography in 5 cases, CT in 3 and excretory urography in 2. Initial treatment for the transitional cell carcinoma consisted of cystectomy with urinary diversion in 6 patients, transurethral resection of the bladder tumor with intravesical chemotherapy in 2 and transurethral resection of bladder tumor in 1, while 1 chose radiation therapy although cystectomy was recommended. Upon diagnosis of aneurysmal disease 5 patients underwent subsequent abdominal aortic aneurysm repair (mean aneurysm size 5.3 cm.). Four patients were followed by close observation consisting of serial sonography every 3 to 6 months (mean aneurysm size 4.3 cm.). One patient with a 7.5 cm. aneurysm refused surgical intervention and is being followed radiographically in a similar fashion. Six patients currently have no clinical evidence of disease. Four patients died: 2 of metastatic transitional cell carcinoma of the bladder and
TABLE 2.
Abdominal Aortic Aneurysm
2 of squamous cell lung carcinoma, although both had no clinical evidence of disease with respect to bladder cancer. Group 3 consisted of 3 patients with an initial diagnosis of aneurysmal disease who were subsequently diagnosed with invasive carcinoma of the bladder (table 3). Interval from aneurysm repair to diagnosis of invasive transitional cell carcinoma of the bladder ranged from 11 to 47 months (mean 32.3). Of the 3 patients 2 underwent cystectomy with urinary diversion and are currently without clinical evidence of disease. The left ureter was encased in the fibrotic reaction surrounding the graft in both of these patients but no early or late complications ensued. After a diagnosis was obtained with transurethral resection of a bladder tumor 1 patient was subsequently diagnosed with squamous cell carcinoma of the lung and died of transitional cell carcinoma of the bladder 37 months after the initial diagnosis. Two polytetrafluoroethylene grafts and 1 monofilament knitted polypropylene graft were used in 3 aneurysm repairs in this group. There were only 2 surgical complications in this high risk population and neither was related to aneurysm repair. Patient 1 in group 1 underwent concomitant aneurysm repair and pelvic lymphadenectomy, and a pelvic lymphocele developed that was drained percutaneously without further incident. Patient 5 in group 2 underwent preoperative and postoperative radiation therapy, and a urinary fistula developed from the conduit to the abdominal skin. Bilateral nephrostomy tubes were initially placed, and after an appropriate delay he subsequently underwent ilea! conduit repair and resection of the abdominal aortic aneurysm in 2 separate procedures.
Group 2 outcomes Transitional Cell Ca
Pt. No. Size (cm.)
Repair
Stage
Grade
Treatment
2
4.8
Yes/polytetrafluorethylene Not done
3
4.2
Not done
T2
III
Transurethral resection of bladder tumor Cystectomy
4
7.5
Not done
T2
II
Cystectomy
5
5.3
T2
II
Cystectomy
6
5.0
Yes/monofilament knitted polypropylene Yes/polytetrafluorethylene
Tl
II/Ca in situ
7
5.0
8 9
4.7 3.6
10
5.5
6.0
Yes/polytetrafluorethylene Not done Not done Yes/polytetrafluorethylene
Outcomes (mos.)
T4
II
External radiation
Dead (60)*
T3-A
III
Dead (17)
T3-B
III
T2 T2
II
Tl
II/Ca in situ
II
* Death from causes other than transitional cell carcinoma or abdominal aortic aneurysm. t Intravesical chemotherapy with thiotepa followed by mitomycin.
Transurethral resection of bladder tumor, chemotherapyt Cystectomy Cystectomy Cystectomy Transurethral resection of bladder tumor, thiotepa
No clinical evidence of disease (23) No cl in cal evidence of disease (158) No clinical evidence of disease (42) No clinical evidence of disease (184) Dead (29) Dead (86)* No clinical evidence of disease (108) No clinical evidence of disease (82)
478
LIERZ AND ASSOCIATES TABLE
3. Group 3 outcomes
Abdominal Aortic Aneurysm
Transitional Cell Ca Outcome (mos.)
Pt. No. Stage
Grade
Yes/polytetrafluorethyJene Yes/monofilament knitted polypropylene
T2
II-III
Cystectomy*
T2
II-III
Yes/polytetrafluorethyJene
T3-A
Transurethral resection of bladder tumor, chemotherapyt Cystectomy
Size (cm.)
Repair
7.0
2
5.2
3
6.1
Treatment
II
No clinical evidence of disease (63) Dead (77):j: No clinical evidence of disease (85)
* Continent urinary reservoir. t Intravesical chemotherapy with thiotepa and later mitomycin. :j: Death from causes other than transitional cell carcinoma or abdominal aortic aneurysm.
DISCUSSION
Malignancy has been reported in up to 12.6% of the patients with abdominal aortic aneurysm and represents a challenge for optimal management, especially when the malignancy is in the abdominal, pelvic or retroperitoneal spaces. 10 If both conditions are diagnosed at the same time, should the aneurysm be repaired first, second or simultaneous with cancer resection? Simultaneous cystectomy, urinary diversion and aneurysm repair would be a difficult procedure with the potential for graft infection from spilled bowel contents and urine. 11 Initial resection of the tumor may risk aneurysm rupture reportedly due to the high rate of collagen turnover observed 7 to 10 days after major operations. 12 Delayed aneurysm repair may also risk ureteral or bowel injury by direct transection or by vascular compromise (for example if the left colon was used for urinary diversion and primarily depends upon inferior mesenteric arterial blood supply). Repair of the aneurysm before cancer resection potentially allows for further growth and spread of tumor in a weakened, possibly immunocompromised host and also risks graft infection if the graft is incompletely healed with protective fibrous capsule and neointima. 13 Some of these considerations clearly apply as well when abdominal aortic aneurysm and invasive bladder cancer are diagnosed consecutively in either order. The optimal time for repair of abdominal aortic aneurysm is unknown and it is beyond the scope of this discussion to review extensively the controversies in this area. Elective repair is recommended when there is bleb formation, or the aneurysm is thin-walled, symptomatic or exceeds 5 cm. in diameter. 9 The risk of rupture for small aysmptomatic aneurysms less than 5 cm. is low (3% per year) and they may be judiciously followed with sonography every 3 months. 6 • 7 Patients with a small aneurysm, good health and a life expectancy of at least several years should consider aneurysm repair, since the mortality rate for elective repair is 2 to 5% (whereas emergency repair has a 50% mortality rate). 14 Treatment for invasive carcinoma of the bladder must be tailored to each patient and must take into consideration age, performance status, and coexisting medical and surgical disorders, as well as the stage, grade and histological subtype of the tumor. While various options exist, radical cystoprostatectomy with urinary diversion remains a mainstay of treatment for patients judged to be suitable candidates. 2 Mortality rates for elective radical cystectomy vary but reportedly have been less than 2% in recent decades. 2 However, overall complication rates approach 25 to 35% in these patients, a significant portion of which are infectious ( 10%), or involve rectal injury (4 %) or other bowel problems (10%). 2 One clearly worries that a preexisting aortic replacement graft might be placed at risk for infection by such complications, although a well healed graft with good neointima formation and fibrous encasement may have adequate resistance to such infection. 13 If the ureters are incorporated into the fibrous tissue surrounding a graft or pass beneath the iliac limbs of the graft, they may have marginal blood supply and can be difficult to dissect during urinary
diversion, further increasing the risk of morbidity following r:ciclic:cil cv>
Size of AAA
2:5cmAAA, Expanding or Symptomatic
AAA repair & Pelvic Lymphadenectomy
l
< 5 cm. AAA & TCCB
l
Cystectomy & Urinary Diversion
o, TURBT
Cystectomy & Urinary Diversion
o,
Observation or Aneurysm
TURBT
Consideration for Repair
&
Proposed management scheme for pati~I_1ts with ~imultaneous abdominal aortic aneurysm (AAA) and trans1t10nal carcmoma of bladder (TCCB). TURBT, transurethral resection of bladder tumors.
ABDOMINAL AORTIC ANEURYSM AND TRANSITIONAL CELL BLADDER CANCER
tion at the time of vascular repair, since subsequent peri-graft fibrosis makes it more difficult at a later date. If the nodes are microscopically positive, conservative management rather than cystectomy/diversion should be considered in view of the diminished long-term cancer prognosis. Early urological involvement also ensures improved communication between vascular and urological surgeons so that the vascular graft will be placed optimally for subsequent ureteral dissection. Patients with small aneurysms should undergo cystectomy and urinary diversion or transurethral resection of bladder tumor with close observation of the aneurysm. Dr. William R. Fair reviewed this manuscript. REFERENCES 1. Boring, C. C., Squires, T. S. and Tong, T: Cancer statistics, 1992. CA, 42: 19, 1992. 2. Catalona, W. J.: Bladder cancer. In: Adult and Pediatric Urology, 2nd ed. Edited by J. Y. Gillenwater, J. T. Grayhack, S. S. Howards and J. W. Duckett. St. Louis: Mosby-Year Book, Inc., vol. 1, chapt. 31, p. 1151, 1991. 3. Bickerstaff, L. K., Hollier, L. H., Van Peenan, H.J., Melton, L. J., III, Pairolero, P. C. and Cherry, K. J.: Abdominal aortic aneurysms: the changing natural history. J. Vase. Surg., 1: 6, 1984. 4. Reilly, J.M. and Tilson, M. D.: Incidence and etiology of abdominal aortic aneurysms. Surg. Clin. N. Amer., 69: 705, 1989. 5. Gewertz, B. L., Graham, A., Lawrence, P. F., Provan, J. and Zarins, C. K.: Diseases of the vascular system. In: Essentials of General Surgery. Edited by P. F. Lawrence. Baltimore: Williams & Wilkins, chapt. 25, p. 317, 1988. 6. Quill, D.S., Colgan, M. P. and Sumner, D.S.: Ultrasonic screening for the detection of abdominal aortic aneurysms. Surg. Clin. N. Amer., 69: 713, 1989.
479
7. Cronenwett, J. L., Murphy, T. F., Zelenock, G. B., Whitehouse, W. M., Jr., Lindenauer, S. M., Graham, L. M., Quint, L. E., Silver, T. M. and Stanley, J. C.: Actuarial analysis of variables associated with rupture of small abdominal aortic aneurysms. Surgery, 98: 472, 1985. 8. Thomas, J. H.: Abdominal aortic aneurysmorrhaphy combined with biliary or gastrointestinal surgery. Surg. Clin. N. Amer., 69: 807, 1989. 9. Szilagyi, D. E., Elliott, J. P. and Berguer, R.: Coincidental malignancy and abdominal aortic aneurysm. Problems of management. Arch. Surg., 95: 402, 1967. 10. Morris, D. M. and Colquitt, J.: Concomitant abdominal aortic aneurysm and malignant disease: a difficult management problem. J. Surg. Oncol., 39: 122, 1988. 11. Hermreck, A. S.: Prevention and management of surgical complications during repair of abdominal aortic aneurysms. Surg. Clin. N. Amer., 69: 869, 1989. 12. Swanson, R. J., Littooy, F. N., Hunt, T. K. and Stoney, R. J.: Laparotomy as a precipitating factor in the rupture of intraabdominal aneurysms. Arch. Surg., 115: 299, 1980. 13. Noble, M. J.: Vascular replacements in urologic surgery. In: Vascular Problems in Urologic Surgery. Edited by A. C. Novick and R. A. Straffon. Philadelphia: W. B. Saunders Co., chapt. 2, pp. 17-30, 1982. 14. Crawford, E. S., Saleh, S. A., Babb, J. W., III, Glaeser, D. H., Vaccaro, P. S. and Silvers, A.: Infrarenal abdominal aortic aneurysm: factors influencing survival after operation performed over a 25-year period. Ann. Surg., 193: 699, 1981. 15. Corriere, J. N., Jr.: Ureteral injuries. In: Adult and Pediatric Urology, 2nd ed. Edited by J. Y. Gillenwater, J. T. Grayhack, S. S. Howards and J. W. Duckett. St. Louis: Mosby-Year Book, Inc., vol. 1, chapt. 12, p. 491, 1991. 16. Grant, J. C. B.: An Atlas of Anatomy, 5th ed. Baltimore: Williams & Wilkins, fig. 163, 1962.
Vol. 149, 476-479, March 1993
Printed in U.S.A.
MANAGEMENT OF ABDOMINAL AORTIC ANEURYSM AND INVASIVE TRANSITIONAL CELL CARCINOMA OF BLADDER MARK F. LIERZ, BRADLEY E. DAVIS,* MARK J. NOBLE,t SCOTT P. WATTENHOFER AND JAMES H. THOMAS From the Department of Surgery, Sections of Vascular Surgery and Urology, University of Kansas Medical Center, and Kansas City Veterans Administration Hospital, Kansas City, Kansas
ABSTRACT
Between Januarv 1980 and June 1990 we treated 21 patients with invasive carcinoma of the bladder and abdo~inal aortic aneurysm. Three distinct gioups of patients were identified. Group 1 comprised 8 patients who were initially diagnosed with invasive bladder cancer and during cancer staging a concomitant abdominal aortic aneurysm was found. Group 2 consisted of 10 patients previously treated for invasive bladder cancer who had aneurysmal disease at a later date. Group 3 included 3 patients who underwent a previous aneurysm repair and subsequently had invasive carcinoma of the bladder. Total survival was 9 of 21 patients (43%) with a mean of 84 months of followup after initial diagnosis. This finding is comparable to long-term (greater than 5 years) survival in patients with invasive carcinoma of the bladder alone. In fact, none of the 21 patients studied experienced rupture of the aneurysm and/or died of aneurysmal disease. We found that patients with abdominal aortic aneurysm and invasive bladder cancer have a poor overall prognosis. Although aneurysm repair presents technical challenges, mortality is dependent upon the carcinoma and other vascular or medical diseases, and does not bear direct relationship to abdominal aortic aneurysm. KEY WORDS: bladder neoplasms; aorta; aneurysm; carcinoma, transitional cell
It had been estimated that there would be approximately 51,600 newly diagnosed cases of bladder cancer in the United States in 1992 and that bladder cancer would account for approximately 9,500 cancer deaths. 1• 2 Several series have placed the incidence of abdominal aortic aneurysm at 1.8 to 6.6%. 3• 4 It is generally accepted that the potential risk of rupture of an abdominal aortic aneurysm increases proportionally with the size of the aneurysm. Aneurysms 5 cm. or larger ih diameter have a significantly increased risk of spontaneous rupture, averaging approximately 10% per year. 5 Aneurysms that are symptomatic and less than 5 cm. in diameter are manageable nonoperatively (by serial radiological or sonographic evaluation).4-6 Smaller (less than 5 cm.) aneurysms have a significantly lower spontaneous rupture rate than larger aneurysms (greater than 5 cm.), although the rate is not insignificant. 7 While the management of abdominal aortic aneurysm in association with other abdominal pathology has been reviewed in the literature, it is unclear how best to manage patients with concomitant abdominal aortic aneurysm and invasive bladder cancer. 8 • 9 In an effort to clarify this problem, we reviewed patients with both disorders who were treated at our institution and we report our findings. MATERIALS AND METHODS
Between January 1980 and June 1990, 21 patients presented with a diagnosis of invasive bladder cancer and abdominal aortic aneurysm, either concurrently or consecutively. Patient age ranged from 65 to 83 years (mean 70.1). All 20 men and 1 woman were white. Inpatient and outpatient hospital records were identified by computer search of patients with aortic aneurysm and bladder cancer. Those satisfying the search were reviewed for patient Accepted for publication July 31, 1992. Read at annual meeting of South Central Section, American Urological Association, Santa Fe, New Mexico, October 13-17, 1990. * Current address: Urology Services, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, New York 10021. t Requests for reprints: Urology, Kansas University Medical Center, 39th St. and Rainbow Blvd., Kansas City, Kansas 66103. 476
age, sex, smoking history, stage and grade of the bladder cancer, size of the aneurysm, type of graft, surgical management plan, operative morbidity and mortality, postoperative followup and long-term mortality. Patient followup from the time of diagnosis and treatment ranged from 4 to 184 months (mean 59.2) and was gathered by telephone conversation, chart review or personal interview. RESULTS
After analysis of the 21 patients in this study 3 distinct groups were identified. Group 1 consisted of 8 patients with a concomitant diagnosis of abdominal aortic aneurysm and transitional cell carcinoma of the bladder requiring treatment planning for both diseases (table 1). All group 1 patients presented with urinary symptoms (that is hematuria, dysuria and so forth) and were subsequently diagnosed with invasive transitional cell carcinoma of the bladder by either transurethral resection of the bladder tumor (7 patients) or cold-cup biopsy and transurethral resection of the bladder tumor (1). The diagnosis of aneurysmal disease was made during a staging evaluation of the bladder cancer with computerized tomography (CT) of the abdomen and pelvis in all 8 patients. Aneurysm size in greatest diameter ranged from 3.7 to 7.7 cm. (mean 5.4). Four patients underwent primary abdominal aortic aneurysm repair with simultaneous pelvic lymphadenectomy. Two patients then had cystectomy and urinary diversion at a mean delay of 44 days. Two patients refused surgical cancer intervention after abdominal aortic aneurysm repair: 1 chose radiation therapy and 1 underwent an intravesical chemotherapy regimen. Patients 5 and 6 in group 1 underwent primary cystectomy with subsequent abdominal aortic aneurysm repair 40 and 93 days later, respectively. One patient with a 3.7 cm. aneurysm who underwent initial cystectomy and urinary diversion subsequently had metastatic disease 3 months postoperatively and the aneurysm was not repaired. After a pathological diagnosis was obtained by transurethral resection of bladder tumor 1 individual did not undergo further treatment of either entity
477
ABDON!II'
Group 1 outcomes Transitional Cell Ca
Abdon1.inal Aortic Aneurysm
Pt. No.
Outcome (mos.)
Size (cm.)
Repair
7.7
Y es/polytetrafluorethylene
T2
II
External radiation
4.7 5.0
Yes/polytetrafluorethylene Yes/polytetraf!uorethylene
T2 T2
III II
4
3.6
5
5.1
Not done Not done
T3-A T3-B
III III
6
6.0 5.2 5.6
Yes/polytetraf!uorethylene Yes/polytetrafluorethylene Yes/polytetraf!uorethylene
T3-A T2 T2
II/Ca in situ III/Ca in situ II
Cystectomy Transurethral resection of bladder tumor, thiotepa Cystectomy Transurethral resection of bladder tumor Cystectomy Cystectomy Cystectomy
2 3
7 8
Stage
Grade
Treatment No clinical evidence of disease (27) Dead (60)* Dead (10)* Dead (6) Dead (4) Dead (24) Dead (51) Dead (42)*
* Death from causes other than transitional cell carcinoma or abdominal aortic aneurysm.
because of poor medical condition (Goldman class 4). No patient died of a ruptured aneurysm and there was no surgical mortality. Of the 8 patients 4 died of metastatic transitional cell carcinoma of the bladder at a mean interval of 35.5 months (range 6 to 60). Three patients died of cardiac related problems (mean 18.6 months) and 1 was alive at 24 months with no clinical evidence of disease. All abdominal aortic aneurysm repairs in group 1 were done with polytetrafluorethylene. Group 2 included 10 patients with an initial diagnosis of transitional cell carcinoma of the bladder and later development of an abdominal aortic aneurysm (table 2). The interval between treatment of the bladder cancer and diagnosis of aneurysmal disease ranged from 13 to 138 months (mean 50.7). Initial diagnosis of abdominal aortic aneurysm was made sonography in 5 cases, CT in 3 and excretory urography in 2. Initial treatment for the transitional cell carcinoma consisted of cystectomy with urinary diversion in 6 patients, transurethral resection of the bladder tumor with intravesical chemotherapy in 2 and transurethral resection of bladder tumor in 1, while 1 chose radiation therapy although cystectomy was recommended. Upon diagnosis of aneurysmal disease 5 patients underwent subsequent abdominal aortic aneurysm repair (mean aneurysm size 5.3 cm.). Four patients were followed by close observation consisting of serial sonography every 3 to 6 months (mean aneurysm size 4.3 cm.). One patient with a 7.5 cm. aneurysm refused surgical intervention and is being followed radiographically in a similar fashion. Six patients currently have no clinical evidence of disease. Four patients died: 2 of metastatic transitional cell carcinoma of the bladder and
TABLE 2.
Abdominal Aortic Aneurysm
2 of squamous cell lung carcinoma, although both had no clinical evidence of disease with respect to bladder cancer. Group 3 consisted of 3 patients with an initial diagnosis of aneurysmal disease who were subsequently diagnosed with invasive carcinoma of the bladder (table 3). Interval from aneurysm repair to diagnosis of invasive transitional cell carcinoma of the bladder ranged from 11 to 47 months (mean 32.3). Of the 3 patients 2 underwent cystectomy with urinary diversion and are currently without clinical evidence of disease. The left ureter was encased in the fibrotic reaction surrounding the graft in both of these patients but no early or late complications ensued. After a diagnosis was obtained with transurethral resection of a bladder tumor 1 patient was subsequently diagnosed with squamous cell carcinoma of the lung and died of transitional cell carcinoma of the bladder 37 months after the initial diagnosis. Two polytetrafluoroethylene grafts and 1 monofilament knitted polypropylene graft were used in 3 aneurysm repairs in this group. There were only 2 surgical complications in this high risk population and neither was related to aneurysm repair. Patient 1 in group 1 underwent concomitant aneurysm repair and pelvic lymphadenectomy, and a pelvic lymphocele developed that was drained percutaneously without further incident. Patient 5 in group 2 underwent preoperative and postoperative radiation therapy, and a urinary fistula developed from the conduit to the abdominal skin. Bilateral nephrostomy tubes were initially placed, and after an appropriate delay he subsequently underwent ilea! conduit repair and resection of the abdominal aortic aneurysm in 2 separate procedures.
Group 2 outcomes Transitional Cell Ca
Pt. No. Size (cm.)
Repair
Stage
Grade
Treatment
2
4.8
Yes/polytetrafluorethylene Not done
3
4.2
Not done
T2
III
Transurethral resection of bladder tumor Cystectomy
4
7.5
Not done
T2
II
Cystectomy
5
5.3
T2
II
Cystectomy
6
5.0
Yes/monofilament knitted polypropylene Yes/polytetrafluorethylene
Tl
II/Ca in situ
7
5.0
8 9
4.7 3.6
10
5.5
6.0
Yes/polytetrafluorethylene Not done Not done Yes/polytetrafluorethylene
Outcomes (mos.)
T4
II
External radiation
Dead (60)*
T3-A
III
Dead (17)
T3-B
III
T2 T2
II
Tl
II/Ca in situ
II
* Death from causes other than transitional cell carcinoma or abdominal aortic aneurysm. t Intravesical chemotherapy with thiotepa followed by mitomycin.
Transurethral resection of bladder tumor, chemotherapyt Cystectomy Cystectomy Cystectomy Transurethral resection of bladder tumor, thiotepa
No clinical evidence of disease (23) No cl in cal evidence of disease (158) No clinical evidence of disease (42) No clinical evidence of disease (184) Dead (29) Dead (86)* No clinical evidence of disease (108) No clinical evidence of disease (82)
478
LIERZ AND ASSOCIATES TABLE
3. Group 3 outcomes
Abdominal Aortic Aneurysm
Transitional Cell Ca Outcome (mos.)
Pt. No. Stage
Grade
Yes/polytetrafluorethyJene Yes/monofilament knitted polypropylene
T2
II-III
Cystectomy*
T2
II-III
Yes/polytetrafluorethyJene
T3-A
Transurethral resection of bladder tumor, chemotherapyt Cystectomy
Size (cm.)
Repair
7.0
2
5.2
3
6.1
Treatment
II
No clinical evidence of disease (63) Dead (77):j: No clinical evidence of disease (85)
* Continent urinary reservoir. t Intravesical chemotherapy with thiotepa and later mitomycin. :j: Death from causes other than transitional cell carcinoma or abdominal aortic aneurysm.
DISCUSSION
Malignancy has been reported in up to 12.6% of the patients with abdominal aortic aneurysm and represents a challenge for optimal management, especially when the malignancy is in the abdominal, pelvic or retroperitoneal spaces. 10 If both conditions are diagnosed at the same time, should the aneurysm be repaired first, second or simultaneous with cancer resection? Simultaneous cystectomy, urinary diversion and aneurysm repair would be a difficult procedure with the potential for graft infection from spilled bowel contents and urine. 11 Initial resection of the tumor may risk aneurysm rupture reportedly due to the high rate of collagen turnover observed 7 to 10 days after major operations. 12 Delayed aneurysm repair may also risk ureteral or bowel injury by direct transection or by vascular compromise (for example if the left colon was used for urinary diversion and primarily depends upon inferior mesenteric arterial blood supply). Repair of the aneurysm before cancer resection potentially allows for further growth and spread of tumor in a weakened, possibly immunocompromised host and also risks graft infection if the graft is incompletely healed with protective fibrous capsule and neointima. 13 Some of these considerations clearly apply as well when abdominal aortic aneurysm and invasive bladder cancer are diagnosed consecutively in either order. The optimal time for repair of abdominal aortic aneurysm is unknown and it is beyond the scope of this discussion to review extensively the controversies in this area. Elective repair is recommended when there is bleb formation, or the aneurysm is thin-walled, symptomatic or exceeds 5 cm. in diameter. 9 The risk of rupture for small aysmptomatic aneurysms less than 5 cm. is low (3% per year) and they may be judiciously followed with sonography every 3 months. 6 • 7 Patients with a small aneurysm, good health and a life expectancy of at least several years should consider aneurysm repair, since the mortality rate for elective repair is 2 to 5% (whereas emergency repair has a 50% mortality rate). 14 Treatment for invasive carcinoma of the bladder must be tailored to each patient and must take into consideration age, performance status, and coexisting medical and surgical disorders, as well as the stage, grade and histological subtype of the tumor. While various options exist, radical cystoprostatectomy with urinary diversion remains a mainstay of treatment for patients judged to be suitable candidates. 2 Mortality rates for elective radical cystectomy vary but reportedly have been less than 2% in recent decades. 2 However, overall complication rates approach 25 to 35% in these patients, a significant portion of which are infectious ( 10%), or involve rectal injury (4 %) or other bowel problems (10%). 2 One clearly worries that a preexisting aortic replacement graft might be placed at risk for infection by such complications, although a well healed graft with good neointima formation and fibrous encasement may have adequate resistance to such infection. 13 If the ureters are incorporated into the fibrous tissue surrounding a graft or pass beneath the iliac limbs of the graft, they may have marginal blood supply and can be difficult to dissect during urinary
diversion, further increasing the risk of morbidity following r:ciclic:cil cv>
Size of AAA
2:5cmAAA, Expanding or Symptomatic
AAA repair & Pelvic Lymphadenectomy
l
< 5 cm. AAA & TCCB
l
Cystectomy & Urinary Diversion
o, TURBT
Cystectomy & Urinary Diversion
o,
Observation or Aneurysm
TURBT
Consideration for Repair
&
Proposed management scheme for pati~I_1ts with ~imultaneous abdominal aortic aneurysm (AAA) and trans1t10nal carcmoma of bladder (TCCB). TURBT, transurethral resection of bladder tumors.
ABDOMINAL AORTIC ANEURYSM AND TRANSITIONAL CELL BLADDER CANCER
tion at the time of vascular repair, since subsequent peri-graft fibrosis makes it more difficult at a later date. If the nodes are microscopically positive, conservative management rather than cystectomy/diversion should be considered in view of the diminished long-term cancer prognosis. Early urological involvement also ensures improved communication between vascular and urological surgeons so that the vascular graft will be placed optimally for subsequent ureteral dissection. Patients with small aneurysms should undergo cystectomy and urinary diversion or transurethral resection of bladder tumor with close observation of the aneurysm. Dr. William R. Fair reviewed this manuscript. REFERENCES 1. Boring, C. C., Squires, T. S. and Tong, T: Cancer statistics, 1992. CA, 42: 19, 1992. 2. Catalona, W. J.: Bladder cancer. In: Adult and Pediatric Urology, 2nd ed. Edited by J. Y. Gillenwater, J. T. Grayhack, S. S. Howards and J. W. Duckett. St. Louis: Mosby-Year Book, Inc., vol. 1, chapt. 31, p. 1151, 1991. 3. Bickerstaff, L. K., Hollier, L. H., Van Peenan, H.J., Melton, L. J., III, Pairolero, P. C. and Cherry, K. J.: Abdominal aortic aneurysms: the changing natural history. J. Vase. Surg., 1: 6, 1984. 4. Reilly, J.M. and Tilson, M. D.: Incidence and etiology of abdominal aortic aneurysms. Surg. Clin. N. Amer., 69: 705, 1989. 5. Gewertz, B. L., Graham, A., Lawrence, P. F., Provan, J. and Zarins, C. K.: Diseases of the vascular system. In: Essentials of General Surgery. Edited by P. F. Lawrence. Baltimore: Williams & Wilkins, chapt. 25, p. 317, 1988. 6. Quill, D.S., Colgan, M. P. and Sumner, D.S.: Ultrasonic screening for the detection of abdominal aortic aneurysms. Surg. Clin. N. Amer., 69: 713, 1989.
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7. Cronenwett, J. L., Murphy, T. F., Zelenock, G. B., Whitehouse, W. M., Jr., Lindenauer, S. M., Graham, L. M., Quint, L. E., Silver, T. M. and Stanley, J. C.: Actuarial analysis of variables associated with rupture of small abdominal aortic aneurysms. Surgery, 98: 472, 1985. 8. Thomas, J. H.: Abdominal aortic aneurysmorrhaphy combined with biliary or gastrointestinal surgery. Surg. Clin. N. Amer., 69: 807, 1989. 9. Szilagyi, D. E., Elliott, J. P. and Berguer, R.: Coincidental malignancy and abdominal aortic aneurysm. Problems of management. Arch. Surg., 95: 402, 1967. 10. Morris, D. M. and Colquitt, J.: Concomitant abdominal aortic aneurysm and malignant disease: a difficult management problem. J. Surg. Oncol., 39: 122, 1988. 11. Hermreck, A. S.: Prevention and management of surgical complications during repair of abdominal aortic aneurysms. Surg. Clin. N. Amer., 69: 869, 1989. 12. Swanson, R. J., Littooy, F. N., Hunt, T. K. and Stoney, R. J.: Laparotomy as a precipitating factor in the rupture of intraabdominal aneurysms. Arch. Surg., 115: 299, 1980. 13. Noble, M. J.: Vascular replacements in urologic surgery. In: Vascular Problems in Urologic Surgery. Edited by A. C. Novick and R. A. Straffon. Philadelphia: W. B. Saunders Co., chapt. 2, pp. 17-30, 1982. 14. Crawford, E. S., Saleh, S. A., Babb, J. W., III, Glaeser, D. H., Vaccaro, P. S. and Silvers, A.: Infrarenal abdominal aortic aneurysm: factors influencing survival after operation performed over a 25-year period. Ann. Surg., 193: 699, 1981. 15. Corriere, J. N., Jr.: Ureteral injuries. In: Adult and Pediatric Urology, 2nd ed. Edited by J. Y. Gillenwater, J. T. Grayhack, S. S. Howards and J. W. Duckett. St. Louis: Mosby-Year Book, Inc., vol. 1, chapt. 12, p. 491, 1991. 16. Grant, J. C. B.: An Atlas of Anatomy, 5th ed. Baltimore: Williams & Wilkins, fig. 163, 1962.