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Retrovesical Sarcoma1
RETROVESICAL SARCOMA1 HARRY C. ROLNICK
The following description appears in Young's Urology: Many tumors arise in the tissues adjoining the bladder, but one of these, the retro-vesical sarcoma is associated with no particular organ, and in its symptoms and diagnosis concerns mostly the bladder. It is found in the space behind the bladder, above the prostate, and between the seminal vesicles. Histologically, it is usually a small round-cell sarcoma, but may be spindlecelled. In its growth it pushes the bladder forward, the rectum backward, and usually the prostate downward. There is little in the literature other than this excellent, and almost complete description, relating to this condition. Although retrovesical sarcoma is rare, it is the commonest sarcoma in the bladder region, occurring more frequently than sarcoma of the bladder itself, which has received much more mention. Retrovesical sarcoma should not be confused with sarcoma of the bladder wall, for it is an extravesical growth, entirely separate from the bladder, and infiltrating it only when far advanced. Sarcoma of the prostate is also entirely distinct from retrovesical sarcoma. I have operated on one patient with a lympho-sarcoma of the prostate, that had invaded the bladder and tissues of the perineum. Wassilje:ff reports a case of sarcoma of the seminal vesicle, which he believes to be similar to the retrovesical sarcoma described by Young. Zahn and Ceelen also describe large pelvic tumors found at autopsy, which were closely attached to the seminal vesicle. These retrovesical and other extravesical tumors are found almost exclusively in the male, and generally in one side of the pelvis, usually closely attached to and displacing the seminal vesicles. Although there may be considerable basis for the belief that retrovesical sarcomata are tumors of the seminal vesicles, they give the definite impression clinically and pathologically of being unattached tumors arising from the loose cellular tissue at the base of the bladder. Furthermore, tumors of the seminal vesicles are very rare. These retrovesical tumors must also be distinguished from other extravesical tumors. Culver and Baker reported 2 cases of extravesical tumor, which were attached to the bones 1
Read before the meeting of the Chicago Urological Society, November 21, 1935. 353
THE JOURNAL OF UROLOGY, VOL.
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HARRY C. ROLNICK
of the pelvis, and were mixed growths. Jeck reported a case of multiple enchondromata of the pelvis. As stated previously, these tumors in their growth do not invade or infiltrate the adnexa or bladder until late in the disease. The bladder is displaced to one side, and frequently to such a degree that the entire suprapubic space is filled by the tumor mass. The seminal vesicles and prostate are often similarly displaced. It is interesting to note the ability of the bladder to accommodate itself to pressure from without. If the mass does not completely surround the bladder, and thus does not
FIG. 1. Intravenous urogram showing bladder displaced to one side by the retrovesical tumor. There is also slight dilatation of the ureters. Some outline of the tumor in the midline may be noted.
interfere with its distention, the patient may have very little or no urinary symptoms, even with marked displacement. The sarcoma of the seminal vesicle reported by Wassiljeff was only an incidental finding at necropsy. Although a large tumor mass was present, the patient had no urinary symptoms. One of our patients had a large tumor extending almost to the umbilicus, but was having no urinary difficulty. These tumors, as is common with other sarcomata, occur most often in early youth, or late in life. The following case presents most of the usual features of an intra-
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355
pelvic extravesical tumor. An intravenous urogram (fig. 1) with a cystogram, showing the bladder displacement gives a fairly accurate picture. Case 1. No. 1465449, J. D., aged 13 years, entered Cook County Hospital, October 23, 1934, with a history of a swelling in the lower abdomen, which he stated was of 3 days' duration. He had been complaining of a slight burning upon urination for a period of one week. He could urinate freely, and the burning ceased after a few days stay in the hospital, but the swelling in the lower abdomen became more pronounced from day to day. The patient felt comfortable, was up and about, but felt a slight tension in the lower abdomen. Examination showed a distention in the midline suprapubically, as far up as the umbilicus, which had all the appearances of a distended bladder. Rectal examination revealed a semi-fluctuant, tense mass, with the resistance similar to that of a distended bladder. After a few days the external contour of the mass, which had previously been globular, began to show some irregularity, with lateral projection. Intravenous urogram showed a dilatation of the ureters and pelves, and marked displacement of the bladder. The patient felt quite well, and it required considerable urging on our part for the parents to give consent for operation. On November 1, 1934, a median suprapubic incision showed a large rounded bluish-gray mass, practically filling the entire suprapubic space, and projecting itself into the wound under tension. The bladder was not seen nor felt. The tumor was covered by a thin fibrous capsule, which was broken through. The tumor tissue was soft, gelatinous and friable, with the consistency of a mushroom, broke readily, and could be scooped out with the hand. However, immediately upon disturbing this tumor, and attempting to remove it, bleeding was profuse and extensive. The hemorrhage was almost as free and profuse as can come from the renal vessels. The wound was hurriedly packed, and the bleeding was stopped, only after some difficulty. No further attempt was made to remove the tumor, and the patient returned to the ward considerably exanguinated, with a poor immediate prognosis. The first 3 days postoperative were quite stormy, but following this he progressed fairly well, so that the packing was completely removed after 8 days. Deep x-ray therapy was then instituted. The entire tumor mass practically melted away within 2 weeks. Under frequent radiations the wound healed completely, and the patient left the hospital on November 22, 1934, feeling quite well. Rectal examination on the day of his discharge, and again one month later, showed complete disappearance of the mass. A small thin strand, apparently of fibrous tissue, could be felt at this time near the left seminal vesicle, and extending upward.
356
HARRY C. ROLNICK
Biopsy of the tissue removed at operation showed a round-cell sarcoma (fig. 2). In view of the high malignancy of this type of sarcoma, the subsequent course could have been foreseen. He re-entered the hospital 6 months later, with metastases to the cranium, and maxilla, with marked erosion of these structures, and marked disfiguration, and died a short time later. Necropsy was not obtained. Ewing, states that sarcomata are bulky, soft and vascular, and tend to grow on a scaffolding of new blood vessels, in contrast with carcinomata, which grow by infiltrating pre-existing tissues. The soft consistence reflects the cellular structure of a rapidly growing tumor, the
FIG. 2 FIG. 3 FIG. 2. Microphotograph of large retrovesical tumor shown in figure 1, demonstrating a round-cell sarcoma. FIG. 3. Spindle-celled neuro-fibrosarcoma, retrovesical tumor found in a man, aged 64 years.
rapidity of growth being due to an abundant blood supply. Edema, hemorrhage, mucoid degeneration, and later, necrosis occur when the limit of the growth is reached. Most sarcomata grow expansively, with the center as well as the peripheral areas expanding, so that whether or not surrounded by a capsule, they are usually not attached to the surrounding tissues. The vascularity of this tumor at operation was almost startling. The rapid immediate response of these highly vascular, often embryonic tumors is well known; and their rapid recurrence is the usual sequel. Case 2. H. S_,., aged 64 years, was operated upon by me at Mt. Sinai Hospital; after a preliminary cystotomy, a second-stage suprapubic prostatectomy was done on August 26, 1935. With the left finger in the rectum to elevate
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the prostate, enucleation was carried out without difficulty. Following this a small soft rounded mass, the size of a walnut was felt, lying on the left side, behind the prostatic capsule, and between it and the rectum. This mass had not been felt previously. A thin capsule covering this mass could be felt. This was broken through, and soft, somewhat gelatinous friable tissue was removed, that had the gross appearance of sarcoma, and was similar to the tissue removed in the preceding case. Having had a previous experience with a massive hemorrhage, I did not consider it wise to attempt a complete removal during a relatively closed operation of a second stage prostatectomy; however, considerable of this mass was removed. Biopsy of the prostate showed benign prostatic hypertrophy. This patient gave a long-standing history of frequency and nocturia, and an attack of urinary retention one year previously. His admission to the hospital followed another attack of acute urinary retention, which required a cystotomy for relief. The clinical picture was that of prostatic obstruction. Biopsy of the tumor tissue shows it to be a spindle-celled neuro-fibrosarcoma (fig. 3). These tumors are not vascular, and are much less malignant than the round-cell sarcoma. They are found in various parts of the body, and respond but little to radiation. Complete removal is apparently curative, but there is practically always a recurrence, which proves to be more malignant if the tissue has not been completely removed. Deep x-ray therapy was instituted. The patient left the hospital September 22, 1935, with the wound completely closed. Cystoscopic examination on November 18, 1935 was negative. Rectal examination was negative. It is too early as yet to determine the end result, but his present condition is entirely satisfactory. I recall one patient with multiple neuro-:fibromata, who developed a retroperitoneal tumor, which progressed slowly, and proved at operation to be a sarcomatous degeneration of a neuro-:fibroma. This condition may have some relation to von Recklingshausen's Disease, for it is often found in association with it. The seminal vesiculograms (fig. 4), which are here shown are those of a patient previously reported by Culver and Baker. The left seminal vesicle has been completely displaced to the right side, but is apparently not invaded. Observations on the other 2 cases, and this vesiculogram indicate that these tumors are not of the seminal vesicle; although they may be closely attached to them. He re-entered the Cook County Hospital a number of times, and on one of these occasions I did a bilateral vasotomy. This tumor was a slow growing, mixed extravesical tumor attached to the ilium, and sacrum, and is to be differentiated from the retrovesical sarcoma, which is unattached.
358
HARRY C. ROLNICK
The entire subject of extravesical tumors is interesting. Guiteras devotes a complete chapter to bladder disturbances due to extravesical causes, most of which are found in the female. Those disturbances in the male can be due to pathology, either in the prostate, seminal vesicles, or rectum; in the female, as a result of pathology in the uterus, tubes or ovaries. In both sexes, bladder disturbances may be due to pathology in the small or large intestine, appendix or omentum. Tumor, cyst, inflammation or suppuration within the pelvis may cause displacement or secondary involvement of the bladder. We have seen 4 patients with carcinoma of the sigmoid, which had invaded the bladder and simulated a primary tumor of the bladder in 3 instances, and in 1, a carcinoma of the prostate.
FrG. 4. Bilateral seminal vesiculogram made by injecting iodized oil through vasotomy incisions on each side, showing left seminal vesicle pushed over to the right by the extra vesical tumor.
Uterine displacements and pelvic tumors are the most common cause of bladder disturbances in the female. Infection, such as pelvic abscess, secondary to adnexal infection, or suppurating appendicitis, may cause bladder pathology, not so much as the result of displacement, but by pericystitis, with secondary invasion of the bladder wall and infiltration. Distortion or displacement of the bladder neck, due to pressure from without, will also give marked symptoms, but displacement of the fundus of the bladder in itself, is most often symptomless. Among other extra vesical tumors found in the pelvis are hydatid and dermoid cysts, the latter of which often infiltrate the bladder wall. Hydatid cysts may closely simulate retrovesical sarcoma. Pelvic tumors may simulate grossly invasive bladder tumors. X-ray will
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FIG. 5 FIG. 6 FIG. 5. Tumor of pubic bone, which had produced pressure on prostate and posterior urethra. FIG. 6. Hematoma in pelvis, secondary to a bullet, with a cystogram showing marked displacement of the bladder.
FIG. 7. Diagrammatic sketch showing the normal structures of the male pelvis and also their displacement by a retrovesical tumor.
360
HARRY C. ROLNICK
differentiate osteo-sarcoma. We present here a flat plate (fig. 5) of the pelvis of a male, aged 24 years, who had an attack of terminal hematuria, which had been preceded by a discharge of 2 weeks' duration, and which had been diagnosed as gonococcal posterior urethritis and prostatitis. Rectal examination revealed a hard mass, at first thought to be prostatic involvement, but proved to be an osteoma of the os pubis, causing pressure symptoms. We also present, through the courtesy of Dr. W. S. Grant, a roentgenogram (fig. 6) showing marking distortion of the bladder, as can be noted on cystogram, due to pressure of a large hematoma, extra-vesical, secondary to a bullet that had penetrated the pelvis, and which had caused profuse bleeding. The patient was comfortable. He had no urinary symptoms, and has improved without operative interference. A diagrammatic sketch (fig. 7) showing the normal pelvic strudures, and one with a retrovesical tumor, is also presented.
104 S. Michigan Ave., Chicago, Illinois. REFERENCES CEELEN: Virchow's Archives, 207: 200-206, 1912. CULVER AND BAKER: Trans. Amer. Assoc. Genito-Urinary Surg., 22: 329-338, 1929. EWING: Neoplastic diseases, p. 258. GuITERAS: Urology, 2: 105-127, 1912. JECK, HoWARD S.: Trans. Amer. Assoc. Genito-Urinary Surg., 22: 329-338, 1929. WASSILJEFF: Ztschr. f. Urol. Chir., 26: 1-12, 1928. Young's Practice of Urology, 1: 558, 1926. ZAHN: Deutsch. Zeit. f. Chir., 22: 22-30, 1885,
The following description appears in Young's Urology: Many tumors arise in the tissues adjoining the bladder, but one of these, the retro-vesical sarcoma is associated with no particular organ, and in its symptoms and diagnosis concerns mostly the bladder. It is found in the space behind the bladder, above the prostate, and between the seminal vesicles. Histologically, it is usually a small round-cell sarcoma, but may be spindlecelled. In its growth it pushes the bladder forward, the rectum backward, and usually the prostate downward. There is little in the literature other than this excellent, and almost complete description, relating to this condition. Although retrovesical sarcoma is rare, it is the commonest sarcoma in the bladder region, occurring more frequently than sarcoma of the bladder itself, which has received much more mention. Retrovesical sarcoma should not be confused with sarcoma of the bladder wall, for it is an extravesical growth, entirely separate from the bladder, and infiltrating it only when far advanced. Sarcoma of the prostate is also entirely distinct from retrovesical sarcoma. I have operated on one patient with a lympho-sarcoma of the prostate, that had invaded the bladder and tissues of the perineum. Wassilje:ff reports a case of sarcoma of the seminal vesicle, which he believes to be similar to the retrovesical sarcoma described by Young. Zahn and Ceelen also describe large pelvic tumors found at autopsy, which were closely attached to the seminal vesicle. These retrovesical and other extravesical tumors are found almost exclusively in the male, and generally in one side of the pelvis, usually closely attached to and displacing the seminal vesicles. Although there may be considerable basis for the belief that retrovesical sarcomata are tumors of the seminal vesicles, they give the definite impression clinically and pathologically of being unattached tumors arising from the loose cellular tissue at the base of the bladder. Furthermore, tumors of the seminal vesicles are very rare. These retrovesical tumors must also be distinguished from other extravesical tumors. Culver and Baker reported 2 cases of extravesical tumor, which were attached to the bones 1
Read before the meeting of the Chicago Urological Society, November 21, 1935. 353
THE JOURNAL OF UROLOGY, VOL.
~5, NO. 3
354
HARRY C. ROLNICK
of the pelvis, and were mixed growths. Jeck reported a case of multiple enchondromata of the pelvis. As stated previously, these tumors in their growth do not invade or infiltrate the adnexa or bladder until late in the disease. The bladder is displaced to one side, and frequently to such a degree that the entire suprapubic space is filled by the tumor mass. The seminal vesicles and prostate are often similarly displaced. It is interesting to note the ability of the bladder to accommodate itself to pressure from without. If the mass does not completely surround the bladder, and thus does not
FIG. 1. Intravenous urogram showing bladder displaced to one side by the retrovesical tumor. There is also slight dilatation of the ureters. Some outline of the tumor in the midline may be noted.
interfere with its distention, the patient may have very little or no urinary symptoms, even with marked displacement. The sarcoma of the seminal vesicle reported by Wassiljeff was only an incidental finding at necropsy. Although a large tumor mass was present, the patient had no urinary symptoms. One of our patients had a large tumor extending almost to the umbilicus, but was having no urinary difficulty. These tumors, as is common with other sarcomata, occur most often in early youth, or late in life. The following case presents most of the usual features of an intra-
RETROVESICAL SARCOMA
355
pelvic extravesical tumor. An intravenous urogram (fig. 1) with a cystogram, showing the bladder displacement gives a fairly accurate picture. Case 1. No. 1465449, J. D., aged 13 years, entered Cook County Hospital, October 23, 1934, with a history of a swelling in the lower abdomen, which he stated was of 3 days' duration. He had been complaining of a slight burning upon urination for a period of one week. He could urinate freely, and the burning ceased after a few days stay in the hospital, but the swelling in the lower abdomen became more pronounced from day to day. The patient felt comfortable, was up and about, but felt a slight tension in the lower abdomen. Examination showed a distention in the midline suprapubically, as far up as the umbilicus, which had all the appearances of a distended bladder. Rectal examination revealed a semi-fluctuant, tense mass, with the resistance similar to that of a distended bladder. After a few days the external contour of the mass, which had previously been globular, began to show some irregularity, with lateral projection. Intravenous urogram showed a dilatation of the ureters and pelves, and marked displacement of the bladder. The patient felt quite well, and it required considerable urging on our part for the parents to give consent for operation. On November 1, 1934, a median suprapubic incision showed a large rounded bluish-gray mass, practically filling the entire suprapubic space, and projecting itself into the wound under tension. The bladder was not seen nor felt. The tumor was covered by a thin fibrous capsule, which was broken through. The tumor tissue was soft, gelatinous and friable, with the consistency of a mushroom, broke readily, and could be scooped out with the hand. However, immediately upon disturbing this tumor, and attempting to remove it, bleeding was profuse and extensive. The hemorrhage was almost as free and profuse as can come from the renal vessels. The wound was hurriedly packed, and the bleeding was stopped, only after some difficulty. No further attempt was made to remove the tumor, and the patient returned to the ward considerably exanguinated, with a poor immediate prognosis. The first 3 days postoperative were quite stormy, but following this he progressed fairly well, so that the packing was completely removed after 8 days. Deep x-ray therapy was then instituted. The entire tumor mass practically melted away within 2 weeks. Under frequent radiations the wound healed completely, and the patient left the hospital on November 22, 1934, feeling quite well. Rectal examination on the day of his discharge, and again one month later, showed complete disappearance of the mass. A small thin strand, apparently of fibrous tissue, could be felt at this time near the left seminal vesicle, and extending upward.
356
HARRY C. ROLNICK
Biopsy of the tissue removed at operation showed a round-cell sarcoma (fig. 2). In view of the high malignancy of this type of sarcoma, the subsequent course could have been foreseen. He re-entered the hospital 6 months later, with metastases to the cranium, and maxilla, with marked erosion of these structures, and marked disfiguration, and died a short time later. Necropsy was not obtained. Ewing, states that sarcomata are bulky, soft and vascular, and tend to grow on a scaffolding of new blood vessels, in contrast with carcinomata, which grow by infiltrating pre-existing tissues. The soft consistence reflects the cellular structure of a rapidly growing tumor, the
FIG. 2 FIG. 3 FIG. 2. Microphotograph of large retrovesical tumor shown in figure 1, demonstrating a round-cell sarcoma. FIG. 3. Spindle-celled neuro-fibrosarcoma, retrovesical tumor found in a man, aged 64 years.
rapidity of growth being due to an abundant blood supply. Edema, hemorrhage, mucoid degeneration, and later, necrosis occur when the limit of the growth is reached. Most sarcomata grow expansively, with the center as well as the peripheral areas expanding, so that whether or not surrounded by a capsule, they are usually not attached to the surrounding tissues. The vascularity of this tumor at operation was almost startling. The rapid immediate response of these highly vascular, often embryonic tumors is well known; and their rapid recurrence is the usual sequel. Case 2. H. S_,., aged 64 years, was operated upon by me at Mt. Sinai Hospital; after a preliminary cystotomy, a second-stage suprapubic prostatectomy was done on August 26, 1935. With the left finger in the rectum to elevate
RETROVESICAL SARCOMA
357
the prostate, enucleation was carried out without difficulty. Following this a small soft rounded mass, the size of a walnut was felt, lying on the left side, behind the prostatic capsule, and between it and the rectum. This mass had not been felt previously. A thin capsule covering this mass could be felt. This was broken through, and soft, somewhat gelatinous friable tissue was removed, that had the gross appearance of sarcoma, and was similar to the tissue removed in the preceding case. Having had a previous experience with a massive hemorrhage, I did not consider it wise to attempt a complete removal during a relatively closed operation of a second stage prostatectomy; however, considerable of this mass was removed. Biopsy of the prostate showed benign prostatic hypertrophy. This patient gave a long-standing history of frequency and nocturia, and an attack of urinary retention one year previously. His admission to the hospital followed another attack of acute urinary retention, which required a cystotomy for relief. The clinical picture was that of prostatic obstruction. Biopsy of the tumor tissue shows it to be a spindle-celled neuro-fibrosarcoma (fig. 3). These tumors are not vascular, and are much less malignant than the round-cell sarcoma. They are found in various parts of the body, and respond but little to radiation. Complete removal is apparently curative, but there is practically always a recurrence, which proves to be more malignant if the tissue has not been completely removed. Deep x-ray therapy was instituted. The patient left the hospital September 22, 1935, with the wound completely closed. Cystoscopic examination on November 18, 1935 was negative. Rectal examination was negative. It is too early as yet to determine the end result, but his present condition is entirely satisfactory. I recall one patient with multiple neuro-:fibromata, who developed a retroperitoneal tumor, which progressed slowly, and proved at operation to be a sarcomatous degeneration of a neuro-:fibroma. This condition may have some relation to von Recklingshausen's Disease, for it is often found in association with it. The seminal vesiculograms (fig. 4), which are here shown are those of a patient previously reported by Culver and Baker. The left seminal vesicle has been completely displaced to the right side, but is apparently not invaded. Observations on the other 2 cases, and this vesiculogram indicate that these tumors are not of the seminal vesicle; although they may be closely attached to them. He re-entered the Cook County Hospital a number of times, and on one of these occasions I did a bilateral vasotomy. This tumor was a slow growing, mixed extravesical tumor attached to the ilium, and sacrum, and is to be differentiated from the retrovesical sarcoma, which is unattached.
358
HARRY C. ROLNICK
The entire subject of extravesical tumors is interesting. Guiteras devotes a complete chapter to bladder disturbances due to extravesical causes, most of which are found in the female. Those disturbances in the male can be due to pathology, either in the prostate, seminal vesicles, or rectum; in the female, as a result of pathology in the uterus, tubes or ovaries. In both sexes, bladder disturbances may be due to pathology in the small or large intestine, appendix or omentum. Tumor, cyst, inflammation or suppuration within the pelvis may cause displacement or secondary involvement of the bladder. We have seen 4 patients with carcinoma of the sigmoid, which had invaded the bladder and simulated a primary tumor of the bladder in 3 instances, and in 1, a carcinoma of the prostate.
FrG. 4. Bilateral seminal vesiculogram made by injecting iodized oil through vasotomy incisions on each side, showing left seminal vesicle pushed over to the right by the extra vesical tumor.
Uterine displacements and pelvic tumors are the most common cause of bladder disturbances in the female. Infection, such as pelvic abscess, secondary to adnexal infection, or suppurating appendicitis, may cause bladder pathology, not so much as the result of displacement, but by pericystitis, with secondary invasion of the bladder wall and infiltration. Distortion or displacement of the bladder neck, due to pressure from without, will also give marked symptoms, but displacement of the fundus of the bladder in itself, is most often symptomless. Among other extra vesical tumors found in the pelvis are hydatid and dermoid cysts, the latter of which often infiltrate the bladder wall. Hydatid cysts may closely simulate retrovesical sarcoma. Pelvic tumors may simulate grossly invasive bladder tumors. X-ray will
RETROVESICAL SARCOMA
359
FIG. 5 FIG. 6 FIG. 5. Tumor of pubic bone, which had produced pressure on prostate and posterior urethra. FIG. 6. Hematoma in pelvis, secondary to a bullet, with a cystogram showing marked displacement of the bladder.
FIG. 7. Diagrammatic sketch showing the normal structures of the male pelvis and also their displacement by a retrovesical tumor.
360
HARRY C. ROLNICK
differentiate osteo-sarcoma. We present here a flat plate (fig. 5) of the pelvis of a male, aged 24 years, who had an attack of terminal hematuria, which had been preceded by a discharge of 2 weeks' duration, and which had been diagnosed as gonococcal posterior urethritis and prostatitis. Rectal examination revealed a hard mass, at first thought to be prostatic involvement, but proved to be an osteoma of the os pubis, causing pressure symptoms. We also present, through the courtesy of Dr. W. S. Grant, a roentgenogram (fig. 6) showing marking distortion of the bladder, as can be noted on cystogram, due to pressure of a large hematoma, extra-vesical, secondary to a bullet that had penetrated the pelvis, and which had caused profuse bleeding. The patient was comfortable. He had no urinary symptoms, and has improved without operative interference. A diagrammatic sketch (fig. 7) showing the normal pelvic strudures, and one with a retrovesical tumor, is also presented.
104 S. Michigan Ave., Chicago, Illinois. REFERENCES CEELEN: Virchow's Archives, 207: 200-206, 1912. CULVER AND BAKER: Trans. Amer. Assoc. Genito-Urinary Surg., 22: 329-338, 1929. EWING: Neoplastic diseases, p. 258. GuITERAS: Urology, 2: 105-127, 1912. JECK, HoWARD S.: Trans. Amer. Assoc. Genito-Urinary Surg., 22: 329-338, 1929. WASSILJEFF: Ztschr. f. Urol. Chir., 26: 1-12, 1928. Young's Practice of Urology, 1: 558, 1926. ZAHN: Deutsch. Zeit. f. Chir., 22: 22-30, 1885,