RADICAL CYSTECTOMY FOR CARCINOMA OF BILHARZIAL
BLADDER
Technique
and Results
MOHAMED
A. GHONEIM,
MOHAMED
N. EL-BOLKAINY,
MOHAMED
A. MANSOUR,
SALAH
M.D.
M. EL-HAMADY.
ALBAIR
PH.D.
G. ASHAMALLAH,
EL-SAYED
M.D.
M.D.
H. SOLIMAN,
M.D M.D.
From the Department of Urology, Mansoura University Hospital, Mansoura, and the Department of Pathology, the Cancer Institute of Cairo University, Cairo, Egypt
ABSTRACT - One hundred and sixty-two patients with carcinoma of the bilharxial bladder were treated by radical cystectomy. The postoperative mortality was 12.9 per cent and the jive-year survival rate was 38.9 per cent. Correlations of the survival figures relative to the various pathologic features of the tumor revealed that squamous and transitional tumors have essentially the same prognosis, and that the most important prognostic index was the tumor grade. In most cases treatment failures were due to local recurrences which developed within one year after operation.
In Egypt carcinoma of the bilharzial bladder presents certain particular features.lb3 Most of the cases are seen in an advanced stage, and the tumors are usually of the squamous cell type and are not radioresponsive. Radical cystectomy with urinary diversion appears to offer the best prospects for cure in most of the cases. The aim of this article is to describe our technique of radical cystectomy and present the end results of treatment using this modality. Material Between 1968 and 1973, 190 patients with clinically “resectable” bladder tumors were admitted to our department. Distribution of age and sex is given in Table I. Of the 190 patients 162 underwent radical cystectomy with some form of urinary diversion. Segmental resection was performed in 19 cases. Six patients were considered inoperable during surgical exploration because of positive lymph nodes above the pelvic brim. -Three patients refused the operation.
UROLOGY
/ DECEMBER
1976 /
VOLUMEVIII, NUMBER6
In general the indications for cystectomy were (1) superficial tumors unsuitable for transurethral resection due to their size, and (2) infiltrating tumors unsuitable for segmental resection in view of their size and/or location. Technique The extent of the radical operation is to remove the bladder with its perivesical fat, peritoneal covering, the prostate, and the seminal vesicles, together with the distal common iliac, internal iliac, and external iliac lymph nodes. In the female, the bladder, urethra, uterus, and upper two thirds of the vagina with the pelvic cellular tissue and the aforementioned lymph nodes are removed. TABLE I. Age and sex distrihtion -~-
Sex
Male Female TOTALS
-30 7 6 13
30-
35-____ 7 17 8 8 --__ 15 25
40 46 14 60
_______
4529 7 36
5019 6 25
55+ 14 2 16
547
--FIGURE 1. Dissection of triangle of Marceille. Psoas muscle is retracted laterally, and common iliac vessels medially. Fatty and lymphatic tissues are cleared from floor of space exposing obturator nerve as it emerges from medial aspect of psoas muscle.
FIGURE 2. Lymphadenectomy is completed. Iliac vessels are “skeletonized. ” Obturator space is cleared fi-om all structures saving obturator nerve.
A lower right paramedian incision extending from 2 inches above the umbilicus to the symphysis pubis is employed. The pelvic and abdominal cavities are explored. The growth is palpated and the degree of mobility of the bladder assessed. If it is decided to proceed with the radical operation, the operating table is tilted into the Trendelenburg position and the intestines packed out of the pelvis. ‘The peritoneal incision is extended posterolaterally on either side along the lateral border of the external iliac vessels up to the common iliac bifurcation. The vas deferens is identified and ligated near the internal ring. The fascia on the
548
iliopsoas is incised and reflected medially. The triangle of Marceille is exposed by retracting the common and external iliac arteries medially and dissecting the space between these vessels and the medial border of the psoas muscle. The cleaning of the fibrolymphatic tissues in this space will expose the obturator nerve as it emerges from the medial border of the psoas muscle (Fig. 1). The fibrofascial sheath covering the distal half of the common iliac and the external iliac vessels is then opened and stripped medially to remove the perivascular lymphatics and lymph nodes. The vessels are gently retracted laterally and immediately below and
UROLOGY
/ DECEMBER
1976 / VOLUME
VIII,
NUMBER
6
FIGURE 3. Bladder is removed. Final hemostatis is achieved by suturing medial edges of two levator ani muscles together.
medial to the cleaned external iliac vein; the obturator space is entered. By working right on the psoas and obturator muscles, all the pelvic fascia is stripped medially without difficulty. The obturator neurovascular bundle is included nerve is in the stripped mass. The obturator identified and separated from the vessels which are divided and ligated as they leave the pelvis through the obturator foramen. Dissection is facilitated and the operating time reduced by the use of electrocoagulation to control lymphatic and small blood vessels throughout the lymphadenectomy. The fibrolympinatic mass is now reflected medially. The internal iliac artery is dissected free and its anterior division is divided and ligated (Fig. 2). Th e ureter is identified where it crosses the common iliac bifurcation, dissected free for 3 to 4 cm., divided, and its distal end ligated. While traction is applied on the ligated ureteric stump of the ureter, finger dissection along its posteromedial border opens the space of Denonvillier laterally. This step greatly helps in the definition of the plane between the bladder and rectum which will be required at a later stage in the operation. The same dissection is carried on the other side of the pelvis. Then the reflection of the peritoneum from the rectum to the seminal vesicles and bladder is incised. The space between the anterior structures and rectum is opened by blunt dissection. A thick and wide
UROLOGY
/ DECEMBER
1976 / VOIJJMEVIII, NUMBER6
fascial band will thus result on either side, connecting the bladder, vesicles, and prostate anteriorly with the sides of the rectum posteriorly (the vesicoprostatopelvic fascia). This is divided piecemeal between clamps which are underrun later. The bladder is now free posteriorly and laterally, and the dissection is carried anteriorly dividing the median puboprostatic ligaments on either side between clamps. A curved clamp is placed on the urethra distal to the prostate, and the specimen is excised. Final hemostasis is achieved by inserting deep catgut sutures between the edges of the levator ani muscles on either side (Fig. 3). No attempt is made to reperitonealize the pelvis. Drainage is achieved by a suprapubic sump tube. In the female, the technique differs only in its posterior phase. The peritoneum at the floor of the pouch of Douglas is incised. The rectum is separated from the vagina by blunt dissection. The vesicovaginorectal fascia including the uterosacral ligaments now appear as a broad fascial sheet on either side connecting the bladder and the vagina anteriorly with the rectum posteriorly. It is cut piecemeal between clamps which are underrun by catgut. The vagina is incised horizontally 1 inch above the introitus. The posterior aspect of the urethra is thus exposed, clamped, and cut distal to the clamp. The cut edges of the vagina are sutured around a sump drainage tube.
549
TABLE II. Stage
Clinical and pathologic stage of tumor
Clinical Number
Pathologic PZ
P,
2
1
P3
p4
1
TI T2 T3
30 129
.. ..
7 22
T4
1
. .
. .
ii
'2
85 . .
22 1
The various methods used for urinary diversion were rectal bladder in 97 cases (MauClaire 89 and Gersuny-Lously B), ureterocutaneous 45, ureterocolonic 7, and ileal loop conduit (Bricker) 13.
were included in the computation of the curves. Eighty-seven patients were followed up for five years or more. Follow-up data were unavailable in 4 cases only. Survival was defined as living without clinical evidence of disease. The five-year survival was 38.9 per cent. Survivals among patients with squamous carcinoma and those with transitional carcinoma were essentially the same (Fig. 4B). Survival and tumor pathologic stage is shown in Figure 4C. This correlation was made on the basis of the pathologic stage since it is more accurate than the clinical one. As expected superficial tumors (P2) had a better survival rate than the infiltrating variety (1'3 and P4) (54.3 and 33.5 per cent, respectively).
Results
one patients died in hospital after Twenty initiation of treatment, a postoperative mortality rate of 12.9 per cent. The various causes of postoperative mortality were septic shock in 9 patients, fecal fistula 3, urinary leakage 3, pulmonary edema 1, hepatorenal failure 2, and deep vein thrombosis and embolism 1. The most important single cause was septic complications. The distribution of cases according to clinical and pathologic stage is presented in Table II. It is clear that most of the cases present initially with an advanced stage. Moreover there was a tendency of underestimating the pathologic extent of the disease, particularly at the T2 stage. The tumor histology and grade are given in Table III. Squamous cell tumors account for 66.7 per cent of the cases; of these, 62 per cent are of well-differentiated variety. Transitional cell carcinoma is less common and represents is 26 per cent of cases, and adenocarcinoma rare, constituting only 5 per cent. Survival was calculated using the actuarial technique (Fig. 4A). Postoperative mortalities
TABLE
Period (Years) Ol2345+
550
IV.
TABLE
III. Tumor histology and grade
-GradeHistology Squamous Transitional Adenocarcinoma
Sarcoma
LOW
71 9 1 . . .
High
Total
40 33 6 . . .
111 42 7 2 162
TOTAL
Low-grade tumors had a five-year survival rate of 52.3 per cent while survival with highgrade tumors was only 25.8 per cent, a statistically significant difference (Fig. 4D). Stratification of the cases into four categories according to their stage and grade allows the definition of the relative prognostic importance of these two pathologic parameters. In general the four curves are distributed into two groups. Low-grade tumors had a better survival rate than high-grade tumors, whether they were superficial (P2) or deep (P3 and P4) (Fig. 4E). The regional lymph nodes were involved in 28 cases (17.2 per cent) (Fig. 4F). Cases with
Treatment failures: distribution according to onset and locality
Regional 36 8 5 1 6 2
General
Undetermined
2 2
8 . . . 1 . . . 1 2
. 1 . . 1
UROLOGY
Total
Per Cent
46 10 6 2 7 5
60.5 13.5 7.8 2.6 9.2 6.5
/ DECEMBER1976
/ VOLUMEVIII, NUMBER6
n
SURVIVAL ACTUARIAL
8
SURVIVAL
PATHOLOGICAL
STAGE
80 -
2
\
60 -
60-
----L
:
\
d s 40 -
20
t A
’
I
I
I
L
6
months 12
16
24
,_
L
L
3
years 4
.
I 5
B
I
’
’
I
6
12
18
I
,,
24
i
,
3
4
of Follow
up
5
%
I
I
I
6
12
18
years
months Period
,
Period
of
Folbw
and
FIGURE
Actuwial
4.
Follow
UP
survival
Period
data. (A) Survivd
of
in generul;
Follow
I
I
3
4 years
a Peraod of
:
Follow
ul,
SURVIVAL
8
Grade STATE
Per,od of
I.
”
months
up
SURVIVAL Stage
1
24
OF
LYMPH
NODES
up
vertical bars in&cute
standard
err-or (P = 0.0s).
(B) Survival and tumor histology; squamous and transitional tumors have essentially same survivnl. (C) Survival und pathologic stage. (0) Survival unrl tumor gracle. (Ej Survival and tumor pathologic stage and grade. (F) Survivul and state of lymph nodes.
negative nodes had a significantly better survival rate than those with positive oues. Nevertheless, the radical operation could provide a ZO-per cent survival for patients with positive nodes. Table TV shows the distribution of treatment failures (recurrences and/or metastasis) according to their site and time of onset. Most of the recurrences were local in the pelvis and de-
UROI,OC~-
/
DECEhlRER
1976
/
VOLUhlE
VIII,
veloped within treatment.
twelve
months
after initiation
of
Comment The general technical principles employed are similar to those previously described by Paquin and Marsl~all,4 and El Sebai.’ The operative mortality of 12.9 per cent compares favorably with other reports.5-7 Hotvever, recent
NUSIRER 6
551
:
articles indicate that these figures can be remarkably reduced by staging of the operative procedure. 8 Rectal bladder with a terminal left iliac colostomy was the most common method utilized for urinary diversion. The technique, its justification, and results were reported in a series of previous articles.‘-I’ Analysis of survival figures relative to the various pathologic features of the tumor revealed that squamous and transitional tumors have essentially the same prognosis. It was also demonstrated that the tumor grade is the most critical prognostic index, a fact which was also emphasized by Thompson. I2 The majority of treatment failures were due to local recurrences in the pelvis; moreover, most developed within twelve months after initiation of treatment. These findings strongly suggest that surgical excision alone, despite being radical, was inadequate to deal with the extent of the “local” pathology. An adjuvant line of treatment directed locally to the pelvis may improve survival. Preoperative radiation appears to provide the logical tool. On these bases a prospective randomized study comparing radical cystectomy and 2,000 rad preoperative radiation dose given in five daily fractions followed by cystectomy, is the subject of a current clinical trial.
552
Mansoura University Hospital Mansoura, Egypt (DR. GHONEIM) References 1. MAKAR, N.: “Urological aspects of bilharziasis in Egypt,” S.O.P. Press, Cairo, 1955, pp. 51-83. 2. EL SEBAI, I.: Cancer of the bladder in Egypt, Kasr El Aini J. Surg. 2: 183 (1961). 3. EL-BOLKAINY, M., GHONEIM, M. A., and MANSOUR, M. A.: Carcinoma of the bilharzial bladder in Egypt, Br. J. Urol. 4: 561 (1972). 4. PAQUIN, A. J., and MARSHALL, V. F.: A technique for radical total cystectomy, Cancer 9: 585 (1956). 5. WHITMORE, W. F., JR., and MARSHALL, V. F.: Radical total cystectomy for cancer of the bladder: 230 cases five years later, J. Ural. 87: 853 (1962). 6. SAKATI, I. A., and MARSHALL, V. F.: Post-operative fatalities in urology, J. Urol. 95: 412 (1966). 7. STONES, J. H., and HODGES, C. V.: Radical cystectomy for invasive bladder cancer, ibid. 96: 207 (1966). 8. CRIMES, J. H., HART, J. M., GLENN, J. F., and ANDERSON, E. E.: Staged approach to invasive vesical malignancy, ibid 108: 872 (1972). 9. GHONEI~~,M. A.: The recta-sigmoid bladder for urinary diversion, Br. J. Urol. 42: 429 (1970). 10. GHONEIM, M. A., and ASHAMALLAH, A.: Further experience with the rectosigmoid bladder, ibid. 46: 511 (1974). 11. GHONEIM, ?(f. A., and SHOUKRY, I.: Rectal bladder with perineal colostomy for urinary diversion, Urology 4: 278 (1974). 12. THOMPSON, G. I.: Prognosis in vesical neoplasms, J.A.M.A. 172: 28 (1960).
UROLOGY / DECEMBER 1976 / VOLUME VIII, NUMBER 6
BLADDER
Technique
and Results
MOHAMED
A. GHONEIM,
MOHAMED
N. EL-BOLKAINY,
MOHAMED
A. MANSOUR,
SALAH
M.D.
M. EL-HAMADY.
ALBAIR
PH.D.
G. ASHAMALLAH,
EL-SAYED
M.D.
M.D.
H. SOLIMAN,
M.D M.D.
From the Department of Urology, Mansoura University Hospital, Mansoura, and the Department of Pathology, the Cancer Institute of Cairo University, Cairo, Egypt
ABSTRACT - One hundred and sixty-two patients with carcinoma of the bilharxial bladder were treated by radical cystectomy. The postoperative mortality was 12.9 per cent and the jive-year survival rate was 38.9 per cent. Correlations of the survival figures relative to the various pathologic features of the tumor revealed that squamous and transitional tumors have essentially the same prognosis, and that the most important prognostic index was the tumor grade. In most cases treatment failures were due to local recurrences which developed within one year after operation.
In Egypt carcinoma of the bilharzial bladder presents certain particular features.lb3 Most of the cases are seen in an advanced stage, and the tumors are usually of the squamous cell type and are not radioresponsive. Radical cystectomy with urinary diversion appears to offer the best prospects for cure in most of the cases. The aim of this article is to describe our technique of radical cystectomy and present the end results of treatment using this modality. Material Between 1968 and 1973, 190 patients with clinically “resectable” bladder tumors were admitted to our department. Distribution of age and sex is given in Table I. Of the 190 patients 162 underwent radical cystectomy with some form of urinary diversion. Segmental resection was performed in 19 cases. Six patients were considered inoperable during surgical exploration because of positive lymph nodes above the pelvic brim. -Three patients refused the operation.
UROLOGY
/ DECEMBER
1976 /
VOLUMEVIII, NUMBER6
In general the indications for cystectomy were (1) superficial tumors unsuitable for transurethral resection due to their size, and (2) infiltrating tumors unsuitable for segmental resection in view of their size and/or location. Technique The extent of the radical operation is to remove the bladder with its perivesical fat, peritoneal covering, the prostate, and the seminal vesicles, together with the distal common iliac, internal iliac, and external iliac lymph nodes. In the female, the bladder, urethra, uterus, and upper two thirds of the vagina with the pelvic cellular tissue and the aforementioned lymph nodes are removed. TABLE I. Age and sex distrihtion -~-
Sex
Male Female TOTALS
-30 7 6 13
30-
35-____ 7 17 8 8 --__ 15 25
40 46 14 60
_______
4529 7 36
5019 6 25
55+ 14 2 16
547
--FIGURE 1. Dissection of triangle of Marceille. Psoas muscle is retracted laterally, and common iliac vessels medially. Fatty and lymphatic tissues are cleared from floor of space exposing obturator nerve as it emerges from medial aspect of psoas muscle.
FIGURE 2. Lymphadenectomy is completed. Iliac vessels are “skeletonized. ” Obturator space is cleared fi-om all structures saving obturator nerve.
A lower right paramedian incision extending from 2 inches above the umbilicus to the symphysis pubis is employed. The pelvic and abdominal cavities are explored. The growth is palpated and the degree of mobility of the bladder assessed. If it is decided to proceed with the radical operation, the operating table is tilted into the Trendelenburg position and the intestines packed out of the pelvis. ‘The peritoneal incision is extended posterolaterally on either side along the lateral border of the external iliac vessels up to the common iliac bifurcation. The vas deferens is identified and ligated near the internal ring. The fascia on the
548
iliopsoas is incised and reflected medially. The triangle of Marceille is exposed by retracting the common and external iliac arteries medially and dissecting the space between these vessels and the medial border of the psoas muscle. The cleaning of the fibrolymphatic tissues in this space will expose the obturator nerve as it emerges from the medial border of the psoas muscle (Fig. 1). The fibrofascial sheath covering the distal half of the common iliac and the external iliac vessels is then opened and stripped medially to remove the perivascular lymphatics and lymph nodes. The vessels are gently retracted laterally and immediately below and
UROLOGY
/ DECEMBER
1976 / VOLUME
VIII,
NUMBER
6
FIGURE 3. Bladder is removed. Final hemostatis is achieved by suturing medial edges of two levator ani muscles together.
medial to the cleaned external iliac vein; the obturator space is entered. By working right on the psoas and obturator muscles, all the pelvic fascia is stripped medially without difficulty. The obturator neurovascular bundle is included nerve is in the stripped mass. The obturator identified and separated from the vessels which are divided and ligated as they leave the pelvis through the obturator foramen. Dissection is facilitated and the operating time reduced by the use of electrocoagulation to control lymphatic and small blood vessels throughout the lymphadenectomy. The fibrolympinatic mass is now reflected medially. The internal iliac artery is dissected free and its anterior division is divided and ligated (Fig. 2). Th e ureter is identified where it crosses the common iliac bifurcation, dissected free for 3 to 4 cm., divided, and its distal end ligated. While traction is applied on the ligated ureteric stump of the ureter, finger dissection along its posteromedial border opens the space of Denonvillier laterally. This step greatly helps in the definition of the plane between the bladder and rectum which will be required at a later stage in the operation. The same dissection is carried on the other side of the pelvis. Then the reflection of the peritoneum from the rectum to the seminal vesicles and bladder is incised. The space between the anterior structures and rectum is opened by blunt dissection. A thick and wide
UROLOGY
/ DECEMBER
1976 / VOIJJMEVIII, NUMBER6
fascial band will thus result on either side, connecting the bladder, vesicles, and prostate anteriorly with the sides of the rectum posteriorly (the vesicoprostatopelvic fascia). This is divided piecemeal between clamps which are underrun later. The bladder is now free posteriorly and laterally, and the dissection is carried anteriorly dividing the median puboprostatic ligaments on either side between clamps. A curved clamp is placed on the urethra distal to the prostate, and the specimen is excised. Final hemostasis is achieved by inserting deep catgut sutures between the edges of the levator ani muscles on either side (Fig. 3). No attempt is made to reperitonealize the pelvis. Drainage is achieved by a suprapubic sump tube. In the female, the technique differs only in its posterior phase. The peritoneum at the floor of the pouch of Douglas is incised. The rectum is separated from the vagina by blunt dissection. The vesicovaginorectal fascia including the uterosacral ligaments now appear as a broad fascial sheet on either side connecting the bladder and the vagina anteriorly with the rectum posteriorly. It is cut piecemeal between clamps which are underrun by catgut. The vagina is incised horizontally 1 inch above the introitus. The posterior aspect of the urethra is thus exposed, clamped, and cut distal to the clamp. The cut edges of the vagina are sutured around a sump drainage tube.
549
TABLE II. Stage
Clinical and pathologic stage of tumor
Clinical Number
Pathologic PZ
P,
2
1
P3
p4
1
TI T2 T3
30 129
.. ..
7 22
T4
1
. .
. .
ii
'2
85 . .
22 1
The various methods used for urinary diversion were rectal bladder in 97 cases (MauClaire 89 and Gersuny-Lously B), ureterocutaneous 45, ureterocolonic 7, and ileal loop conduit (Bricker) 13.
were included in the computation of the curves. Eighty-seven patients were followed up for five years or more. Follow-up data were unavailable in 4 cases only. Survival was defined as living without clinical evidence of disease. The five-year survival was 38.9 per cent. Survivals among patients with squamous carcinoma and those with transitional carcinoma were essentially the same (Fig. 4B). Survival and tumor pathologic stage is shown in Figure 4C. This correlation was made on the basis of the pathologic stage since it is more accurate than the clinical one. As expected superficial tumors (P2) had a better survival rate than the infiltrating variety (1'3 and P4) (54.3 and 33.5 per cent, respectively).
Results
one patients died in hospital after Twenty initiation of treatment, a postoperative mortality rate of 12.9 per cent. The various causes of postoperative mortality were septic shock in 9 patients, fecal fistula 3, urinary leakage 3, pulmonary edema 1, hepatorenal failure 2, and deep vein thrombosis and embolism 1. The most important single cause was septic complications. The distribution of cases according to clinical and pathologic stage is presented in Table II. It is clear that most of the cases present initially with an advanced stage. Moreover there was a tendency of underestimating the pathologic extent of the disease, particularly at the T2 stage. The tumor histology and grade are given in Table III. Squamous cell tumors account for 66.7 per cent of the cases; of these, 62 per cent are of well-differentiated variety. Transitional cell carcinoma is less common and represents is 26 per cent of cases, and adenocarcinoma rare, constituting only 5 per cent. Survival was calculated using the actuarial technique (Fig. 4A). Postoperative mortalities
TABLE
Period (Years) Ol2345+
550
IV.
TABLE
III. Tumor histology and grade
-GradeHistology Squamous Transitional Adenocarcinoma
Sarcoma
LOW
71 9 1 . . .
High
Total
40 33 6 . . .
111 42 7 2 162
TOTAL
Low-grade tumors had a five-year survival rate of 52.3 per cent while survival with highgrade tumors was only 25.8 per cent, a statistically significant difference (Fig. 4D). Stratification of the cases into four categories according to their stage and grade allows the definition of the relative prognostic importance of these two pathologic parameters. In general the four curves are distributed into two groups. Low-grade tumors had a better survival rate than high-grade tumors, whether they were superficial (P2) or deep (P3 and P4) (Fig. 4E). The regional lymph nodes were involved in 28 cases (17.2 per cent) (Fig. 4F). Cases with
Treatment failures: distribution according to onset and locality
Regional 36 8 5 1 6 2
General
Undetermined
2 2
8 . . . 1 . . . 1 2
. 1 . . 1
UROLOGY
Total
Per Cent
46 10 6 2 7 5
60.5 13.5 7.8 2.6 9.2 6.5
/ DECEMBER1976
/ VOLUMEVIII, NUMBER6
n
SURVIVAL ACTUARIAL
8
SURVIVAL
PATHOLOGICAL
STAGE
80 -
2
\
60 -
60-
----L
:
\
d s 40 -
20
t A
’
I
I
I
L
6
months 12
16
24
,_
L
L
3
years 4
.
I 5
B
I
’
’
I
6
12
18
I
,,
24
i
,
3
4
of Follow
up
5
%
I
I
I
6
12
18
years
months Period
,
Period
of
Folbw
and
FIGURE
Actuwial
4.
Follow
UP
survival
Period
data. (A) Survivd
of
in generul;
Follow
I
I
3
4 years
a Peraod of
:
Follow
ul,
SURVIVAL
8
Grade STATE
Per,od of
I.
”
months
up
SURVIVAL Stage
1
24
OF
LYMPH
NODES
up
vertical bars in&cute
standard
err-or (P = 0.0s).
(B) Survival and tumor histology; squamous and transitional tumors have essentially same survivnl. (C) Survival und pathologic stage. (0) Survival unrl tumor gracle. (Ej Survival and tumor pathologic stage and grade. (F) Survivul and state of lymph nodes.
negative nodes had a significantly better survival rate than those with positive oues. Nevertheless, the radical operation could provide a ZO-per cent survival for patients with positive nodes. Table TV shows the distribution of treatment failures (recurrences and/or metastasis) according to their site and time of onset. Most of the recurrences were local in the pelvis and de-
UROI,OC~-
/
DECEhlRER
1976
/
VOLUhlE
VIII,
veloped within treatment.
twelve
months
after initiation
of
Comment The general technical principles employed are similar to those previously described by Paquin and Marsl~all,4 and El Sebai.’ The operative mortality of 12.9 per cent compares favorably with other reports.5-7 Hotvever, recent
NUSIRER 6
551
:
articles indicate that these figures can be remarkably reduced by staging of the operative procedure. 8 Rectal bladder with a terminal left iliac colostomy was the most common method utilized for urinary diversion. The technique, its justification, and results were reported in a series of previous articles.‘-I’ Analysis of survival figures relative to the various pathologic features of the tumor revealed that squamous and transitional tumors have essentially the same prognosis. It was also demonstrated that the tumor grade is the most critical prognostic index, a fact which was also emphasized by Thompson. I2 The majority of treatment failures were due to local recurrences in the pelvis; moreover, most developed within twelve months after initiation of treatment. These findings strongly suggest that surgical excision alone, despite being radical, was inadequate to deal with the extent of the “local” pathology. An adjuvant line of treatment directed locally to the pelvis may improve survival. Preoperative radiation appears to provide the logical tool. On these bases a prospective randomized study comparing radical cystectomy and 2,000 rad preoperative radiation dose given in five daily fractions followed by cystectomy, is the subject of a current clinical trial.
552
Mansoura University Hospital Mansoura, Egypt (DR. GHONEIM) References 1. MAKAR, N.: “Urological aspects of bilharziasis in Egypt,” S.O.P. Press, Cairo, 1955, pp. 51-83. 2. EL SEBAI, I.: Cancer of the bladder in Egypt, Kasr El Aini J. Surg. 2: 183 (1961). 3. EL-BOLKAINY, M., GHONEIM, M. A., and MANSOUR, M. A.: Carcinoma of the bilharzial bladder in Egypt, Br. J. Urol. 4: 561 (1972). 4. PAQUIN, A. J., and MARSHALL, V. F.: A technique for radical total cystectomy, Cancer 9: 585 (1956). 5. WHITMORE, W. F., JR., and MARSHALL, V. F.: Radical total cystectomy for cancer of the bladder: 230 cases five years later, J. Ural. 87: 853 (1962). 6. SAKATI, I. A., and MARSHALL, V. F.: Post-operative fatalities in urology, J. Urol. 95: 412 (1966). 7. STONES, J. H., and HODGES, C. V.: Radical cystectomy for invasive bladder cancer, ibid. 96: 207 (1966). 8. CRIMES, J. H., HART, J. M., GLENN, J. F., and ANDERSON, E. E.: Staged approach to invasive vesical malignancy, ibid 108: 872 (1972). 9. GHONEI~~,M. A.: The recta-sigmoid bladder for urinary diversion, Br. J. Urol. 42: 429 (1970). 10. GHONEIM, M. A., and ASHAMALLAH, A.: Further experience with the rectosigmoid bladder, ibid. 46: 511 (1974). 11. GHONEIM, ?(f. A., and SHOUKRY, I.: Rectal bladder with perineal colostomy for urinary diversion, Urology 4: 278 (1974). 12. THOMPSON, G. I.: Prognosis in vesical neoplasms, J.A.M.A. 172: 28 (1960).
UROLOGY / DECEMBER 1976 / VOLUME VIII, NUMBER 6
