The urological complications of carcinoma of the cervix

THE UROLOGICAL

COMPLICATIONS THE CERVIX*

ROGER C. GRAVES,

M.D.

AND

OF CARCINOMA

C. J. E. KICKHAM,

OF

M.D.

BOSTON, MASSACHUSETTS

T

HERE has been, unti1 recentIy, a genera1 Iack of recognition of the fact that pathoIogica1 changes in the urinary system are common compIications of carcinoma of the cervix, either as a direct result of extension of the disease or as sequeIae of its treatment. Faerber, Herger and Schreiner, CoIby, Schmitz, Martin and Rogers and others, have published exceIIent papers on the subject and a11 have stressed the paramount importance of uroIogica1 study in cases of cervix maIigthe nancy. I n previous communications, authors have described the frequent invoIvement of the urinary bIadder and they have stressed the high incidence of uretera obstruction in a Iarge series of cases studied cIinicaIIy and at post-mortem examination with reference to changes in the upper urinary tract. Reference is made to these reports for a detaiIed discussion of this subject. Our origina materia1 was drawn from 683 cases of carcinoma of the cervix admitted to the PondviIIe HospitaI (Massachusetts Department of PubIic HeaIth) since 1927, 257 of which were investigated uroIogicaIIy in some detai1. Since the pubIication of these papers we have examined 133 additiona cases. Before discussing the urinary tract compIications of the disease, it is essential that we be cognizant of its character and the pathways of its extension. Carcinoma of the cervix may spread upward and IateraIIy into the parametrium, anteriorIy toward the bladder, and posteriorIy toward It very frequentIy extends the rectum. along the vagina1 waI1. The spread of the Iesion depends in some degree on the nature of the growth. Three genera1 types the proIiferative, uIcerare recognized; * From the Urologica

and GynecoIogicaI

ative, and invertive. The proliferative (fungating or cauIifIower) group is often buIky in character and frequentIy of Iowgrade malignancy. Its buIk may give some protection to the bIadder during irradiation and it may present the picture of extravesica1 pressure on bIadder inspection. The invertive (endocervica1) type remains confined to the cervix for a reIativeIy Iong time before invading the bIadder or extending into the broad Iigament area. The uIcerative type is in most cases of high maIignancy and has a greater tendency to bIadder invasion and f%tuIa formation. A cIassification of the maIignant process as regards extent of disease is aIso of the utmost importance in this discussion. Group A is that in which the carcinoma is confined to the cervix. Group B is that in which there is uterine cavity or vagina1 waI1 invoIvement. Group c incIudes those cases which have disease extension to the broad Iigaments, and Group D those in which there is wide fixation of the peIvis or even ObviousIy, involveremote metastases. ment of the urinary organs is more frequent in the c and D groups and it is aIso true that the detection of such invoIvement by cystoscopy, sometimes Ieads to more accurate CIassification than is possibIe by peIvic examination aIone. The faiIure to recognize the presence of urinary tract pathoIogy in this disease is due in many instances to the absence of symptoms referabIe to the bIadder or upper urinary organs. Definite bIadder involvement and advanced renaI damage may take disturbances suffIcientIy place without marked to attract attention. Urinary frequency is the most common bIadder symptom, but with the advent of infec-

Clinics of the Pondville HeaIth).

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tion, extravesical pressure or actual malignant invasion, dysuria and urgency may develop. Incontinence, partia1 or complete,

of Cervix

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cystoscopy in this disease. The authors h ave described it as presenting the picture, eIevation of . . . “ usuaI1y of a uniform

FIG. I. Photograph of pyelograms, PondviIIe Hospital, No. 2103. Case of woman, age 52, who had radium treatment for carcinoma of the cervix in April, 1930, and a right nephrectomy in June, 1937. There is no present evidence of active malignant disease in the cervix. Note the extreme hydroureter and hydronephrosis resuking from ureteral occlusion on the right side.

suggests the possibIe deveIopment of vesicovaginal fistuIa, aIthough distortion of the bIadder floor and sphincter by the encroaching tumor may be a factor in faulty contro1. The most distressing symptoms that we have encountered are referable to the upper urinary tract and are those of ureteral obstruction and renaI insuffIciency. Inspection of the bIadder was carried out in 238 cases of our series. It is a procedure of great vaIue both in prognosis and in the accurate grouping of the malignant neoplasm. The initia1 indication of direct vesica1 disturbance by the tumor presents itseIf as a distortion from extra-vesica1 pressure. It is without question the most common bladder abnormalitv a found bvu’

FIG.

2.

Photograph of specimen removed described in Fig. I.

in cast

the proxima1 trigone and posterior waI1 covered with normaI mucosa and unaffected by distention. It may resembIe the ordinary uterine eminence seen so often in the femaIe bIadder Aoor, or may be so accentuated as to form deep IateraI s&i on each side.” The picture must be correIated with the peIvic findings, of course, to be certain that it resuIts from tumor. LocaIized areas of increased vascuIarity, mucosa1 hemorrhage, and edema, suggest imminent bIadder waI1 invasion or actua1

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involvement. It is probabIe that extravesical pressure associated with edema connotes actuaI mahgnant disease in the bladder waI1. In more advanced cases, one may see submucosal noduIes or definite neopIasm projecting into the bIadder cavity. The end stage of this whole process lies in the deveIopment of a vesico-vagina1 fistuIa, though in its earIiest stages the opening may be so minute that cIinica1 or cystoscopic recognition is impossibIe. A most important bIadder compIication of carcinoma of the cervix is one which resuIts from the treatment of the maIignant disease rather than from the disease itselfthe so-called “remote radium reaction.” This must be distinguished from the transient earIy or acute reaction which occurs at the height of the radiation effect in the cervix. The Iate reaction presents itseIf many months or even years after treatment, and is due to vascuIar changes varying from a miId endarteritis to a compIete ischemic necrosis. The bIadder picture may be very characteristic and present a sharply defined area of centra1 sIough surrounded by a zone of hyperemia and edema Iocated in the posterior midIine just above the trigone. However, the picture may vary from a smaI1 area of congestion to definite uIceration and sIough, and its Iocation in the bIadder depends on the region of maximum radiation effect. The development of fistuIa from the effect of radiation rather than from disease itseIf is not common. The symptoms of the late radiation reaction are the triad of frequency, dysuria, and hematuria, which in most instances appear acuteIy without a previous urinary history, Iong after radium treatment directed to the cervix. The clinica distinction between this entity and actua1 vesica1 invasion by tumor, frequentIy taxes the diagnostic acumen of the most briIIiant cystoscopist. A definite diagnosis can be made onIy by a correIation between the bIadder picture and the status of the disease in the pelvis, and by repeated observations of the bladder reIative to regression and progression of the Iesion.

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Biopsy may be justifiabIe at times. The prognosis as regards heaIing is good in most cases. Due to the anatomica proximity of the dista1 ureters to the broad Iigament regions and the anterior vagina1 waI1, their involvement as the disease progresses wouId be expected. Warren has stated that the most common cause of death in this disease is the impairment of renaI function due to ureteral occlusion, and Ewing has written that the natura1 termination of most cases of uterine cancer is through uremia from occlusion of the ureters. The siIent death of a kidney is not uncommon. In most cases, the encroaching tumor itseIf is the direct cause of the ureteral occIusion, aIthough infIammation and edema in the region of the tumor may exert the first effect. ActuaI compression by growth is followed, as the Iesion advances, by invasion of the ureteral waI1 and Lumen. In quiescent or cured cases, fibrosis aIone may be the cause of the stenosis. It is probabIy true also that irradiation, either by X-ray or radium, may precipitate complete uretera1 obstruction through edema, where previous partia1 occlusion has been present. We are of this opinion because we have encountered cases in which anutia has occurred so soon after treatment that there has seemed to be no other reasonabIe expIanation for its occurrence. In the writers’ original series, in which 174 cases were investigated uroIogicaIIy or by post-mortem study, 123, or 70.7 per cent, showed positive signs of ureteral obstruction; 46 were CIass c, and 77 were CIass D cases, showing, as might be expected, that the incidence of uretera invoIvement varies in direct ratio with the extent of the disease. In view of the estabIished frequency of uroIogica1 complications, we are subjecting a11 cases of maIignant disease of the cervix at the PondviIIe HospitaI and those encountered through consuItation in private practice to cystoscopic study when they are first seen, and before treatment is instituted, so that bIadder invoIvement or

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interference with ureteral drainage wiII be recognized promptIy. It is true that the investigation of most of the Group A and B cases wiII reveaI no evidence of uroIogica1 disease, but even in such cases we have a baseline for comparison with Iater observations as the disease advances. In the study of a11 cases specific questioning of the patient is important, with reference to symptoms which may signa bIadder invoIvement or uretera occIusion with resulting renaI impairment. The routine physica examination may fai1 to detect these changes. Determination of renaI vaIues by the ‘phthaIein function test and estimations of bIood chemistry are of great importance, aIthough kidney damage is earIiest and best detected by the former. We have found in many instances that the bIood nitrogen IeveI may remain within norma limits unti1 the very Iate stages of the disease, whiIe the ‘phthaIein excretion is Iow or absent. Routine inspection of the bIadder and urethra shouId be carried out to determine the presence or absence of IocaI tumor invasion, fistuIa, or radiation reaction. At times, urethra1 involvement with obstruction may be encountered as the disease spreads from the vagina1 waI1. It shouId be emphasized that a negative bIadder picture, and uretera orifices norma in appearance, does not excIude the possibiIity of serious uretera occIusion. Catheterization of the ureters, if possibIe, shouId be routine. Obstruction, when present, may vary in degree from compIete stenosis to Iesser grades of narrowing. When resistance to the catheter, or obstruction, is encountered, it is usuaIIy at a point 4-6 cm. above the bIadder where the ureter Iies beneath the broad Iigament and adjacent to the cervix. UreteraI catheter specimens of urine shouId be examined microscopicaIIy and bacterioIogicaIIy because the presence or absence of infection bears heaviIy on the whoIe probIem of the bIocked kidney. An asymptomatic obstruction with the advent of infection may become cIinicaIIy evident through chiIIs, fever, and IocaIized pain. If

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urete;aI catheterization cannot be carried out, indigocarmin may be used to ascertain the renal vaIues or to assist in the identification of the uretera openings in difYficuIt cases. It shouId be noted that easy catheterization with catheters of ordinary size does not preclude the possibiIity of obstructive changes in the ureter and renaI peIvis. VisuaIization of the kidney and ureter by X-ray studies, and especiaIIy by retrograde reveaIs better than uretero-pyelograms, in any other way the degree and extent of uretera diIatation. In those cases where the ureters cannot be catheterized, intravenous urography is of great vaIue, but the information derived by this method is Iess concIusive as a ruIe. For the treatment of patients with uretera occIusion, we have at our disposa1 uretera diIatation, nephrostomy, nephrectomy and ureterostomy, and ureterointestina1 anastamosis, in addition to the genera1 program of medica measures directed to the improvement of renaI vaIues. We are of the opinion that transpIantation of the ureters into the bowe1 should rareIy, if ever, be attempted, as the changes in the peIvis usuaIIy wiI1 make this operation diff%uIt or impossibIe, and in many instances the renaI damage is too marked to warrant the risk of further kidney infection from the intestinal tract. Ureterostomy, the transpIantation of the ureters into the skin, may be resorted to but in many cases the upward spread of maIignant disease, or extensive fibrosis wiI1 make the peIvic field unfavorabIe for this procedure. The most conservative program consistent with reIief shouId be chosen for the patient with active carcinoma. UreteraI diIatation is the simpIest therapeutic measure. It is essentiaIIy paIIiative and has no Iasting vaIue where the bIockage of the ureter is the resuIt of tumor. We must diIate the ureters with great caution in such cases Iest we precipitate compIete occIusion and make surgica1 intervention imperative. Where the uretera obstruction is due to fibrosis, diIatation is of great vaIue.

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It has been our experience that nephrostomy, either unilateral or biIatera1, is the surgica1 procedure of choice to meet the conditions which arise from uretera obstruction. It may be an emergency procedure or an operation of election. The results are frequentIy astounding and the operation can be performed without severe reaction on the part of the patient. It must be noted, however, that the results are better in the presence of definite obstructive pathoIogy than in cases of non-obstrucIn our previous comtive pyelonephritis. munication on the subject, we enumerated the indications to be “the pain of ureteral and renaI peIvis distention unrelieved by sepsis within the obsimpIer measures, structed kidney, and the signs of advancing uremia with ohguria and anuria from extreme uretera occIusion.” We have employed biIatera1 nephrostomy in several instances with spectacuIar results. The removal of a kidney is not often advisabIe in this group of individuaIs, especiaIly in the presence of active maIignant

Carcinoma

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disease in the cervix. However, persistent pain, chiIIs and fever, due to an active pyeIonephritis in an obstructed kidney, might make nephrectomy justifiable. In the patient without active disease the removal of an infected functionIess kidney is certainIy warranted in the presence of a norma ureter and kidney on the other side. (Figs. I and 2.) In this whole question of the treatment of the urinary complications of carcinoma of the cervix, one must be inff uenced by the entire urological picture, the extent and activity of the disease in the peIvis, the expectancy of life, and the general condition of the patient. REFERENCES GRAVES, ROGER C., KICKHAM, C. J. E. and NATHANSON, IRA T. The Bladder Complications of Carcinoma of the Cervix. Swg. Gynec. and Obst., 63: 785-793 (December) 1936. GRAVES, ROGER C., KICKHAM, C. J. E. and NATHANSON, IRA T. The Ureteral and Rena1 Complications of Carcinoma of the Cervix. J. Uwf., 36: No. 6 (December) 1936.