Vol. ll8, October Printed in U .SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
ILEAL CONDUIT AND CYSTECTOMY: A IO-YEAR RETROSPECTIVE STUDY OF ILEAL CONDUITS PERFORMED IN CONJUNCTION WITH CYSTECTOMY AND WITH A MINIMUM 5-YEAR FOLLOWUP JAMES D. DAUGHTRY,* LUAY P. SUSAN, BRUCE H. STEWART
AND
RALPH A. STRAFFON
From the Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT
A 10-year retrospective study was done on 55 patients with primary carcinoma of the bladder who underwent cystectomy with ileal conduit urinary diversion. The 5-year survival rate was 52 per cent for patients with stages 0, A and Bl tumors, 45 per cent for those with stages B2 and C tumors and Oper cent for those with stage D tumors. Patients with squamous cell carcinoma had the worst prognosis, with no patients surviving more than 2 years. Operative mortality rate was 8.9 per cent and all deaths occurred in patients undergoing radical cystectomy and pelvic lymphadenectomy. The operative mortality in this group was 16 per cent, versus no mortality in 24 patients undergoing simple cystectomy. Since no patient with positive pelvic nodes lived more than 20 months postoperatively there appears to be little justification in recommending routine pelvic lymphadenectomy in patients with operable bladder carcinoma. We believe that preoperative radiation added to the morbidity rate and increased the incidence of urinary leakage. Since 80 per cent of the patients who died (4 of 5) had massive pulmonary emboli low dose heparin prophylaxis should be considered in all patients undergoing cystectomy in whom intraoperative bleeding is not a problem. The ileal conduit has remained a popular method of urinary diversion since its introduction by Bricker. However, many series ofileal conduit with cystectomy have had high mortality and morbidity rates. To evaluate the merit of ileal conduits in conjunction with cystectomy for primary carcinoma of the bladder we reviewed 55 consecutive cases with a minimum followup of 5 years. MATERIAL AND METHOD
Between 1960 and 1970, 55 patients underwent simple or radical cystectomy at our hospital. Indications for an operation and criteria used for cystectomy and urinary diversion include 1) sessile lesions of a high grade malignancy, 2) muscle invasion noted on biopsy, 3) rapid recurrence of tumors with increase in stage and/or grade, 4) multiple poorly differentiated lesions and 5) lesions not amenable to endoscopic or segmental resection. The clinical staging of Jewett and Strong, and the histologic grading of Broders were used. The classical Bricker ureteroileal cutaneous diversion was performed in all cases. Simple cystectomy was done in 24 instances and radical cystectomy with pelvic lymphadenectomy was done in the remaining 31 patients. Simple cystectomy included removal of the bladder, prostate and seminal vesicles. Four men underwent total urethrectomy and 6 women had anterior pelvic exenteration. No patient required digitalization or anticoagulant therapy. Ureteral stents were used in 16 patients (28 per cent). The male to female ratio was 1.5 to 1, that is 37 men to 18 women. The patients ranged in age from 40 to 76 years, with an average of 60.5 and a mean of 60. No patient was lost to followup and those dying of unknown causes were presumed to have died of the primary disease. Operative mortality was defined as any case in which the patient died within 30 days of the operation. Four individuals were free of tumor after 9 years and the longest survival was 10 years. Accepted for publication January 7, 1977. Read at annual meeting of North Central Section, American Urological Association, Palm Beach, Florida, October 17-24, 1976. * Current address: 1643 Briarcliff Rd., No. 4, Atlanta, Georgia 30306. 556
Preoperative radiation with 2,400 to 5,500 rads was done in 13 cases (23 per cent). Postoperative radiation with 6,000 rads was done in 11 cases (20 per cent). RESULTS
The over-all operative mortality rate was 8.9 per cent (5 cases). This mortality for cystectomy and ileal conduit compares favorably to other reported series (table 1). 1-s Four of the 5 patients who died had massive pulmonary emboli and all had undergone radical cystectomy (table 2). Prophylactic anticoagulation was not used in any case. No correlation could be discerned between the grade and stage of the lesion, and the operative mortality. Early and late complications are given in table 3. Wound infections accounted for approximately 18 per cent of the cases (deep wound infections 13 per cent and superficial wound infections 5.5 per cent). Late complications, that is bowel obstruction and ureteroileal stenosis, occurred in 2 instances several years postoperatively. It is noteworthy that neither preoperative nor postoperative radiation resulted in any improvement over that obtained with an operation alone but preoperative radiation added to the morbidity of the procedure. Three of the the 4 patients in whom urinary leakage developed had preoperative radiation therapy and none of these patients had stents. Our 5-year survival of 52 per cent of patients with stages 0, A and Bl tumors, 45 per cent of those with stages B2 and C tumors and O per cent of those with stage D tumor compares TABLE
1. Over-all operative mortality rate for cystectomy
References
% Mortality
Burnham and Farrer1 Glantz' Pearse and associates
3
Riches' Parkhurst and Leadbetter' Brannan and associates' Current series Wajsman and associates' Richie and associates'
21.8 19.6 19
15 14 11.9 8.9 8.7
8.5
557
ILEAL CONDUIT AND CYSTECTOMY TABLE
Pt. Age (yrs.)
2. Operatiue mortality*
Grade and Stage
50
III, Bl III, Bl
51
II.Bl
74 57
II, B2 III,B2
59
Cause of Death Massive pulmonary embolus Pulmonary embolus, pneumonia, mesenteric vein thrombosis Pulmonary embolus, It. lower lobe pneumonia Acute hemorrhagic pancreatitis Pelvic abscess, pulmonary embolus
* All 5 patients undervvent radical cystectomy and pelvic lymphadenectomy. TABLE 3.
Early and late complications No. Pts.
Major morbidity: Deep wound infection Ureteroileal urinary leakage Rectal perforation Minor morbidity: Peristomal hernia Superficial wound infection Bronchopneumonia Late complications: Bowel obstruction Ureteroileal stenosis TABLE
7 4
1 1 3
4. Fiue-year survival statistics 0, A, Bl(%)
References
B2, C (%)
51 47
Cordonnier" Whitmore and Marshall 10 Jewett and a.ssociates 11 Wajsman and associates 7 Current series
50 14 13
38
D (%) 0
50
31. 7
52
45
0 0 0 0
the advantages of routine lymphadenectomy. Presently available data indicate that low doses of prophylaxis will diminish significantly postoperative nary embolism in patients more than 40 years old and sub jected to a major abdominal operation. These advantages must be weighed against the increased risk of wound hematornas and minor bleeding in patients undergoing heparin nP,~n''"laxis. 12- 14 Prophylactic vena caval plication or umbrella filters described by Mobin-Uddin and associates or Eichelter sieves have been successful in against recurrent thromboembolism. 15 • should be considered as prophylaxis against pulmonary embolism in high risk patients of this type, at the same time recognizing the possibility of creating increased venous pressure and excessive local bleeding as a result of these measures. Of the 4 patients who had ureteroileal urinary had preoperative radiotherapy and none had stents. For patients who did not receive preoperative radiation (42 patients), urinary extravasation occurred in 1 (2.3 cent). The incidence of urinary extravasation in µo.cn,wc0 preoperative radiation was 23 per cent or 3 13 Because of the relatively high morbidity rate associated with preoperative radiation we temporarily abandoned its use. view of recent figures indicating improved survival raieR in patients receiving preoperative radiation, simple with urinary diversion in combination with nrc,_,,.,,,u,,.,,-,,,rrm radiation therapy may become the treatment REFERENCES
1. Burnham, J.P. and Farrer, J.: A group experience with uretero-
5. Five-year survival according to stage
TABLE
ft~.-.
Tumor Stage
A
1/2 7/13 16/24 3/9 0/4
Bl B2 C
D
(%)
2.
(50) (37)
(66.6) (33.3) (0)
3.
4.
* Patients survived/total patients. 5. TABLE
6. Five-year survival according to grade
Tumor Grade I II III IV
6.
ftt•
(%)
0
(0)
8/14 (57) 16/35 (38) 1/2 (50)
7.
* Patients survived/total patients. favorably to that in other series (table 4). 7 , 9-ll The over-all 5year survival rates according to stage of tumor are given in table 5. Correlation between grading and survival is shown in table 6. Squamous cell carcinoma was present in 3 patients and none of these patients lived more than 2 years, living 2, 12 and 20 months. DISCUSSION
Although aggressive management is required in certain cases of bladder tumor the morbidity and mortality rates as a consequence of the operation are increased. Radical cystectomy with pelvic lymphadenectomy is not a benign procedure. The operative mortality may be as high as 21 per cent. 1 Our over-all mortality rate of 8.9 per cent compares favorably to that ra,nrnrtD,n in other series. 2-s Four of 5 patients who died had massive pulmonary embolism and all had undergone radical cystectomy and pelvic lymphadenectomy. Furthermore, none of the patients in the radical group who underwent lymphadeand had positive nodes lived more than 2 years postTherefore, simple cystectomy appears to have much lower mortality and morbidity rates and may outweigh
8. 9. 10.
11.
12. 13. 14. 15. 16.
ileal-cutaneous anastomosis for urinary diversion: results and complications of the isolated ilea! cond.uit (Bricker procedure) in 96 patients. J. Urol., 83: 622, 1960. Glantz, G. M.: Cystectomy and urinary diversion. J. Urol., 96: 714, 1966. Pearse, H. D., Pappas, J. T. and Hodges, C. V.: Radical cystectomy for bladder cancer: 10-year survival. J. Urol., 109: 623, 1973. Riches, E.: Choice of treatment in carcinoma of the bladder. ,J Urol., 84: 472, 1960. Parkhurst, E. C. and Leadbetter, W. F.: A report on 93 ileal loop urinary diversions. J. Urol., 83: 398, 1960. Brannan, W., Ochsner, M. G., Whitehead, M. C. and Rosecrandts, D.: Cystectomy and segmental resection for carcinoma of the bladder. Experiences at the Ochsner 1942 to 1948. South. Med. J., 66: 241, 1973. Wajsman, Z., Merrin, C., Moore, R. and Murphy, G. P.: Current results from treatment of bladder tumors with total tomy at Roswell Park Memorial Institute. J. Urol., 1975. Richie, J.P., Skinner, D. G. and Kaufman, J. J.: Radical cystectomy for carcinoma of the bladder: 16 years of experience. Urol., 113: 186, 1975. Cordonnier, J. J.: Cystectomy for carcinoma of the bladder. J Urol., 99: 172, 1968. Whitmore, W. F., Jr. and Marshall, V. F.: Radical total cystectomy for cancer of the bladder: 230 consecutive cases five years later. J. Urol., 87: 853, 1962. Jewett, H. J., King, L. R. and Shelley, W. M.: A study of cases of infiltrating bladder cancer: relation of certain logical characteristics to prognosis after extirpation. J. 92: 668, 1964. Kakkar, V. V., Corrigan, T. P. and Schribman, I. G.: Prevention of fatal postoperative pulmonary embolism by low doses of heparin. Lancet, 2: 45, 1975, Wessler, S.: Heparin as an antithrombotic agent: low dose phylaxis. J.A.M.A., 236: 389, 1976. Gallus, H.J.: Anticoagulants in venous thromboembolism: phylaxis and therapeutic use. Postgrad. Med., 55: 211, Mobin-Uddin, K., Trinkle, J. K. and Bryan, L. R.: Present status of inferior vena cava umbrella filters. Surgery, 70: 914, 1971. Greenfield, L. J.: Pulmonary embolism: diagnosis and manag1,ment. Curr. Prob. Surg., 13: 1, 1976.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
ILEAL CONDUIT AND CYSTECTOMY: A IO-YEAR RETROSPECTIVE STUDY OF ILEAL CONDUITS PERFORMED IN CONJUNCTION WITH CYSTECTOMY AND WITH A MINIMUM 5-YEAR FOLLOWUP JAMES D. DAUGHTRY,* LUAY P. SUSAN, BRUCE H. STEWART
AND
RALPH A. STRAFFON
From the Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT
A 10-year retrospective study was done on 55 patients with primary carcinoma of the bladder who underwent cystectomy with ileal conduit urinary diversion. The 5-year survival rate was 52 per cent for patients with stages 0, A and Bl tumors, 45 per cent for those with stages B2 and C tumors and Oper cent for those with stage D tumors. Patients with squamous cell carcinoma had the worst prognosis, with no patients surviving more than 2 years. Operative mortality rate was 8.9 per cent and all deaths occurred in patients undergoing radical cystectomy and pelvic lymphadenectomy. The operative mortality in this group was 16 per cent, versus no mortality in 24 patients undergoing simple cystectomy. Since no patient with positive pelvic nodes lived more than 20 months postoperatively there appears to be little justification in recommending routine pelvic lymphadenectomy in patients with operable bladder carcinoma. We believe that preoperative radiation added to the morbidity rate and increased the incidence of urinary leakage. Since 80 per cent of the patients who died (4 of 5) had massive pulmonary emboli low dose heparin prophylaxis should be considered in all patients undergoing cystectomy in whom intraoperative bleeding is not a problem. The ileal conduit has remained a popular method of urinary diversion since its introduction by Bricker. However, many series ofileal conduit with cystectomy have had high mortality and morbidity rates. To evaluate the merit of ileal conduits in conjunction with cystectomy for primary carcinoma of the bladder we reviewed 55 consecutive cases with a minimum followup of 5 years. MATERIAL AND METHOD
Between 1960 and 1970, 55 patients underwent simple or radical cystectomy at our hospital. Indications for an operation and criteria used for cystectomy and urinary diversion include 1) sessile lesions of a high grade malignancy, 2) muscle invasion noted on biopsy, 3) rapid recurrence of tumors with increase in stage and/or grade, 4) multiple poorly differentiated lesions and 5) lesions not amenable to endoscopic or segmental resection. The clinical staging of Jewett and Strong, and the histologic grading of Broders were used. The classical Bricker ureteroileal cutaneous diversion was performed in all cases. Simple cystectomy was done in 24 instances and radical cystectomy with pelvic lymphadenectomy was done in the remaining 31 patients. Simple cystectomy included removal of the bladder, prostate and seminal vesicles. Four men underwent total urethrectomy and 6 women had anterior pelvic exenteration. No patient required digitalization or anticoagulant therapy. Ureteral stents were used in 16 patients (28 per cent). The male to female ratio was 1.5 to 1, that is 37 men to 18 women. The patients ranged in age from 40 to 76 years, with an average of 60.5 and a mean of 60. No patient was lost to followup and those dying of unknown causes were presumed to have died of the primary disease. Operative mortality was defined as any case in which the patient died within 30 days of the operation. Four individuals were free of tumor after 9 years and the longest survival was 10 years. Accepted for publication January 7, 1977. Read at annual meeting of North Central Section, American Urological Association, Palm Beach, Florida, October 17-24, 1976. * Current address: 1643 Briarcliff Rd., No. 4, Atlanta, Georgia 30306. 556
Preoperative radiation with 2,400 to 5,500 rads was done in 13 cases (23 per cent). Postoperative radiation with 6,000 rads was done in 11 cases (20 per cent). RESULTS
The over-all operative mortality rate was 8.9 per cent (5 cases). This mortality for cystectomy and ileal conduit compares favorably to other reported series (table 1). 1-s Four of the 5 patients who died had massive pulmonary emboli and all had undergone radical cystectomy (table 2). Prophylactic anticoagulation was not used in any case. No correlation could be discerned between the grade and stage of the lesion, and the operative mortality. Early and late complications are given in table 3. Wound infections accounted for approximately 18 per cent of the cases (deep wound infections 13 per cent and superficial wound infections 5.5 per cent). Late complications, that is bowel obstruction and ureteroileal stenosis, occurred in 2 instances several years postoperatively. It is noteworthy that neither preoperative nor postoperative radiation resulted in any improvement over that obtained with an operation alone but preoperative radiation added to the morbidity of the procedure. Three of the the 4 patients in whom urinary leakage developed had preoperative radiation therapy and none of these patients had stents. Our 5-year survival of 52 per cent of patients with stages 0, A and Bl tumors, 45 per cent of those with stages B2 and C tumors and O per cent of those with stage D tumor compares TABLE
1. Over-all operative mortality rate for cystectomy
References
% Mortality
Burnham and Farrer1 Glantz' Pearse and associates
3
Riches' Parkhurst and Leadbetter' Brannan and associates' Current series Wajsman and associates' Richie and associates'
21.8 19.6 19
15 14 11.9 8.9 8.7
8.5
557
ILEAL CONDUIT AND CYSTECTOMY TABLE
Pt. Age (yrs.)
2. Operatiue mortality*
Grade and Stage
50
III, Bl III, Bl
51
II.Bl
74 57
II, B2 III,B2
59
Cause of Death Massive pulmonary embolus Pulmonary embolus, pneumonia, mesenteric vein thrombosis Pulmonary embolus, It. lower lobe pneumonia Acute hemorrhagic pancreatitis Pelvic abscess, pulmonary embolus
* All 5 patients undervvent radical cystectomy and pelvic lymphadenectomy. TABLE 3.
Early and late complications No. Pts.
Major morbidity: Deep wound infection Ureteroileal urinary leakage Rectal perforation Minor morbidity: Peristomal hernia Superficial wound infection Bronchopneumonia Late complications: Bowel obstruction Ureteroileal stenosis TABLE
7 4
1 1 3
4. Fiue-year survival statistics 0, A, Bl(%)
References
B2, C (%)
51 47
Cordonnier" Whitmore and Marshall 10 Jewett and a.ssociates 11 Wajsman and associates 7 Current series
50 14 13
38
D (%) 0
50
31. 7
52
45
0 0 0 0
the advantages of routine lymphadenectomy. Presently available data indicate that low doses of prophylaxis will diminish significantly postoperative nary embolism in patients more than 40 years old and sub jected to a major abdominal operation. These advantages must be weighed against the increased risk of wound hematornas and minor bleeding in patients undergoing heparin nP,~n''"laxis. 12- 14 Prophylactic vena caval plication or umbrella filters described by Mobin-Uddin and associates or Eichelter sieves have been successful in against recurrent thromboembolism. 15 • should be considered as prophylaxis against pulmonary embolism in high risk patients of this type, at the same time recognizing the possibility of creating increased venous pressure and excessive local bleeding as a result of these measures. Of the 4 patients who had ureteroileal urinary had preoperative radiotherapy and none had stents. For patients who did not receive preoperative radiation (42 patients), urinary extravasation occurred in 1 (2.3 cent). The incidence of urinary extravasation in µo.cn,wc0 preoperative radiation was 23 per cent or 3 13 Because of the relatively high morbidity rate associated with preoperative radiation we temporarily abandoned its use. view of recent figures indicating improved survival raieR in patients receiving preoperative radiation, simple with urinary diversion in combination with nrc,_,,.,,,u,,.,,-,,,rrm radiation therapy may become the treatment REFERENCES
1. Burnham, J.P. and Farrer, J.: A group experience with uretero-
5. Five-year survival according to stage
TABLE
ft~.-.
Tumor Stage
A
1/2 7/13 16/24 3/9 0/4
Bl B2 C
D
(%)
2.
(50) (37)
(66.6) (33.3) (0)
3.
4.
* Patients survived/total patients. 5. TABLE
6. Five-year survival according to grade
Tumor Grade I II III IV
6.
ftt•
(%)
0
(0)
8/14 (57) 16/35 (38) 1/2 (50)
7.
* Patients survived/total patients. favorably to that in other series (table 4). 7 , 9-ll The over-all 5year survival rates according to stage of tumor are given in table 5. Correlation between grading and survival is shown in table 6. Squamous cell carcinoma was present in 3 patients and none of these patients lived more than 2 years, living 2, 12 and 20 months. DISCUSSION
Although aggressive management is required in certain cases of bladder tumor the morbidity and mortality rates as a consequence of the operation are increased. Radical cystectomy with pelvic lymphadenectomy is not a benign procedure. The operative mortality may be as high as 21 per cent. 1 Our over-all mortality rate of 8.9 per cent compares favorably to that ra,nrnrtD,n in other series. 2-s Four of 5 patients who died had massive pulmonary embolism and all had undergone radical cystectomy and pelvic lymphadenectomy. Furthermore, none of the patients in the radical group who underwent lymphadeand had positive nodes lived more than 2 years postTherefore, simple cystectomy appears to have much lower mortality and morbidity rates and may outweigh
8. 9. 10.
11.
12. 13. 14. 15. 16.
ileal-cutaneous anastomosis for urinary diversion: results and complications of the isolated ilea! cond.uit (Bricker procedure) in 96 patients. J. Urol., 83: 622, 1960. Glantz, G. M.: Cystectomy and urinary diversion. J. Urol., 96: 714, 1966. Pearse, H. D., Pappas, J. T. and Hodges, C. V.: Radical cystectomy for bladder cancer: 10-year survival. J. Urol., 109: 623, 1973. Riches, E.: Choice of treatment in carcinoma of the bladder. ,J Urol., 84: 472, 1960. Parkhurst, E. C. and Leadbetter, W. F.: A report on 93 ileal loop urinary diversions. J. Urol., 83: 398, 1960. Brannan, W., Ochsner, M. G., Whitehead, M. C. and Rosecrandts, D.: Cystectomy and segmental resection for carcinoma of the bladder. Experiences at the Ochsner 1942 to 1948. South. Med. J., 66: 241, 1973. Wajsman, Z., Merrin, C., Moore, R. and Murphy, G. P.: Current results from treatment of bladder tumors with total tomy at Roswell Park Memorial Institute. J. Urol., 1975. Richie, J.P., Skinner, D. G. and Kaufman, J. J.: Radical cystectomy for carcinoma of the bladder: 16 years of experience. Urol., 113: 186, 1975. Cordonnier, J. J.: Cystectomy for carcinoma of the bladder. J Urol., 99: 172, 1968. Whitmore, W. F., Jr. and Marshall, V. F.: Radical total cystectomy for cancer of the bladder: 230 consecutive cases five years later. J. Urol., 87: 853, 1962. Jewett, H. J., King, L. R. and Shelley, W. M.: A study of cases of infiltrating bladder cancer: relation of certain logical characteristics to prognosis after extirpation. J. 92: 668, 1964. Kakkar, V. V., Corrigan, T. P. and Schribman, I. G.: Prevention of fatal postoperative pulmonary embolism by low doses of heparin. Lancet, 2: 45, 1975, Wessler, S.: Heparin as an antithrombotic agent: low dose phylaxis. J.A.M.A., 236: 389, 1976. Gallus, H.J.: Anticoagulants in venous thromboembolism: phylaxis and therapeutic use. Postgrad. Med., 55: 211, Mobin-Uddin, K., Trinkle, J. K. and Bryan, L. R.: Present status of inferior vena cava umbrella filters. Surgery, 70: 914, 1971. Greenfield, L. J.: Pulmonary embolism: diagnosis and manag1,ment. Curr. Prob. Surg., 13: 1, 1976.
