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Radical Cystectomy for Advanced Carcinoma of the Bladder
THE JOURNAL OF UROLOGY
Vol. 78, No. 4, October 1957 Printed in U.S.A.
RADICAL CYSTECTOMY FOR ADVAN CED CARCINOMA OF THE BLADDER THOMAS J. FLORENCE
Vesical cancers show tremendous individual variations. The types of neoplasm, their sizes, locations and number; the depth of invasion present, the existence of local or distant metastases: all these make no two cases alike as to treatment or prognosis. In this discussion I would like to postulate that particular growth which might be cured or greatly helped by total cystectomy. Urine is formed continuously in the kidneys and only by the development of a suitable reservoir has man become a social animal. To date this reservoir, the urinary bladder, has resisted "successful" imitation. Therefore its removal is no trivial affair, making any but an aquatic existence precarious. The immediate and chief problem is where to place the ureters. Two methods are now in well established usage. Skin ureterostomy may be done or some portion of the gastrointestinal tract can be used. Both procedures are consistent with several years of fairly normal life and each deserves consideration if a serious disease can be cured or greatly ameliorated. However certain major objections exist, such as ureteral obstruction, reabsorption of electrolytes, infection and inconvenience to the patient. For many reasons a more natural or physiologic solution has been desired. Stimulated probably by the observation that the bladder has a remarkable regenerative power, partial cystectomy has been carried to the extreme in the experimental work of Bohne, Osborne and Hettle at the Henry Ford Hospital in Detroit. They removed the entire bladder in dogs and obtained a regenerated pouch lined with transitional epithelium and containing smooth muscle in its wall. Six to ten weeks were required for epithelization. Smooth muscle was present at fourteen to sixteen weeks. In one dog a section at 21 weeks showed ganglion cells and nerve tissue. Functionally a number of the animals were continent and voided in a normal manner. The longest survivor at the time of reporting was nine months. Only 3 cases were described in detail and ureteral reflux was mentioned in two of these. Technically the entire bladder was removed and a plastic mold inserted to serve as a framework for the future "bladder." Later a collapsible plastic bag with ureteral extensions was used. This could be deflated and removed through the urethra. The overall mortality and morbidity were high. CASE REPORT
A 44-year-old married Negro man was seen April 6, 1956 because of gross hematuria due possibly to excessive lifting on his job at a potato chip factory. The urinalysis showed many blood cells, 2 plus albumin and no sugar. Marked phimosis was present. On rectal examination hardness and irregularity of the prostate and bladder region were felt with questionable fixation. Preliminary intravenous urograms in the office demonstrated bilateral moderate hydronephrosis, ureteral dilatation, and a small, irregular bladder. Ten days later during hosRead at annual meeting of South Central Section of American Urological Association, Mexico City, October 28-November 1, 1956. 410
RADICAL CYSTECTOMY FOR ADVANCED VESICAL CALCULl
411
pitalization at Hughes Spalding Pavilion a tedious circmncision for obliterative balanoposthitis and an internal urethrotomy for dense strictures were done. Cystoscopy was performed and was deemed technically unsatisfactory due to severe cystitis or extensive tumor formation. Antibiotics were given for infection and on May 11, 1956 another cystoscopy under local anesthesia in the office was interpreted as showing generalized bladder neoplasm. The patient was admitted to the hm,pital and routine preparations made for cystectomy and bowel transplants using sulfathalidine. The work of Bohne and associates had been noted and the following procedure was performed: Spinal anesthe8ia vrns administered. With the patient supine the abdomen and genitalia were prepared and draped and a midline incision made from the symphysis pubis to the umbilicus. Bleeders were clamped and ligated with 00 chromic catgut. The rectus fascia was incised and the recti muscles separated. Retracting the peritoneurn superiorly, blunt dissection ,vas used to free the anterior and lateral sides of the bladder and prostate. By placing transfixion sutures of Ko. l chromic catgut in the puboprostatic vascular pedicle the prostatic urethra could be severed at the apex with minimal hemorrhage. The prostate was then grasped on its free end with two Allis forceps and the remaining prostate and posterior bladder dissected carefully off the rectum. The lateral vascular pedicles including the vasa deferentia were clamped in multiple series, divided and ligated with No. 1 chromic catgut. The ureters were cut about 1.5 cm . above the bladder. Then the entire specimen including the prostate, bladder, seminal vesicles, parts of the vasa deferentia and parts of the lower ureters were removed in one mass. No nodes were found but probable rectal fixation was present. The lower ureters could be seen free in the empty pelvic cavity and by crossing in a straight line the ureters could be approximated to the cut posterior urethra without tension. Then t,vo 10:F red rubber urethral catheters were inserted through the penile urethra, about 15 cm. projecting above the severed prostatic urethra and about 6 to 9 cm. projecting beyond the meatus. One catheter was threaded up one ureter and the other up the other ureter. The ureters and pos terior urethra were then approximated with two sutures of 00 chromic catgut. The catheters were anchored to the penis by sutures to the glans and by adhesive tape. A one-half inch Penrose drain was left in the space of Retzius and the wound closed with N·o. 1 chromic catgut for the muscle and fascia and ;:i~O black silk for the skin. The operating time was 2 hours; 1 pint of blood was used; the condition of the patient remained satisfactory. The pathological report was advanced adenocarcinoma involving the prostate, bladder and seminal vesicles and extending through the line of excision. Postoperatively the urethral catheters were left indwelling for ;3 weeks. Moderate suprapubic drainage occurred for 10 days, then ceased. After removing the catheters the patient complained of marked frequency with precipitous voidi.ng for about tivo weeks. On June 15, 1956 he was seen in the office and voided 3 ounces with good control and a "normal stream." One month later the capacity was 10 ounces ,vith only occasional enuresis. Two months after cystectomy a cystogram revealed a large "bladder" and bilateral ureteral reflux. A film made
412
THOMAS J. FLORENCE
immediately after voiding showed complete emptying with much drainage of the dilated pelves and ureters. Intravenous urograms 2 days later demonstrated prompt and good function with little change in the hydronephrosis from that before surgery. Hospitalization for further studies was done in September 1956. The blood urea nitrogen was 20 mg. per cent. A cystogram again showed bilateral reflux and some diminution in "bladder capacity." Investigative zeal prompted a probably unwise attempt at cystoscopy and biopsy of the new "bladder." The "bladder" wall appeared smooth and not unlike normal mucosa except in the floor where recurrent tumor was suspected. At this point manipulation resulted in penetration of the superior wall with visualized entrance of a piece of greater omentum through the tear. Cystoscopy was discontinued and a 20F Foley catheter inserted to keep the bladder empty for 10 days. To our surprise no complications occurred. At the present time the patient is living with cancer. His general condition is fair. The urine contains many pus cells and there have been two episodes of acute pyelonephritis which responded to penicillin and streptomycin. A normal sensation to void developed 6 weeks after surgery. In assaying the worth of a new procedure one example is woefully inadequate. Also any particular example might well be completely misleading. However such was done and an attempt will be made to give a personal evaluation. The method is attractive because of simplicity in execution and naturalness of results. After removing the pathological process the operation is essentially over, certainly an advantage over surgery which incorporates bowel transplants. The patient can still void in a normal manner and a closed urinary tract is preserved against invading micro-organisms. Data are still necessary to determine whether such a simple procedure as was done in this case will suffice or whether an inflatable apparatus produces a better bladder. The permanent vesical capacity and how often reflux will occur must be determined in human cases. Also what effects this type of reflux will have on kidney function and if any method of correction can be done pose intriguing problems. From the important standpoint of total removal of cancer I believe this method is as effective as any not involving removal of the rectum. In conclusion, a new operative procedure is reported. It is technically feasible and probably workable. However it is neither recommended nor condemned but merely presented in the hope that other urologists may by frequent usage establish its true place in the treatment of bladder cancer.
403 Boulevard, N. E., Atlanta, Ga. REFERENCES BAUMGARTEN. Quoted by Schiller, H. BERRY, F.: The regeneration of smooth muscle cells. J. Med. Res., 41: 365, 1920. BOHNE, H. W., OSBORNE, R. W. AND HETTLE, P. J.: Regeneration of urinary bladder in dog following total cystectomy. Surg., Gynec. & Obst., 100: 259, 1956. BowDEN, K.: New formation of smooth muscle in the lung. Med. J. Australia, 2: 623, 1947. BusAcHI, T.: Ueber die Regeneration der glatten Muskeln. Cbl. med. Wissensch., 25: 113, 1887.
FOLSOM, A., O'BRIEN, H. AND CALDWELL, G.: Subtotal cystectomy in treatment of Hunner ulcer. J. Urol., 44: 650, 1940. GARRETT, R.: Unpublished observation.
TIADICAL CYSTEC'l'OMY FOH .·\DVAl\CED VESICAL CALCULI
I-L~RPER, S.: Fibrous healing as seen in transparent chambers inserted in ears of rnbbits Thesis, Graduate School, University of Minnesota, 1942. h,KnIOWITSCH: Ueber die Regeneration der glatten lVInskelfasern. CbL Deutsch. med. Wschr., 27: 897, 1879. KRETSCHMER, H. L. A0TD BARBER, IL: Regeneration of bladder following resections. J.A.M.A., 90: 355, HJ28. l'vIAxrnow, A. AND BLOOM, W. A.: Textbook of Histology, 5th ed. Philadelphia and London. W. B. Saunders Co., 1948, p. 161. PERLJ\HNN, S.: Demonstration of bladder regeneration. Ztschr. & lirol., 21: 621, HJ27. RICHARDSON, E. J.: Bladder regeneration. Minn. Med., 35: 547, 1952. SCHILLER, H.: Regeneration of resected urinary bladders in rabbits. Surg., Gynec. & Obst., 36: 24, 1923. SCHWARTZ, R.: Ricerche in proposito clella rigenernzione della vescica urinaria. Sperimentale, 45: 484, 1891. LAND NEu, V.: The regeneration of the bladder; report of a ca.se. Trans. Am ..Assoc. Surg., 32: 197, 1939. STILLING .• H. AND PFITZNER, W.: Ueber die Regeneration der glatten lVfusk. Arch. miluo. AnaL, 28: 396, 1886 Trzzom, G. AND Foom, A.: Die Wiederherstellung der Harnblase. Zentralbl. 15: 921 . 1888.
Vol. 78, No. 4, October 1957 Printed in U.S.A.
RADICAL CYSTECTOMY FOR ADVAN CED CARCINOMA OF THE BLADDER THOMAS J. FLORENCE
Vesical cancers show tremendous individual variations. The types of neoplasm, their sizes, locations and number; the depth of invasion present, the existence of local or distant metastases: all these make no two cases alike as to treatment or prognosis. In this discussion I would like to postulate that particular growth which might be cured or greatly helped by total cystectomy. Urine is formed continuously in the kidneys and only by the development of a suitable reservoir has man become a social animal. To date this reservoir, the urinary bladder, has resisted "successful" imitation. Therefore its removal is no trivial affair, making any but an aquatic existence precarious. The immediate and chief problem is where to place the ureters. Two methods are now in well established usage. Skin ureterostomy may be done or some portion of the gastrointestinal tract can be used. Both procedures are consistent with several years of fairly normal life and each deserves consideration if a serious disease can be cured or greatly ameliorated. However certain major objections exist, such as ureteral obstruction, reabsorption of electrolytes, infection and inconvenience to the patient. For many reasons a more natural or physiologic solution has been desired. Stimulated probably by the observation that the bladder has a remarkable regenerative power, partial cystectomy has been carried to the extreme in the experimental work of Bohne, Osborne and Hettle at the Henry Ford Hospital in Detroit. They removed the entire bladder in dogs and obtained a regenerated pouch lined with transitional epithelium and containing smooth muscle in its wall. Six to ten weeks were required for epithelization. Smooth muscle was present at fourteen to sixteen weeks. In one dog a section at 21 weeks showed ganglion cells and nerve tissue. Functionally a number of the animals were continent and voided in a normal manner. The longest survivor at the time of reporting was nine months. Only 3 cases were described in detail and ureteral reflux was mentioned in two of these. Technically the entire bladder was removed and a plastic mold inserted to serve as a framework for the future "bladder." Later a collapsible plastic bag with ureteral extensions was used. This could be deflated and removed through the urethra. The overall mortality and morbidity were high. CASE REPORT
A 44-year-old married Negro man was seen April 6, 1956 because of gross hematuria due possibly to excessive lifting on his job at a potato chip factory. The urinalysis showed many blood cells, 2 plus albumin and no sugar. Marked phimosis was present. On rectal examination hardness and irregularity of the prostate and bladder region were felt with questionable fixation. Preliminary intravenous urograms in the office demonstrated bilateral moderate hydronephrosis, ureteral dilatation, and a small, irregular bladder. Ten days later during hosRead at annual meeting of South Central Section of American Urological Association, Mexico City, October 28-November 1, 1956. 410
RADICAL CYSTECTOMY FOR ADVANCED VESICAL CALCULl
411
pitalization at Hughes Spalding Pavilion a tedious circmncision for obliterative balanoposthitis and an internal urethrotomy for dense strictures were done. Cystoscopy was performed and was deemed technically unsatisfactory due to severe cystitis or extensive tumor formation. Antibiotics were given for infection and on May 11, 1956 another cystoscopy under local anesthesia in the office was interpreted as showing generalized bladder neoplasm. The patient was admitted to the hm,pital and routine preparations made for cystectomy and bowel transplants using sulfathalidine. The work of Bohne and associates had been noted and the following procedure was performed: Spinal anesthe8ia vrns administered. With the patient supine the abdomen and genitalia were prepared and draped and a midline incision made from the symphysis pubis to the umbilicus. Bleeders were clamped and ligated with 00 chromic catgut. The rectus fascia was incised and the recti muscles separated. Retracting the peritoneurn superiorly, blunt dissection ,vas used to free the anterior and lateral sides of the bladder and prostate. By placing transfixion sutures of Ko. l chromic catgut in the puboprostatic vascular pedicle the prostatic urethra could be severed at the apex with minimal hemorrhage. The prostate was then grasped on its free end with two Allis forceps and the remaining prostate and posterior bladder dissected carefully off the rectum. The lateral vascular pedicles including the vasa deferentia were clamped in multiple series, divided and ligated with No. 1 chromic catgut. The ureters were cut about 1.5 cm . above the bladder. Then the entire specimen including the prostate, bladder, seminal vesicles, parts of the vasa deferentia and parts of the lower ureters were removed in one mass. No nodes were found but probable rectal fixation was present. The lower ureters could be seen free in the empty pelvic cavity and by crossing in a straight line the ureters could be approximated to the cut posterior urethra without tension. Then t,vo 10:F red rubber urethral catheters were inserted through the penile urethra, about 15 cm. projecting above the severed prostatic urethra and about 6 to 9 cm. projecting beyond the meatus. One catheter was threaded up one ureter and the other up the other ureter. The ureters and pos terior urethra were then approximated with two sutures of 00 chromic catgut. The catheters were anchored to the penis by sutures to the glans and by adhesive tape. A one-half inch Penrose drain was left in the space of Retzius and the wound closed with N·o. 1 chromic catgut for the muscle and fascia and ;:i~O black silk for the skin. The operating time was 2 hours; 1 pint of blood was used; the condition of the patient remained satisfactory. The pathological report was advanced adenocarcinoma involving the prostate, bladder and seminal vesicles and extending through the line of excision. Postoperatively the urethral catheters were left indwelling for ;3 weeks. Moderate suprapubic drainage occurred for 10 days, then ceased. After removing the catheters the patient complained of marked frequency with precipitous voidi.ng for about tivo weeks. On June 15, 1956 he was seen in the office and voided 3 ounces with good control and a "normal stream." One month later the capacity was 10 ounces ,vith only occasional enuresis. Two months after cystectomy a cystogram revealed a large "bladder" and bilateral ureteral reflux. A film made
412
THOMAS J. FLORENCE
immediately after voiding showed complete emptying with much drainage of the dilated pelves and ureters. Intravenous urograms 2 days later demonstrated prompt and good function with little change in the hydronephrosis from that before surgery. Hospitalization for further studies was done in September 1956. The blood urea nitrogen was 20 mg. per cent. A cystogram again showed bilateral reflux and some diminution in "bladder capacity." Investigative zeal prompted a probably unwise attempt at cystoscopy and biopsy of the new "bladder." The "bladder" wall appeared smooth and not unlike normal mucosa except in the floor where recurrent tumor was suspected. At this point manipulation resulted in penetration of the superior wall with visualized entrance of a piece of greater omentum through the tear. Cystoscopy was discontinued and a 20F Foley catheter inserted to keep the bladder empty for 10 days. To our surprise no complications occurred. At the present time the patient is living with cancer. His general condition is fair. The urine contains many pus cells and there have been two episodes of acute pyelonephritis which responded to penicillin and streptomycin. A normal sensation to void developed 6 weeks after surgery. In assaying the worth of a new procedure one example is woefully inadequate. Also any particular example might well be completely misleading. However such was done and an attempt will be made to give a personal evaluation. The method is attractive because of simplicity in execution and naturalness of results. After removing the pathological process the operation is essentially over, certainly an advantage over surgery which incorporates bowel transplants. The patient can still void in a normal manner and a closed urinary tract is preserved against invading micro-organisms. Data are still necessary to determine whether such a simple procedure as was done in this case will suffice or whether an inflatable apparatus produces a better bladder. The permanent vesical capacity and how often reflux will occur must be determined in human cases. Also what effects this type of reflux will have on kidney function and if any method of correction can be done pose intriguing problems. From the important standpoint of total removal of cancer I believe this method is as effective as any not involving removal of the rectum. In conclusion, a new operative procedure is reported. It is technically feasible and probably workable. However it is neither recommended nor condemned but merely presented in the hope that other urologists may by frequent usage establish its true place in the treatment of bladder cancer.
403 Boulevard, N. E., Atlanta, Ga. REFERENCES BAUMGARTEN. Quoted by Schiller, H. BERRY, F.: The regeneration of smooth muscle cells. J. Med. Res., 41: 365, 1920. BOHNE, H. W., OSBORNE, R. W. AND HETTLE, P. J.: Regeneration of urinary bladder in dog following total cystectomy. Surg., Gynec. & Obst., 100: 259, 1956. BowDEN, K.: New formation of smooth muscle in the lung. Med. J. Australia, 2: 623, 1947. BusAcHI, T.: Ueber die Regeneration der glatten Muskeln. Cbl. med. Wissensch., 25: 113, 1887.
FOLSOM, A., O'BRIEN, H. AND CALDWELL, G.: Subtotal cystectomy in treatment of Hunner ulcer. J. Urol., 44: 650, 1940. GARRETT, R.: Unpublished observation.
TIADICAL CYSTEC'l'OMY FOH .·\DVAl\CED VESICAL CALCULI
I-L~RPER, S.: Fibrous healing as seen in transparent chambers inserted in ears of rnbbits Thesis, Graduate School, University of Minnesota, 1942. h,KnIOWITSCH: Ueber die Regeneration der glatten lVInskelfasern. CbL Deutsch. med. Wschr., 27: 897, 1879. KRETSCHMER, H. L. A0TD BARBER, IL: Regeneration of bladder following resections. J.A.M.A., 90: 355, HJ28. l'vIAxrnow, A. AND BLOOM, W. A.: Textbook of Histology, 5th ed. Philadelphia and London. W. B. Saunders Co., 1948, p. 161. PERLJ\HNN, S.: Demonstration of bladder regeneration. Ztschr. & lirol., 21: 621, HJ27. RICHARDSON, E. J.: Bladder regeneration. Minn. Med., 35: 547, 1952. SCHILLER, H.: Regeneration of resected urinary bladders in rabbits. Surg., Gynec. & Obst., 36: 24, 1923. SCHWARTZ, R.: Ricerche in proposito clella rigenernzione della vescica urinaria. Sperimentale, 45: 484, 1891. LAND NEu, V.: The regeneration of the bladder; report of a ca.se. Trans. Am ..Assoc. Surg., 32: 197, 1939. STILLING .• H. AND PFITZNER, W.: Ueber die Regeneration der glatten lVfusk. Arch. miluo. AnaL, 28: 396, 1886 Trzzom, G. AND Foom, A.: Die Wiederherstellung der Harnblase. Zentralbl. 15: 921 . 1888.