International Urology and Nephrology 9 (3), pp. 225--229 (1977)
Cancer of the Urinary Bladder and Pyelonephritis Yu. A. PYTEL I. Moscow Medical Institute, Urological Clinic, Moscow, USSR (Received June 29, 1976)
Successful traetment of cancer of the urinary bladder consists not only in elimination of the tumour process, but also in prophylaxis of various complications. Among complications caused by the tumour process as well as by the applied methods of its therapy a certain place belongs to pyelonephritis. Pyelonephritis develops in consequence of the disturbance of the function of the urinary bladder after hemicystectomy resulting from the change of the bladder's form. With the view of preserving the anatomo-physiological function of the urinary bladder and preventing complications the author suggests a method of reconstruction of the bladder consisting in shaping it in a spherical form after hemicystectomy. Such shape of the urinary bladder ensures nearly normal conditions for both urination act and urinary flow from the upper urinary pathways, this being the prophylaxis of pyelonephritis.
Renal inflammation may develop due to the vesical tumour itself and following radical operation. When taking an acute course, pyelonephritis may sometimes threaten the patient's life. All this makes it necessary to study the pathogenesis of pyelonephritis in patients with cancer of the bladder during the postoperative period and to search for prophylactic measures against this formidable complication. Vesical tumour, with its growth, causes vesical disturbance which manifests itself in dyskinesis.-The developed dyskinesis does not necessarily lead to dysuria, for the latter results, as a rule, from an advanced turnout or when this process is localized at the vesical triangle and neck. Dyskinesis of a tumorous bladder may produce no clinical symptoms for it changes the bladder's evacuating function, which provides for good urinary flow from the upper urinary tract rather than disturbing voiding itself. There is a close association between the functions of the ureters and the urinary bladder, which ensures normal urinary flow from the upper urinary tract. Prior to the contraction of the terminal part of the ureter there occurs dilatation of the urinary bladder, due to which a relatively negative pressure is created in it. And then, with minimal muscular effort of the ureter, the urine flows easily into the bladder from the sphere of high pressure to the sphere of low pressure. In other words, the urinary bladder performs the function of a suction device aspirating urine from the ureters. Dyskinesia of the urinary International Urology and Nephrology 9, 1977
226
Pytel: Cancer of the bladder and pyelonephritis
bladder caused by tumour breaks synchronization between a contractile ability of the ureters and a dilatating function of the urinary bladder. This, in turn, leads to dyskinesis of the ureters and to the disturbance of the function of the calyceal-pelvic system, too. This causes high intrapelvic pressure and pelvicrenal refluxes, which are the main factors in the genesis and progression of pyelonephritis. It should be mentioned that the degree of vesical disturbance is directly dependent on the tumour localization. The lesion in the vesical base and triangle leads earliest to vesical dyskinesis, though vesical disturbance may also be observed when a new growth is localized on the lateral or even anterior wall of the bladder. Vesical dyskinesis resulting from a vesical new growth is relatively seldom complicated by vesicoureteral reflux, either active or passive (according to our findings in 1.4 ~ of cases), usually observed at T~ stage of a vesical triangle new growth. This is another indication of the fact that pyelonephritis in patients with cancer of the bladder is associated mainly with an early development of dyskinesis and a disturbed correlation between the functions of the ureters and the urinary bladder and to a lesser extent with vesicoureteral reflux. Those outlined above explain the origin of pyelonephritis in patients with cancer of the urinary bladder even in cases when the ureteral ostium is not involved in the tumorous process. Pyelonephritis which develops in patients with cancer of the urinary bladder seldom has obvious clinical manifestations: there occur occasionally dull pains in the loin region, and moderate leukocyturia. TV pyeloureteroscopy gives a chance of observing the disturbance of the functions of the upper urinary tract, which is shown in hyperkinesis, dyskinesis, and at times in the lowering of tonus and contractile ability of the ureters. Producing negligible clinical symptoms, pyelonephritis as a complication of cancer of the bladder may take an acute course in the postoperative period. Before the operation vesicoureteral reflux occurs, as noted above, in only 1.4~ of the cases, while after resection of the urinary bladder it is observed very frequently, in 15.6 ~ of the cases, developing after the injection of 50-60 ml of contrast solution under atmospheric pressure, and is always passive. It must be emphasized that a unilateral or bilateral passive vesicoureteral reflux is not always the consequence of an injury to the ureteral ostium region. Reflux develops after resection of the lateral or even anterior wall of the urinary bladder. Our earlier cystographic examinations of patients with cystostorey after adenectomy showed that vesicoureteral reflux develops mainly as a consequence of the bladder's ceasing to perform - owing to cystostomy its inherent function, rather than because of vesical injury. Due to cystostomy the urinary bladder loses its sucking-off, evacuating function, which leads very rapidly to the breaking of a complex locking-up mechanism of the terminal section of the ureter, and this manifests itself in vesicoureteral reflux which, according to our findings, develops most frequently on the 4th or 5th day. Since vesical resection on account of cancer is commonly accompanied by cystostomy, it is the latter, in our opinion, that leads to vesicoureteral International Urology and Nephrology 9, 1977
Pytel: Cancer of the bladder and pyelonephritis
227
reflux, the operative trauma being an additional factor. The existence of a passive vesicoureteral reflux in the immediate postoperative period largely predetermines the occurrence and progression of pyelonephritis. Even a minor disturbance of urinary flow through cystostoma after operation threatens with an acute suppurative renal inflammation. These circumstances dictate a timely detection of vesicoureteral reflux during the immediate postoperative period and the application of therapeutic measures directed to its elimination, this being the prophylaxis of pyelonephritis. With that object in view, on the fourth day after urinary bladder resection we perform cystography, injecting radiopaque solution through the cystostoma without additional pressure. At the first sign of the bladder filling up, with the appearance of the slightest urge to urinate, we cease injecting the constrast solution and carry out roentgenography. If the cystogram shows vesicoureteral reflux, measures are taken for an active aspiration of the bladder's content, modelling the bladder's function of sucking off urine from the ureters. For this purpose we make use of a well-known sucking-off device, a hermetically sealed jar filled with aseptic liquid in which the cystostoma is placed. As the liquid flows out of the jar, a negative pressure is created in it, owing to which aspiration of the bladder's content takes place. Our observations showed that the optimal negative pressure ensuring good urinary flow from the ureters is 0.02 atmospheres. To achieve such a negative pressure the liquid level in the jar must be 200 mm. Active urinary aspiration from the bladder after its resection is not only favourable to a normal urinary evacuation from the upper urinary tract preventing vesicoureteral reflux and pyelonephritis, but it also creates conditions excluding urinary infiltration into the tissues around the bladder, that is, it serves as a prophylactic measure against suppurative complications, whose absence determines in many respects a good vesical function. Our experience has shown that active urinary aspiration from the bladder through the cystostoma eliminates the vesicoureteral reflux very quickly, usually on the 10th to 12th day after operation, closes the cystostoma, restores vesical function, ensures a normal urinary flow from the upper urinary tract and thus may prevent pyelonephritis or creates conditions for its rapid elimination. An important role is played by the pathogenesis of pyelonephritis in patients with cancer of the urinary bladder during the postoperative period by the change in the shape of the bladder and the vesical disturbance resulting from this change. This is most obviously manifested after hemicystectomy. For that reason, when performing hemicystectomy the surgeon should try to shape the urinary bladder in such a way as to ensure, as much as possible, its subsequent normal functioning. Since hemicystectomy is, as a rule, accompanied by ureterocystoneostomy, the operation of ablating half of the organ calls for reconstruction aimed at creating the most favourable anatomo-physiological conditions for reimplantation of the ureter into the remaining part of the bladder. The urination act, as well as the evacuation of urine from the upper urinary tract are ensured best when the urinary bladder has retained its spherical shape. International Urology and Nephrology 9, 1977
228
Pytel: Cancer of the bladder and pyelonephritis
Only such a shape of the urinary bladder creates optimum conditions for evacuating urine from it with the help of anterior abdominal wall muscles, pelvic fundus muscles and intraabdominal pressure. Moreover, the contractile ability of the urinary bladder, provided its spherical shape is preserved, creates the most favourable conditions for evacuating urine from the upper urinary tract. All this makes it necessary for the surgeon, when performing hemicystectomy with ureterocystoneostomy, to create conditions ensuring to a certain extent a normal shape of the bladder.
Fig. 1
Fig. 2
Hemicystectomy with suturing of the bladder wound, which is widely used in surgical practice nowadays, results in the bladder's assuming a cigar-like shape which, as a consequence, disturbs the urination act, while the arising perifocal inflammation leads to retaining the urinary bladder's configuration, which subsequently influences unfavourably the functions of the urinary bladder as well as of the upper urinary tract. All this calls for searching the reconstruction techniques of shaping the urinary bladder after hemicystectomy. With that object in view, for the last four years we have been making reconstruction after hemicystectomy aimed at shaping the urinary bladder in the form of a globe. For this purpose, having widely exposed the urinary bladder, which is done, as a rule, transperitoneally, and having performed hemicystectomy (Fig. 1), we suture the remaining apex of the bladder using [-]-shaped catgut suture, whose two threads are run through the vesical neck or base by means of puncture (Fig. 2). By pulling the suture we draw the remaining apex of the urinary bladder to its neck, the bladder assuming the form of a globe (Fig. 3). Two wounds International Urology and Nel)hrology 9. 1977
Pytel: Cancer o f the bladder and pyelonephritis
229
are thus made on the anterior and posterior walls of the urinary bladder. Subsequently, these wounds are sutured (Fig. 4). Cystostomy is performed through the bladder's contra-aperture, which creates the most favourable conditions for healing of the wound.
\\x\~
Fig. 3
Fig. 4
Shaping a globe-like urinary bladder in this way not only creates favourable conditions for urination with the help of anterior abdominal wall muscles, pelvic fundus muscles and intraabdominal pressure, but also considerably lessens the tension of the ureter when we perform ureterocystoneostomy. Such reconstructive operation after hemicystectomy results functionally in the most adequate shape of the urinary bladder and thus ensures almost normal conditions for both the urination act and urinary flow from the upper urinary pathways. This is also a kind of prophylaxis of pyelonephritis frequently occurring after hemicystectomy and ureterocystoneostomy. The preventive and surgical treatment of patients with cancer of the urinary bladder described in this paper lessens considerably the danger of developing such a formidable complication as pyelonephritis.
3
International Urology and INephrology 9, 1977
Cancer of the Urinary Bladder and Pyelonephritis Yu. A. PYTEL I. Moscow Medical Institute, Urological Clinic, Moscow, USSR (Received June 29, 1976)
Successful traetment of cancer of the urinary bladder consists not only in elimination of the tumour process, but also in prophylaxis of various complications. Among complications caused by the tumour process as well as by the applied methods of its therapy a certain place belongs to pyelonephritis. Pyelonephritis develops in consequence of the disturbance of the function of the urinary bladder after hemicystectomy resulting from the change of the bladder's form. With the view of preserving the anatomo-physiological function of the urinary bladder and preventing complications the author suggests a method of reconstruction of the bladder consisting in shaping it in a spherical form after hemicystectomy. Such shape of the urinary bladder ensures nearly normal conditions for both urination act and urinary flow from the upper urinary pathways, this being the prophylaxis of pyelonephritis.
Renal inflammation may develop due to the vesical tumour itself and following radical operation. When taking an acute course, pyelonephritis may sometimes threaten the patient's life. All this makes it necessary to study the pathogenesis of pyelonephritis in patients with cancer of the bladder during the postoperative period and to search for prophylactic measures against this formidable complication. Vesical tumour, with its growth, causes vesical disturbance which manifests itself in dyskinesis.-The developed dyskinesis does not necessarily lead to dysuria, for the latter results, as a rule, from an advanced turnout or when this process is localized at the vesical triangle and neck. Dyskinesis of a tumorous bladder may produce no clinical symptoms for it changes the bladder's evacuating function, which provides for good urinary flow from the upper urinary tract rather than disturbing voiding itself. There is a close association between the functions of the ureters and the urinary bladder, which ensures normal urinary flow from the upper urinary tract. Prior to the contraction of the terminal part of the ureter there occurs dilatation of the urinary bladder, due to which a relatively negative pressure is created in it. And then, with minimal muscular effort of the ureter, the urine flows easily into the bladder from the sphere of high pressure to the sphere of low pressure. In other words, the urinary bladder performs the function of a suction device aspirating urine from the ureters. Dyskinesia of the urinary International Urology and Nephrology 9, 1977
226
Pytel: Cancer of the bladder and pyelonephritis
bladder caused by tumour breaks synchronization between a contractile ability of the ureters and a dilatating function of the urinary bladder. This, in turn, leads to dyskinesis of the ureters and to the disturbance of the function of the calyceal-pelvic system, too. This causes high intrapelvic pressure and pelvicrenal refluxes, which are the main factors in the genesis and progression of pyelonephritis. It should be mentioned that the degree of vesical disturbance is directly dependent on the tumour localization. The lesion in the vesical base and triangle leads earliest to vesical dyskinesis, though vesical disturbance may also be observed when a new growth is localized on the lateral or even anterior wall of the bladder. Vesical dyskinesis resulting from a vesical new growth is relatively seldom complicated by vesicoureteral reflux, either active or passive (according to our findings in 1.4 ~ of cases), usually observed at T~ stage of a vesical triangle new growth. This is another indication of the fact that pyelonephritis in patients with cancer of the bladder is associated mainly with an early development of dyskinesis and a disturbed correlation between the functions of the ureters and the urinary bladder and to a lesser extent with vesicoureteral reflux. Those outlined above explain the origin of pyelonephritis in patients with cancer of the urinary bladder even in cases when the ureteral ostium is not involved in the tumorous process. Pyelonephritis which develops in patients with cancer of the urinary bladder seldom has obvious clinical manifestations: there occur occasionally dull pains in the loin region, and moderate leukocyturia. TV pyeloureteroscopy gives a chance of observing the disturbance of the functions of the upper urinary tract, which is shown in hyperkinesis, dyskinesis, and at times in the lowering of tonus and contractile ability of the ureters. Producing negligible clinical symptoms, pyelonephritis as a complication of cancer of the bladder may take an acute course in the postoperative period. Before the operation vesicoureteral reflux occurs, as noted above, in only 1.4~ of the cases, while after resection of the urinary bladder it is observed very frequently, in 15.6 ~ of the cases, developing after the injection of 50-60 ml of contrast solution under atmospheric pressure, and is always passive. It must be emphasized that a unilateral or bilateral passive vesicoureteral reflux is not always the consequence of an injury to the ureteral ostium region. Reflux develops after resection of the lateral or even anterior wall of the urinary bladder. Our earlier cystographic examinations of patients with cystostorey after adenectomy showed that vesicoureteral reflux develops mainly as a consequence of the bladder's ceasing to perform - owing to cystostomy its inherent function, rather than because of vesical injury. Due to cystostomy the urinary bladder loses its sucking-off, evacuating function, which leads very rapidly to the breaking of a complex locking-up mechanism of the terminal section of the ureter, and this manifests itself in vesicoureteral reflux which, according to our findings, develops most frequently on the 4th or 5th day. Since vesical resection on account of cancer is commonly accompanied by cystostomy, it is the latter, in our opinion, that leads to vesicoureteral International Urology and Nephrology 9, 1977
Pytel: Cancer of the bladder and pyelonephritis
227
reflux, the operative trauma being an additional factor. The existence of a passive vesicoureteral reflux in the immediate postoperative period largely predetermines the occurrence and progression of pyelonephritis. Even a minor disturbance of urinary flow through cystostoma after operation threatens with an acute suppurative renal inflammation. These circumstances dictate a timely detection of vesicoureteral reflux during the immediate postoperative period and the application of therapeutic measures directed to its elimination, this being the prophylaxis of pyelonephritis. With that object in view, on the fourth day after urinary bladder resection we perform cystography, injecting radiopaque solution through the cystostoma without additional pressure. At the first sign of the bladder filling up, with the appearance of the slightest urge to urinate, we cease injecting the constrast solution and carry out roentgenography. If the cystogram shows vesicoureteral reflux, measures are taken for an active aspiration of the bladder's content, modelling the bladder's function of sucking off urine from the ureters. For this purpose we make use of a well-known sucking-off device, a hermetically sealed jar filled with aseptic liquid in which the cystostoma is placed. As the liquid flows out of the jar, a negative pressure is created in it, owing to which aspiration of the bladder's content takes place. Our observations showed that the optimal negative pressure ensuring good urinary flow from the ureters is 0.02 atmospheres. To achieve such a negative pressure the liquid level in the jar must be 200 mm. Active urinary aspiration from the bladder after its resection is not only favourable to a normal urinary evacuation from the upper urinary tract preventing vesicoureteral reflux and pyelonephritis, but it also creates conditions excluding urinary infiltration into the tissues around the bladder, that is, it serves as a prophylactic measure against suppurative complications, whose absence determines in many respects a good vesical function. Our experience has shown that active urinary aspiration from the bladder through the cystostoma eliminates the vesicoureteral reflux very quickly, usually on the 10th to 12th day after operation, closes the cystostoma, restores vesical function, ensures a normal urinary flow from the upper urinary tract and thus may prevent pyelonephritis or creates conditions for its rapid elimination. An important role is played by the pathogenesis of pyelonephritis in patients with cancer of the urinary bladder during the postoperative period by the change in the shape of the bladder and the vesical disturbance resulting from this change. This is most obviously manifested after hemicystectomy. For that reason, when performing hemicystectomy the surgeon should try to shape the urinary bladder in such a way as to ensure, as much as possible, its subsequent normal functioning. Since hemicystectomy is, as a rule, accompanied by ureterocystoneostomy, the operation of ablating half of the organ calls for reconstruction aimed at creating the most favourable anatomo-physiological conditions for reimplantation of the ureter into the remaining part of the bladder. The urination act, as well as the evacuation of urine from the upper urinary tract are ensured best when the urinary bladder has retained its spherical shape. International Urology and Nephrology 9, 1977
228
Pytel: Cancer of the bladder and pyelonephritis
Only such a shape of the urinary bladder creates optimum conditions for evacuating urine from it with the help of anterior abdominal wall muscles, pelvic fundus muscles and intraabdominal pressure. Moreover, the contractile ability of the urinary bladder, provided its spherical shape is preserved, creates the most favourable conditions for evacuating urine from the upper urinary tract. All this makes it necessary for the surgeon, when performing hemicystectomy with ureterocystoneostomy, to create conditions ensuring to a certain extent a normal shape of the bladder.
Fig. 1
Fig. 2
Hemicystectomy with suturing of the bladder wound, which is widely used in surgical practice nowadays, results in the bladder's assuming a cigar-like shape which, as a consequence, disturbs the urination act, while the arising perifocal inflammation leads to retaining the urinary bladder's configuration, which subsequently influences unfavourably the functions of the urinary bladder as well as of the upper urinary tract. All this calls for searching the reconstruction techniques of shaping the urinary bladder after hemicystectomy. With that object in view, for the last four years we have been making reconstruction after hemicystectomy aimed at shaping the urinary bladder in the form of a globe. For this purpose, having widely exposed the urinary bladder, which is done, as a rule, transperitoneally, and having performed hemicystectomy (Fig. 1), we suture the remaining apex of the bladder using [-]-shaped catgut suture, whose two threads are run through the vesical neck or base by means of puncture (Fig. 2). By pulling the suture we draw the remaining apex of the urinary bladder to its neck, the bladder assuming the form of a globe (Fig. 3). Two wounds International Urology and Nel)hrology 9. 1977
Pytel: Cancer o f the bladder and pyelonephritis
229
are thus made on the anterior and posterior walls of the urinary bladder. Subsequently, these wounds are sutured (Fig. 4). Cystostomy is performed through the bladder's contra-aperture, which creates the most favourable conditions for healing of the wound.
\\x\~
Fig. 3
Fig. 4
Shaping a globe-like urinary bladder in this way not only creates favourable conditions for urination with the help of anterior abdominal wall muscles, pelvic fundus muscles and intraabdominal pressure, but also considerably lessens the tension of the ureter when we perform ureterocystoneostomy. Such reconstructive operation after hemicystectomy results functionally in the most adequate shape of the urinary bladder and thus ensures almost normal conditions for both the urination act and urinary flow from the upper urinary pathways. This is also a kind of prophylaxis of pyelonephritis frequently occurring after hemicystectomy and ureterocystoneostomy. The preventive and surgical treatment of patients with cancer of the urinary bladder described in this paper lessens considerably the danger of developing such a formidable complication as pyelonephritis.
3
International Urology and INephrology 9, 1977
