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Resection of Pubic Rami for Urologic Cancer
VoL 100, Oct. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1968 by The Williams & Wilkins Co.
RESECTION OF PUBIC RAMJ FOR UROLOGIC CAN"CER A. RANALD MACKENZIE
AND
WILLET F. WHITMORE, JR.
From the Urologic Service, Department of Smgery, ~Memorial ancl James Ewing Hospitals, New York, New York
The pubic rami have been resected in 9 patients in Memorial Hospital as part of operations to remove locally advanced cancer of urologic origin. Our report concerns the indications, technique and results of this procedure. The extent of the operation is shown in the case reports and in the table. In each patient the clinical extent of the disease made it most unlikely that more limited excision would be curative. In 5 patients bladder cancer was felt to have extended iatrogenically to the retropubic space or into the anterior abdominal wall following a suprapubic operation. Two patients had advanced cancer of the penis, recurrent after partial amputation and 2 patients, both women, had cancer of the urethra. TECHNIQUE
A low lithotomy position is generally employed, thighs being abducted 45 degrees, flexed 30 degrees and externally rotated. A midline laparotomy is made, the lower end of which does not encroach upon any indurated area anterior to the bladder. If tumor is suspected in the anterior abdominal wall or in the retropubic space, the incision is carried down in inverted Y fashion toward each femoral canal through full thickness of abdominal wall, as much skin as possible being preserved. Dissection of the posterior and lateral pelvic walls is carried out in the usual fashion for radical cystectomy or pelvic exenteration, as indicated by the extent of the disease. When the specimen has been thoroughly mobilized from its lateral and posterior attachments, the superior and inferior pubic rami are exposed on their anteroinferior surfaces. In the male subject the suspensory ligament is divided if the penis is to be preserved. In female patients the skin incisions diverge to encompass the clitoris and a variable amount of vulva and join the incisions made from above, down the lateral walls of the vagina. Following exposure of the upper ends of the adductor longus, gracilie, adductor brevis, pectineus and part of the adductor magnus, Accepted for publication October 20, 1967. 546
these muscles are transected along with the obturator internus and externus and the pubic rami. We have used a Gigli saw for dividing the rami. The specimen is then quickly removed by dividing the remaining muscular attachments, i.e. fibers of the obturator internus and externus and the fibers of the levator ani. Rather copious bleeding, which is apt to occur from the obturator veins after the bellies of the obturator muscles are transected, cannot be controlled until the specimen is removed. While this account describes the basic procedure, it is modified according to the specific requirements of each patient. CASE REPORTS
Case 1. W. T. (45-20-38), a 57-year-old white man, underwent partial cystectomy for cancer of the bladder in 1947. He was first seen in Memorial Hospital with recurrent disease in September 1950, tumor being adherent to the superior pubic ramus on the right. All 4 pubic rami were removed in continuity with the bladder, rectum, pelvic peritoneum and lymph nodes and the lower 4 cm. of the right rectus muscle. Grossly and microscopically tumor was seen to invade the entire wall of the bladder, the rectus muscle and the periosteum of the pubis; microscopically epidermoid carcinoma invaded bone. The patient died of peritoneal metastases 5 months after operation. Case 2. P. V. (14-14-90), a 56-year-old white woman, underwent a suprapubic operation for cancer of the bladder in December 1952. She was first seen in Memorial Hospital in May 1953 with recurrent disease which was removed on June 3, 1953. The tumor penetrated the bladder into perivesical space and extended to the periosteum of the posterior surface of the pubic symphysis. Microscopically it was anaplastic epidermoid carcinoma of bladder, grade 3. The bone and periosteum were not affected and all lymph nodes were free of tumor. She died of renal failure on January 9, 1958, 4~ 2 years after cystectomy. There was no evidence of recurrent disease. Case 3. J. N. (14-91-46), a 56-year-old white
HESECTIOX OF PUBIC RA.MI FOR UHOLOGIC CA:\ICEH
Type and c:r/enl of tumors m patients having pubic resection ci
:z;
I
Sex·
en
b
Tumor
Previous Treatment
-------
---------
~
bD
-- --
-<
-
57
Epidermo.i.d
Date of Operation
M
56
Epidermoid ca. bladder
Blackler, prostate, rectum, pelvic lymph nodes and "1 pubic rami
Innuled hlad
Died of metastases 5 mos. later
Regmental resection
6-3-53
Blackler, uterus, tubes,
Extended up to but did not invade
Died
oYaries, vagina, pelYic lymph nodes and pubic symphysis
Squamous
Subtotal penectomy
ca. penis
and left superficial groin dissection
5-31-56
48 ! Epidermoid ca. bladder
Segmental resection. 4900R T. D. (Co 60 )
2-HJ-64
1I
60
Epidermoid ca. bladder
8-14-64
Epidermoid ca. urethra
Transuretl1rai resections of bladder tumors (X3). Segmental resection. Co 00 X 37 2125R T.D. (2MEV). Interstitial Ra 222 (24
Epidermoid ca. bladder
Transurethral resection, segmental
64
70
re,rnction, 56
Squamous ca. penis
F
58
Epidermoid ca. urethra
Result
9-28-50
M
F
Extent of Tumor
Segmental resedion
ca. bladder
56
Surgical Specimen
5-26-65
Couo
Partial amputation
9-7-66
and bilateral groin dissection
2050R T. D. (Co60)
Blackler, prostate, rectum, scrotum, testes,
Invaded bladder, scroturn, perineu1n, bone
perineum, pelvic lymph nodes, 4 pubic rami and part of abdominal -.,vall Bladder, prostate, reetum, penis, 4 pubic rami and part of abdominal wall
and origins of addnctors
Bladder,
prostate,
pubic rarni and part of abdominal -.,yall
9-16-64
3-17-67
pericsteum
Bladder, urethra, ut-
Invaded bladder, peri,;;csical fat, prostate, penis and ureters
Invaded peri,;;esical fat and prostate. Extended to periostemn
Invaded bladder and
of
uremia
4.5 yrs. later. :-Jc• recurrence
Dierl of aeute gastroenteritis 7 mos. later. Re-· current tmnor at autopsy 1\:Iassi...-e pelvic recttrrence 6 UJ.O}-L later. Translnmbar amputation on 9--23-G4. Well Alive
Postoperative
deatli.-subluxaurethra extended to erus, tubes, ovaries, tion of sacroiliac but did not invade anterior wall of vagjoints and small ina, most of vulva pubis bowel fistulas and 4 pubic rami Died 6 mos. later Bladder, prostate, rec- Invaded abdominal at home. No au-· tum, superior pubic wall, pubis and rectopsy rami and part of abtum dominal ·wall
Bladder, prostate, rectum, pelvic lymph nodes, penis, scrotum, testes and pubic rami Bladder, urethra, uterus, tubes, ovaries, part of vulva and inferior l)ll bic rami
man, was first seen in J'vlemorial Hospital in JVIay 1956. On May 31, 1956 he underwent radical excision of a massive carcinoma of the penis recurrent 9 months after subtotal penectomy, perineal urethrostomy and left superficial groin dissection. The specimen showed squamous carcinoma, grade 2, involving the perineum and scrotum with direct extension into the pelvis to involve bladder. It also invaded the periosteum of the right inferior pubic ranrns and the muscles at the resected margin of the left pubic rami. He died of acute gastroenteritis on December 28, 1956. At autopsy recurrent tumor was found in
Extended to within 1 cm. of prostate and
Died of recurrenc.e 6 mos. later
invaded 01·igins of adductor muscles
Diffusely infiltrated urethra and bladder neck. ~o metastases
Well
the soft tissues of the pelvis and the adjacent loops of small bowel (fig. 1). Case 4. J. C. (26-14-82), a 48-year-old white man, was first seen in .Memorial Hospital in December 1963 with suprapubic recurrence of bladder cancer following segmental resection 5 months before. The tumor increased in size de-spite delivery of a tumor dose of 4900R vm cobalt 60. On February 19, 1964 the patient underwent pelvic exenteration with removal of penis, pubic rami and part of the abdominal wall. Squamous carcinoma, grade 2, deeply infiltrated perivesical soft tissues and involved
548
MACKENZIE AND WHIT:VIORE
Fm. 1. Case 3. A, x-ray of pelvis before wide excision of pubic rami in continuity with pelvic exenteration for recnrrent carcinoma of penis. Tumor invaded right inferior ramns. B, shows extent of pubic resection. C, patient prior to discharge. Demonstrates epithelialization of granulations covering fascia! graft and greater omentum following placement of postage stamp skin grafts.
the prostate, base of penis and ureters. There were no lymphatic metastases. The course after operation was uneventful and the patient vrns dismissed in 23 days. He later returned to work, but re-entered the hospital with intestinal obstruction and a large pelvic recul'!'ence. He underwent translumbar amputation on September 23, 1964 and is alive and free of disease. Case 5. P. C. (24-92-45), a 60-year-old white man, was first admitted to :\iemorial Hospital on August 9, 1964 with recurrent carcinoma of the bladder. He had previously been treated elsewhere over a period of 2 years by transurethral resection or fulguration on 3 occasions, by segmental resection and he had received 37 treatments by telecobalt. On admission hemoglobin was 6.6 gm., hematocrit 21 per cent, blood urea nitrogen 43 mg. per cent. Excretory urography showed moderate right hydronephrosis and questionable function 011 the left side. On
August 14, 1966, after evacuation of clots from the bladder, bimanual examination revealed a solid mass extending from the prostate to the suprapubic area. During subsequent laparotomy care was taken to avoid entering the prevesical space by opening the abdomen through an inverted Y-shaped incision, saving only the skin. Radical cystectomy was performed in continuity with excision of 4 pubic rami. The genitalia and rectum were preserved. Convalescence was uneventful and the patient left the hospital in 16 clays. In the surgical :,pecim.en, grade 2 epidermoicl carcinoma of the bladder had invaded the prostate and perivesical soft tissues covering a large part of the posterior surface of the removed pubis. The patient returned to work as a longshorern.an and is clinically free of cancer. Case 6. E. B. (24-91-67), a 64-year-old white woman, weighing 250 pounds, underwent radical excision of the bladder, urethra, fallopian tubes,
RESECTION OF PUBIC RA!VII FOR UROLOGIC CAlsiCE!{
Frn. 2. Case 6. A, x-ray of pelvis of 250 pound woman shows radon 222 seeds implanted for car<'inonrn of uret;hra. B, wide separation of pllbic bones following surgical disruption of pelvic ring and reseetion of pubic rami.
ovaries, cervix, anterior vaginal wall, 4 pubic rami and most of the vulva Oil September 16, 1964 for locally advanced carcinoma of the urethra occupying the full width of the vagina and firmly adherent to the pubic arch on both sides. An unexpected finding ,vas wide separation of the divided pubic rami following removal of the surgical specimen . A difficult closure was followed by evisceration and the appearance of multiple small bowel fistulas on Septernber 28. Three subsequent operations failed to control the fistulas and the patient died on October 16; an autopsy was not performed. The surgical specimen showed infiltrating epidermoid carcinoma, grade 3, involving urethra and bladder neck. Tumor approached but did not involve the pubic bone (fig. 2). Case 7 . .J. P. (60-16-12), a 70-year-old white man underwent radical exeision of carcinoma of the bladder (recurrent after transurethral resections), segmental resection and a course of telecobalt on May 26, 1965. The ;;pecimen showed two foci of cpidermoid carcinoma of the bladder, grade 3, invading the pubic bone and abdominal wall anteriorly and the pcrirectal tissue posteriorly. He died at home on ::\"ovember 14. Case 8. L. D. (60-57-07), a 56-year-old white man underwent radical excision of a recurrent cancer of the penis on September 7, 1966. The specimen contained squamous carcinoma involving the urethra and extending to within one cm. of the prostate. Tumor was found also in the adductor muscles on the right side close to their origin from the pubis. Convalescence was uneventful and the patient was discharged on the twenty-second day. He derived .-mbstantial
palliation until shortly before his death, 6 1nontb.s after operation (fig. 3). Case .9 . .J. S. (26-92-42), a underwent anterior excnteration with resection of the inferior publie ran1i on JVIareh 19, l9G7 for carcinoma of the urethra. She left the hospital on the fifteenth day after an uneventful convalescence. The specimen showed diffusely infiltrating epidermoid carcinoma of the urethra. o tumor was found in lymph nodes. DISC1J8SION
vVith widespread use of segmental resection for carcinoma of the bladder, it is tha,b local recurrence in the perivesical space will [01 continue to provide the mo::;t common the use of pubic re.section in conjunction with radical cystectomy or pelvic exenteration. The absence of lymph node metastases m all patients who had massive invasion of tbe prevesical space after segmental re~ection suggests that the condition may not be hopeless. This, together with the surTi-val of two of tho;;e patients for 4}2 and 3 years "·ithout recurrence, prnvides incentiire to continue this operation. Before recommending trarn;lumbar amputation for lesions situated anterior to the bladder, we believe pubic re,;ection de~erves ,1 trial, especially since there may ~till be an opportunity to perform the more radical procedme later should recurrence dcn,Jop after pubic resection, as illustrated in case 4. Translumbar amputation is, we feel, best re.served for lesions in the region of the sacrum or sciatic nerve when pelvic exenteration cannot prnviclc an adequate margin of normal tissue. Patients with cancer of the penis are ,mmetimes
550
MACKENZIE AND WHITMORE
Fm. 3. Case 8. A, carcinoma of penis recurrent after partial amputation and bilateral inguinal lymphadenectomy. B, shows extent of pubic resection after pelvic exenteration and emasculation. C, wound 2 weeks after operation. particularly prone to neglect seeking medical aid. Two such patients thus became candidates for pubic resection. The propensity for advanced cancer of the penis to remain localized invites an aggressive approach. At the same time the apparent tendency of this disease to invade the thighs, as happened in both of our patients, clearly imposes a narrow range of usefulness for this operation. The use of pubic resection in cancer of the female urethra is justified by the proximity of the urethra to the pubic arch and the high incidence of local recurrence in this disease following treatment by other methods. In 67 women treated in Memorial Center for cancer of the urethra, local recurrence was seen in 60 per cent. The need to excise a wide margin of normal tissue does not, however, preclude use of interstitial radioactive implantation as a definitive or
preoperative procedure; early results with this modality are encouraging. Excision of only the inferior pubic rami will probably be adequate in carcinoma of the female urethra, thus maintaining the integrity of the pelvic ring and avoiding the catastrophe we encountered in case 6. We believe that excision of all 4 pubic rami should be avoided in obese patients because of the possibility of sacroiliac subluxation. The aim of pubic resection in conjunction with radical cystectomy or pelvic exenteration is not to excise bone which has been penetrated by tumor arising anterior or posterior to the pubis. The survival of 3 patients in whom microscopic evidence of bony invasion was found has been 5, 6 and 7 months respectively, not long enough to warrant an operation of this magnitude. The aim is to provide a margin of normal tissue around the excised cancer and to avoid spilling cancer
RESECTION OF PUBIC RAMI FOR UROLOGIC CANCER
cells. For this reason we have sometimes proceeded with the operation without establishing, by open biopsy, that an indurated mass in the prevesical space is cancer rather than fibrosis. The existence of cancer of the bladder may be shown by endoscopic biopsy or exfoliative
5Eil
cytology. Determination of its extent would in this event rest solely on palpation, clinical and surgical. Such means of evaluation have not yet led to an unnecessarily mutilating operation. Ai times the extent of the tumor would, in retrospect, have justified a more radical operation.
THE JOURNAL OF UROLOGY
Copyright © 1968 by The Williams & Wilkins Co.
RESECTION OF PUBIC RAMJ FOR UROLOGIC CAN"CER A. RANALD MACKENZIE
AND
WILLET F. WHITMORE, JR.
From the Urologic Service, Department of Smgery, ~Memorial ancl James Ewing Hospitals, New York, New York
The pubic rami have been resected in 9 patients in Memorial Hospital as part of operations to remove locally advanced cancer of urologic origin. Our report concerns the indications, technique and results of this procedure. The extent of the operation is shown in the case reports and in the table. In each patient the clinical extent of the disease made it most unlikely that more limited excision would be curative. In 5 patients bladder cancer was felt to have extended iatrogenically to the retropubic space or into the anterior abdominal wall following a suprapubic operation. Two patients had advanced cancer of the penis, recurrent after partial amputation and 2 patients, both women, had cancer of the urethra. TECHNIQUE
A low lithotomy position is generally employed, thighs being abducted 45 degrees, flexed 30 degrees and externally rotated. A midline laparotomy is made, the lower end of which does not encroach upon any indurated area anterior to the bladder. If tumor is suspected in the anterior abdominal wall or in the retropubic space, the incision is carried down in inverted Y fashion toward each femoral canal through full thickness of abdominal wall, as much skin as possible being preserved. Dissection of the posterior and lateral pelvic walls is carried out in the usual fashion for radical cystectomy or pelvic exenteration, as indicated by the extent of the disease. When the specimen has been thoroughly mobilized from its lateral and posterior attachments, the superior and inferior pubic rami are exposed on their anteroinferior surfaces. In the male subject the suspensory ligament is divided if the penis is to be preserved. In female patients the skin incisions diverge to encompass the clitoris and a variable amount of vulva and join the incisions made from above, down the lateral walls of the vagina. Following exposure of the upper ends of the adductor longus, gracilie, adductor brevis, pectineus and part of the adductor magnus, Accepted for publication October 20, 1967. 546
these muscles are transected along with the obturator internus and externus and the pubic rami. We have used a Gigli saw for dividing the rami. The specimen is then quickly removed by dividing the remaining muscular attachments, i.e. fibers of the obturator internus and externus and the fibers of the levator ani. Rather copious bleeding, which is apt to occur from the obturator veins after the bellies of the obturator muscles are transected, cannot be controlled until the specimen is removed. While this account describes the basic procedure, it is modified according to the specific requirements of each patient. CASE REPORTS
Case 1. W. T. (45-20-38), a 57-year-old white man, underwent partial cystectomy for cancer of the bladder in 1947. He was first seen in Memorial Hospital with recurrent disease in September 1950, tumor being adherent to the superior pubic ramus on the right. All 4 pubic rami were removed in continuity with the bladder, rectum, pelvic peritoneum and lymph nodes and the lower 4 cm. of the right rectus muscle. Grossly and microscopically tumor was seen to invade the entire wall of the bladder, the rectus muscle and the periosteum of the pubis; microscopically epidermoid carcinoma invaded bone. The patient died of peritoneal metastases 5 months after operation. Case 2. P. V. (14-14-90), a 56-year-old white woman, underwent a suprapubic operation for cancer of the bladder in December 1952. She was first seen in Memorial Hospital in May 1953 with recurrent disease which was removed on June 3, 1953. The tumor penetrated the bladder into perivesical space and extended to the periosteum of the posterior surface of the pubic symphysis. Microscopically it was anaplastic epidermoid carcinoma of bladder, grade 3. The bone and periosteum were not affected and all lymph nodes were free of tumor. She died of renal failure on January 9, 1958, 4~ 2 years after cystectomy. There was no evidence of recurrent disease. Case 3. J. N. (14-91-46), a 56-year-old white
HESECTIOX OF PUBIC RA.MI FOR UHOLOGIC CA:\ICEH
Type and c:r/enl of tumors m patients having pubic resection ci
:z;
I
Sex·
en
b
Tumor
Previous Treatment
-------
---------
~
bD
-- --
-<
-
57
Epidermo.i.d
Date of Operation
M
56
Epidermoid ca. bladder
Blackler, prostate, rectum, pelvic lymph nodes and "1 pubic rami
Innuled hlad
Died of metastases 5 mos. later
Regmental resection
6-3-53
Blackler, uterus, tubes,
Extended up to but did not invade
Died
oYaries, vagina, pelYic lymph nodes and pubic symphysis
Squamous
Subtotal penectomy
ca. penis
and left superficial groin dissection
5-31-56
48 ! Epidermoid ca. bladder
Segmental resection. 4900R T. D. (Co 60 )
2-HJ-64
1I
60
Epidermoid ca. bladder
8-14-64
Epidermoid ca. urethra
Transuretl1rai resections of bladder tumors (X3). Segmental resection. Co 00 X 37 2125R T.D. (2MEV). Interstitial Ra 222 (24
Epidermoid ca. bladder
Transurethral resection, segmental
64
70
re,rnction, 56
Squamous ca. penis
F
58
Epidermoid ca. urethra
Result
9-28-50
M
F
Extent of Tumor
Segmental resedion
ca. bladder
56
Surgical Specimen
5-26-65
Couo
Partial amputation
9-7-66
and bilateral groin dissection
2050R T. D. (Co60)
Blackler, prostate, rectum, scrotum, testes,
Invaded bladder, scroturn, perineu1n, bone
perineum, pelvic lymph nodes, 4 pubic rami and part of abdominal -.,vall Bladder, prostate, reetum, penis, 4 pubic rami and part of abdominal wall
and origins of addnctors
Bladder,
prostate,
pubic rarni and part of abdominal -.,yall
9-16-64
3-17-67
pericsteum
Bladder, urethra, ut-
Invaded bladder, peri,;;csical fat, prostate, penis and ureters
Invaded peri,;;esical fat and prostate. Extended to periostemn
Invaded bladder and
of
uremia
4.5 yrs. later. :-Jc• recurrence
Dierl of aeute gastroenteritis 7 mos. later. Re-· current tmnor at autopsy 1\:Iassi...-e pelvic recttrrence 6 UJ.O}-L later. Translnmbar amputation on 9--23-G4. Well Alive
Postoperative
deatli.-subluxaurethra extended to erus, tubes, ovaries, tion of sacroiliac but did not invade anterior wall of vagjoints and small ina, most of vulva pubis bowel fistulas and 4 pubic rami Died 6 mos. later Bladder, prostate, rec- Invaded abdominal at home. No au-· tum, superior pubic wall, pubis and rectopsy rami and part of abtum dominal ·wall
Bladder, prostate, rectum, pelvic lymph nodes, penis, scrotum, testes and pubic rami Bladder, urethra, uterus, tubes, ovaries, part of vulva and inferior l)ll bic rami
man, was first seen in J'vlemorial Hospital in JVIay 1956. On May 31, 1956 he underwent radical excision of a massive carcinoma of the penis recurrent 9 months after subtotal penectomy, perineal urethrostomy and left superficial groin dissection. The specimen showed squamous carcinoma, grade 2, involving the perineum and scrotum with direct extension into the pelvis to involve bladder. It also invaded the periosteum of the right inferior pubic ranrns and the muscles at the resected margin of the left pubic rami. He died of acute gastroenteritis on December 28, 1956. At autopsy recurrent tumor was found in
Extended to within 1 cm. of prostate and
Died of recurrenc.e 6 mos. later
invaded 01·igins of adductor muscles
Diffusely infiltrated urethra and bladder neck. ~o metastases
Well
the soft tissues of the pelvis and the adjacent loops of small bowel (fig. 1). Case 4. J. C. (26-14-82), a 48-year-old white man, was first seen in .Memorial Hospital in December 1963 with suprapubic recurrence of bladder cancer following segmental resection 5 months before. The tumor increased in size de-spite delivery of a tumor dose of 4900R vm cobalt 60. On February 19, 1964 the patient underwent pelvic exenteration with removal of penis, pubic rami and part of the abdominal wall. Squamous carcinoma, grade 2, deeply infiltrated perivesical soft tissues and involved
548
MACKENZIE AND WHIT:VIORE
Fm. 1. Case 3. A, x-ray of pelvis before wide excision of pubic rami in continuity with pelvic exenteration for recnrrent carcinoma of penis. Tumor invaded right inferior ramns. B, shows extent of pubic resection. C, patient prior to discharge. Demonstrates epithelialization of granulations covering fascia! graft and greater omentum following placement of postage stamp skin grafts.
the prostate, base of penis and ureters. There were no lymphatic metastases. The course after operation was uneventful and the patient vrns dismissed in 23 days. He later returned to work, but re-entered the hospital with intestinal obstruction and a large pelvic recul'!'ence. He underwent translumbar amputation on September 23, 1964 and is alive and free of disease. Case 5. P. C. (24-92-45), a 60-year-old white man, was first admitted to :\iemorial Hospital on August 9, 1964 with recurrent carcinoma of the bladder. He had previously been treated elsewhere over a period of 2 years by transurethral resection or fulguration on 3 occasions, by segmental resection and he had received 37 treatments by telecobalt. On admission hemoglobin was 6.6 gm., hematocrit 21 per cent, blood urea nitrogen 43 mg. per cent. Excretory urography showed moderate right hydronephrosis and questionable function 011 the left side. On
August 14, 1966, after evacuation of clots from the bladder, bimanual examination revealed a solid mass extending from the prostate to the suprapubic area. During subsequent laparotomy care was taken to avoid entering the prevesical space by opening the abdomen through an inverted Y-shaped incision, saving only the skin. Radical cystectomy was performed in continuity with excision of 4 pubic rami. The genitalia and rectum were preserved. Convalescence was uneventful and the patient left the hospital in 16 clays. In the surgical :,pecim.en, grade 2 epidermoicl carcinoma of the bladder had invaded the prostate and perivesical soft tissues covering a large part of the posterior surface of the removed pubis. The patient returned to work as a longshorern.an and is clinically free of cancer. Case 6. E. B. (24-91-67), a 64-year-old white woman, weighing 250 pounds, underwent radical excision of the bladder, urethra, fallopian tubes,
RESECTION OF PUBIC RA!VII FOR UROLOGIC CAlsiCE!{
Frn. 2. Case 6. A, x-ray of pelvis of 250 pound woman shows radon 222 seeds implanted for car<'inonrn of uret;hra. B, wide separation of pllbic bones following surgical disruption of pelvic ring and reseetion of pubic rami.
ovaries, cervix, anterior vaginal wall, 4 pubic rami and most of the vulva Oil September 16, 1964 for locally advanced carcinoma of the urethra occupying the full width of the vagina and firmly adherent to the pubic arch on both sides. An unexpected finding ,vas wide separation of the divided pubic rami following removal of the surgical specimen . A difficult closure was followed by evisceration and the appearance of multiple small bowel fistulas on Septernber 28. Three subsequent operations failed to control the fistulas and the patient died on October 16; an autopsy was not performed. The surgical specimen showed infiltrating epidermoid carcinoma, grade 3, involving urethra and bladder neck. Tumor approached but did not involve the pubic bone (fig. 2). Case 7 . .J. P. (60-16-12), a 70-year-old white man underwent radical exeision of carcinoma of the bladder (recurrent after transurethral resections), segmental resection and a course of telecobalt on May 26, 1965. The ;;pecimen showed two foci of cpidermoid carcinoma of the bladder, grade 3, invading the pubic bone and abdominal wall anteriorly and the pcrirectal tissue posteriorly. He died at home on ::\"ovember 14. Case 8. L. D. (60-57-07), a 56-year-old white man underwent radical excision of a recurrent cancer of the penis on September 7, 1966. The specimen contained squamous carcinoma involving the urethra and extending to within one cm. of the prostate. Tumor was found also in the adductor muscles on the right side close to their origin from the pubis. Convalescence was uneventful and the patient was discharged on the twenty-second day. He derived .-mbstantial
palliation until shortly before his death, 6 1nontb.s after operation (fig. 3). Case .9 . .J. S. (26-92-42), a underwent anterior excnteration with resection of the inferior publie ran1i on JVIareh 19, l9G7 for carcinoma of the urethra. She left the hospital on the fifteenth day after an uneventful convalescence. The specimen showed diffusely infiltrating epidermoid carcinoma of the urethra. o tumor was found in lymph nodes. DISC1J8SION
vVith widespread use of segmental resection for carcinoma of the bladder, it is tha,b local recurrence in the perivesical space will [01 continue to provide the mo::;t common the use of pubic re.section in conjunction with radical cystectomy or pelvic exenteration. The absence of lymph node metastases m all patients who had massive invasion of tbe prevesical space after segmental re~ection suggests that the condition may not be hopeless. This, together with the surTi-val of two of tho;;e patients for 4}2 and 3 years "·ithout recurrence, prnvides incentiire to continue this operation. Before recommending trarn;lumbar amputation for lesions situated anterior to the bladder, we believe pubic re,;ection de~erves ,1 trial, especially since there may ~till be an opportunity to perform the more radical procedme later should recurrence dcn,Jop after pubic resection, as illustrated in case 4. Translumbar amputation is, we feel, best re.served for lesions in the region of the sacrum or sciatic nerve when pelvic exenteration cannot prnviclc an adequate margin of normal tissue. Patients with cancer of the penis are ,mmetimes
550
MACKENZIE AND WHITMORE
Fm. 3. Case 8. A, carcinoma of penis recurrent after partial amputation and bilateral inguinal lymphadenectomy. B, shows extent of pubic resection after pelvic exenteration and emasculation. C, wound 2 weeks after operation. particularly prone to neglect seeking medical aid. Two such patients thus became candidates for pubic resection. The propensity for advanced cancer of the penis to remain localized invites an aggressive approach. At the same time the apparent tendency of this disease to invade the thighs, as happened in both of our patients, clearly imposes a narrow range of usefulness for this operation. The use of pubic resection in cancer of the female urethra is justified by the proximity of the urethra to the pubic arch and the high incidence of local recurrence in this disease following treatment by other methods. In 67 women treated in Memorial Center for cancer of the urethra, local recurrence was seen in 60 per cent. The need to excise a wide margin of normal tissue does not, however, preclude use of interstitial radioactive implantation as a definitive or
preoperative procedure; early results with this modality are encouraging. Excision of only the inferior pubic rami will probably be adequate in carcinoma of the female urethra, thus maintaining the integrity of the pelvic ring and avoiding the catastrophe we encountered in case 6. We believe that excision of all 4 pubic rami should be avoided in obese patients because of the possibility of sacroiliac subluxation. The aim of pubic resection in conjunction with radical cystectomy or pelvic exenteration is not to excise bone which has been penetrated by tumor arising anterior or posterior to the pubis. The survival of 3 patients in whom microscopic evidence of bony invasion was found has been 5, 6 and 7 months respectively, not long enough to warrant an operation of this magnitude. The aim is to provide a margin of normal tissue around the excised cancer and to avoid spilling cancer
RESECTION OF PUBIC RAMI FOR UROLOGIC CANCER
cells. For this reason we have sometimes proceeded with the operation without establishing, by open biopsy, that an indurated mass in the prevesical space is cancer rather than fibrosis. The existence of cancer of the bladder may be shown by endoscopic biopsy or exfoliative
5Eil
cytology. Determination of its extent would in this event rest solely on palpation, clinical and surgical. Such means of evaluation have not yet led to an unnecessarily mutilating operation. Ai times the extent of the tumor would, in retrospect, have justified a more radical operation.