Vol. 113, February
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1975 by The Williams & Wilkins Co.
RADICAL CYSTECTOMY FOR CARCINOMA OF THE BLADDER: 16 YEARS OF EXPERIENCE JEROME P. RICHIE, DONALD G. SKINNER
AND
JOSEPH J. KAUFMAN
From the Department of Surgery, Division of Urology, University of California School of Medicine, Los Angeles, California
unknown causes were presumed to be dead of disease. Pathologic stage and grade were obtained from the final pathology report. Whenever a question arose the slides were reviewed by a urological pathologist. Survival rates were calculated by computer analysis with life table methods and excluded operative mortality.
The variable nature and aggressive potential of bladder carcinoma pose, in each case in which it is encountered, a therapeutic dilemma: What are the merits of conservative versus radical management? Our review was directed toward a resolution of the difficult question of proper timing for radical cystectomy. METHODS AND MATERIALS
RESULTS
Between 1955 and 1971, 141 patients underwent simple or radical cystectomy at our hospital. The male to female ratio of 3 to 1 was consistent with reports from previous studies. 1-3 The patients ranged in age from 37 to 80 years, with a mean of 59 years. More than 90 per cent had a .history of cigarette smoking. Hematuria was the most common presenting symptom (table 1) and duration of symptoms prior to diagnosis was 5 days to 8 years. In the earlier years of the series irradiation of 5,000 rads was administered during the 4 to 6 weeks preoperatively followed by cystectomy 1 month later. However, more recent patients received 1,600 rads during a 4-day period followed by cystectomy within 10 days. Of the total group of patients 39.7 per cent received the higher dose and 14.2 per cent were given the lower dose. Radical cystectomy with node dissection was performed in 32.6 per cent of patients and without node dissection in 47 .5 per cent. The remaining 19.9 per cent were treated by simple cystectomy. The classic Bricker ureteroileal cutaneous diversion was performed in 51.8 per cent of the cases, 4 the Wallace conjoint anastomosis in 23.4 per cent 5 and ureterosigmoidostomy in 19.9 per cent. Five per cent had other anastomoses, predominantly cutaneous ureterostomy. Ureteral stents (44.7 per cent) were used at the discretion of the surgeon. No patient was lost to followup and those dying of
Although over-all operative mortality was 8.5 per cent, only 1 death has occurred among the last 50 cystectomies. In this last group of 50 patients, preoperative digitalization and postoperative prophylactic anticoagulation were commonly used and represent the main difference in management as compared to the preceding 91 cystectomies. No correlation could be discerned between grade and stage of lesion and operative mortality. Indeed, half of the deaths occurred in patients with stage 0 or A lesions. Of the 12 patients who died urinary leakage was present in 5 and cardiac complications TABLE
1. Presenting symptoms in 141 cases No. Cases
Hematuria Dysuria Frequency Oliguria
Accepted for publication July 12, 1974. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. Supported in part by the University Medical Research Foundation and the Kennedy Foundation. 1 Bowles, W. T. and Silber, I.: Carcinoma of the bladder: a computer analysis of 516 patients. J. Ural., 107: 245, 1972. 2 Stone, J. H. and Hodges, C. V.: Radical cystectomy for invasive bladder cancer. J. Urol., 96: 207, 1966. • Cox, C. E., Cass, A. S. and Boyce, W. H.: Bladder cancer: a 26-year review. J. Urol., 101: 550, 1969. •Bricker, E. M.: Symposium on clinical surgery; bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 5 Wallace, D. M.: Urinary diversion using a conduit: a simplified technique. Brit. J. Urol., 38: 522, 1966.
108 31 12
18
in 3; wound infection and sepsis were contributing factors in 6 cases. Survival time ranged from Oto 17 years, with a mean of 2.5 and a median of 1.1. Errors in preoperative determination of grade were common and in 18.8 per cent the pathologic grade proved to be higher than that estimated from transurethral biopsy. However, in an equal number of patients pathologic grade was lower. Preoperative radiotherapy did not influence change in grade. The clinical stage of these tumors is compared to the pathological stage in table 2. Errors in clinical staging were also common-26.1 per cent were overstaged and 39.6 per cent were understaged. Improvement in stage (overstaging) was significantly higher (p less than 0.02) in patients who received 5,000 rads (table 3) but no difference was noted in those who received 1,600 rads. Of the lesions overstaged 89 per cent were clinical stage 0, A or B,. Of the lesions understaged 51 per cent were B 2 or C. No significant difference in overstag-
186
18?
RADICAL CYSTECTOMY FOR CARCINOMA OF BLADDER TABLE 2.
Pathological Stage No tumor 0
Comparison of clinical and pathological staging Clinical Stage Totals
B,
0
A
1 [3]
9 8 [27] 3
A B,
B, C
D
4
Totals
4
51
B,
C
6
1 [4] 14
15 13 36 7 15 23 25
22
21
134*
4
1 8 [4] 6 12 1 36
[8] 7
* 7 cases-no clinical stage.
TABLE
3. Effect of preoperative radiotherapy on pathological stage Stage Improved (path. stage < clin. stage) No.
1,600 rads 5,000 rads None Over-all
(%)
Stage Worsened (path. stage > clin. stage) No.
(%)
1/19 (5.2) 21/51 (41.2)
15/51 (29.4)
13/64 (20.3) 35/134 (26. I)
53/134 (39.6)
11/19 (57.9) 27/64 (42.2)
ing in relation to clinical grade was detected but higher grade lesions tended to be understaged (table 4). The over-all 5-year survival rate was 44 per cent. As has been previously described 6 - 8 stage was more important than grade in determining survival (table 5). Although traditional emphasis has been placed on invasion of tumor through more than half of the musculature of the bladder," in this series any invasion of muscle significantly decreased the survival rate, irrespective of pathologic grade (table 6). Patients with dysuria unassociated with infection had a lower 5-year survival rate than did those without dysuria (30.1 as compared to 47.3 per cent). Likewise, those with duration of symptoms for more than 6 months prior to diagnosis had a decreased 5-year survival rate (28.6 versus 44.5 per cent). In neither group was there a difference in distribution among the various stages and grades to account for this lower survival rate. The most common complication encountered was wound infection (24.8 per cent), which was significantly lower (p less than 0.01) in patients with classic Bricker diversions (table 7). High dose irradiation was associated with an increased incidence of wound infection. leakage, en6 Jewett, H. J.: Carcinoma of the bladder: influence of depth of infiltration on the 5-year results following complete extirpation of the primary growth. J. Urol., 67: 672, 1952. 7 Cordonnier, J. J.: Value of cystectomy in management of carcinoma of bladder. J. Urol., 77: 432, 1957. 'Long, R. T. L., Grummon, R. A., Spratt, J. S. and Perez-Mesa, C.: Carcinoma of the urinary bladder (comparison with radical, simple, and partial cystectomy and intravesical formalin). Cancer, 29: 98, 1972.
countered in 11 patients, was fatal in remaining 6 patients had an average of 42 days. A higher incidence of urinary was noted in those patients with stents, as well as those with ureterosigmoidostomies. Although monary emboli developed in 3 patients, 1 undergone node dissection. Addition of node section to radical cystectomy did not increase the incidence of cardiac complications. No significant difference in operative was seen for patients treated by simple cystectomy (10.7 per cent), by radical cystectomy (Hi per cent) or by radical cystectomy plus node dissecticrn (8.7 per cent). In patients most likely to have a difficult postoperative course for reasons of high dose irradiation, marked obesity or associated diseases, a staged procedure of urinary diversion was fol-lowed by cystectomy 3 months later. Although 5 such difficult cases were so treated the mortality was zero and the single complication was a wound infection. This staggered sents a valuable adjunct for certain patients. Three of 12 patients with stage D 1 lesions treated with radical cystectomy and node dissection survived at least 3 years. DISCUSSION
Although low grade and low stage tumors can be treated adequately by conservative methods, the 4. Effect of grading on understaging
TABLE
Grade
TABLE
% Understaged
I
12.5
II III
26.7
34.5
IV
65.2
5. Correlation of pathologic grade and stage with 5-year survival
Grade No tumor I II
78.2
50.0 58.6
III IV
?+.
No tumor 0
78.2 65.6 86.4 39.9
A
B, B,
37.2 36.3 42.6
Squamous
TABLE 6.
Stage
%
40.4
C D
19.1 6.2
Pathologic stages and 5-year survival
Stage Survival(%)
B,,B 2 OA 78.6 40.0 p < 0.01
C
D
19.7
6.2
Stage(%) Grade
All I-II Ill-IV
* 5 patients only.
OA,B,
B,,C. D
74.0 68.9
18.0 0.0*
80.6
15 0
188 TABLE
RICHIE, SKINNER AND KAUFMAN
7. Incidence of postoperative complications in 141 patients: correlation with preoperative and intraoperative parameters Wound Infection Parameters
No.
(%)
Bowel
Cardiac
No.
(%)
No.
(%)
No.
(%)
11 (7.8)
8 (5.6)
11 (7.8)
11 (15.1) 13 (39.4) 11 (39.3)
5 (6.8) 2 (6.1) 4 (14.3)
4 (5.4) 4 (12.1) 0 (0.0)
5 (6.8) 2 (6.1) 3 (10.7) 1 (14.3)
63 78
14 (22.2) 21 (26.9)
7 (11.1) 4 (5.1)
5 (7.9) 3 (3.8)
3 (4.8) 8 (10.1)
28 67 46
9 (32.1) 15 (22.4) 11 (23.9)
5 (17 .9) 3 (4.5) 3 (6.5)
0 (0.0) 4 (6.0) 4 (8.7)
3 (10.7) 5 (7.4) 3 (6.5)
65 20 56
14 (21.5) 4 (20.0) 17 (30.4)
3 (4.6) 1 (5.0) 7 (12.5)
2 (3.1) 2 (10.0) 4 (7.1)
7 (10.8) 1 (5.0) 3 (5.4)
35 (24.8) Type diversion: Classic Wallace Ureterosig. Other Stents: With Without Cystectomy: Simple Radical Rad. plus nodes Radiation: None 1,600 rads 5,000 rads
Urine Leak
No. Pts.
73 33 28 7
natural history of bladder tumors is such that, at some point in time, the relatively innocuous tumor may change and become more aggressive, either by histologic dedifferentiation or by extension into the deeper tissues of the bladder. If the exact moment of this theoretical transformation could be predicted accurately, the question of proper timing for radical cystectomy would be eliminated. Since such is not the case the urologist must decide when to treat by transurethral resection and conservative management, leaving the patient at risk from his tumor, or when to treat radically, placing the patient at risk from operative intervention. One pertinent finding from this series was that higher grade lesions tend to be higher stage and are more frequently understaged. Whitmore and Marshall reviewed 230 cases of radical cystectomy and reported understaging in only 1 of 30 low grade lesions but in 15 of 34 high grade lesions. 9 Prognosis correlated more closely with stage of tumor rather than histologic grade. Although Jewett's classic study demonstrated a marked decrease in survival when the tumor had invaded more than halfway through the muscle layer, 6 the present study reveals a significantly decreased survival with any evidence of muscle invasion. No difference was noted in B 1 versus B 2 lesions. The decreased survival rate in patients with dysuria cannot be explained by differences in stage and grade of lesion. In a previous report 74 per cent of 29 patients with dysuria were found to have carcinoma in situ in their cystectomy specimens. 10 These findings suggest that the symptoms of dysuria may represent some unrecognized infiltration or irritation associated with a tendency to
earlier penetration and spread of tumor or that the carcinoma in situ per se predisposes to recurrence and spread. Certainly patients presenting with dysuria who are found to have bladder tumor should be closely scrutinized, random biopsies taken and consideration given for earlier cystectomy. In our series neither operative morbidity nor operative mortality was significantly altered by radical cystectomy and pelvic lymph node dissection compared to patients treated by simple cystectomy or radical cystectomy without lymph node dissection. Three patients with stage D 1 lesions have survived at least 3 years and lend support to other reports in the literature, suggesting that lymph node dissection can safely improve the prognosis for some patients afflicted with advanced carcinoma of the bladder. 11 , 12 Although the number of patients in the series with squamous cell carcinoma is small, their survival rate of 42 per cent is encouraging. In addition, all of these patients had B 1 or higher stage lesions. We believe that the recent decrease in operative mortality can be attributed to improved fluid management, preoperative digitalization and postoperative anticoagulation therapy. This marked improvement in mortality has allowed a more aggressive attitude toward the management of bladder carcinoma.
: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. 10 Skinner, D. G., Richie, J.P., Cooper, P. H., Waisman, J. and Kaufman, J. J.: The clinical significance of carcinoma in situ of the bladder and its association with overt carcinoma. J. Urol., 112: 68, 1974.
11 Dretler, S. P., Ragsdale, B. D. and Leadbetter, W. F., Jr.: The value of pelvic lymphadenectomy in the surgical treatment of bladder cancer. J. Urol., 109: 414, 1973. 12 DeCenzo, J. M. and Leadbetter, G. W., Jr.: Survival with stage D bladder carcinoma. Surgical improvement. Urology, 3: 221, 1974.
SUMMARY
The records of 141 consecutive patients who underwent simple or radical cystectomy between 1955 and 1971 were reviewed. Symptoms, interval before diagnosis, and stage and grade of lesion were
RADICAL CYSTECTOMY FOR CARCINOMA OF BLADDER
analyzed and correlated with survival rates. Although stage was the most critical determinant of survival, grade, presence or absence of dysuria and delay in diagnosis were also important. Preoperative radiotherapy caused downstaging in 41.2 per cent of patients, with complete disappearance of tumor in some. Postoperative complications from cystectomy
189
and from various forms of urinary diversion were correlated with the type of diversion, type ureteral anastomosis, radiotherapy and stents. Improved operative techniques, method of fluid balance, and preoperative and postoperative care have led to a progressively decreased mortality in patients with carcinoma of the bladder.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1975 by The Williams & Wilkins Co.
RADICAL CYSTECTOMY FOR CARCINOMA OF THE BLADDER: 16 YEARS OF EXPERIENCE JEROME P. RICHIE, DONALD G. SKINNER
AND
JOSEPH J. KAUFMAN
From the Department of Surgery, Division of Urology, University of California School of Medicine, Los Angeles, California
unknown causes were presumed to be dead of disease. Pathologic stage and grade were obtained from the final pathology report. Whenever a question arose the slides were reviewed by a urological pathologist. Survival rates were calculated by computer analysis with life table methods and excluded operative mortality.
The variable nature and aggressive potential of bladder carcinoma pose, in each case in which it is encountered, a therapeutic dilemma: What are the merits of conservative versus radical management? Our review was directed toward a resolution of the difficult question of proper timing for radical cystectomy. METHODS AND MATERIALS
RESULTS
Between 1955 and 1971, 141 patients underwent simple or radical cystectomy at our hospital. The male to female ratio of 3 to 1 was consistent with reports from previous studies. 1-3 The patients ranged in age from 37 to 80 years, with a mean of 59 years. More than 90 per cent had a .history of cigarette smoking. Hematuria was the most common presenting symptom (table 1) and duration of symptoms prior to diagnosis was 5 days to 8 years. In the earlier years of the series irradiation of 5,000 rads was administered during the 4 to 6 weeks preoperatively followed by cystectomy 1 month later. However, more recent patients received 1,600 rads during a 4-day period followed by cystectomy within 10 days. Of the total group of patients 39.7 per cent received the higher dose and 14.2 per cent were given the lower dose. Radical cystectomy with node dissection was performed in 32.6 per cent of patients and without node dissection in 47 .5 per cent. The remaining 19.9 per cent were treated by simple cystectomy. The classic Bricker ureteroileal cutaneous diversion was performed in 51.8 per cent of the cases, 4 the Wallace conjoint anastomosis in 23.4 per cent 5 and ureterosigmoidostomy in 19.9 per cent. Five per cent had other anastomoses, predominantly cutaneous ureterostomy. Ureteral stents (44.7 per cent) were used at the discretion of the surgeon. No patient was lost to followup and those dying of
Although over-all operative mortality was 8.5 per cent, only 1 death has occurred among the last 50 cystectomies. In this last group of 50 patients, preoperative digitalization and postoperative prophylactic anticoagulation were commonly used and represent the main difference in management as compared to the preceding 91 cystectomies. No correlation could be discerned between grade and stage of lesion and operative mortality. Indeed, half of the deaths occurred in patients with stage 0 or A lesions. Of the 12 patients who died urinary leakage was present in 5 and cardiac complications TABLE
1. Presenting symptoms in 141 cases No. Cases
Hematuria Dysuria Frequency Oliguria
Accepted for publication July 12, 1974. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. Supported in part by the University Medical Research Foundation and the Kennedy Foundation. 1 Bowles, W. T. and Silber, I.: Carcinoma of the bladder: a computer analysis of 516 patients. J. Ural., 107: 245, 1972. 2 Stone, J. H. and Hodges, C. V.: Radical cystectomy for invasive bladder cancer. J. Urol., 96: 207, 1966. • Cox, C. E., Cass, A. S. and Boyce, W. H.: Bladder cancer: a 26-year review. J. Urol., 101: 550, 1969. •Bricker, E. M.: Symposium on clinical surgery; bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 5 Wallace, D. M.: Urinary diversion using a conduit: a simplified technique. Brit. J. Urol., 38: 522, 1966.
108 31 12
18
in 3; wound infection and sepsis were contributing factors in 6 cases. Survival time ranged from Oto 17 years, with a mean of 2.5 and a median of 1.1. Errors in preoperative determination of grade were common and in 18.8 per cent the pathologic grade proved to be higher than that estimated from transurethral biopsy. However, in an equal number of patients pathologic grade was lower. Preoperative radiotherapy did not influence change in grade. The clinical stage of these tumors is compared to the pathological stage in table 2. Errors in clinical staging were also common-26.1 per cent were overstaged and 39.6 per cent were understaged. Improvement in stage (overstaging) was significantly higher (p less than 0.02) in patients who received 5,000 rads (table 3) but no difference was noted in those who received 1,600 rads. Of the lesions overstaged 89 per cent were clinical stage 0, A or B,. Of the lesions understaged 51 per cent were B 2 or C. No significant difference in overstag-
186
18?
RADICAL CYSTECTOMY FOR CARCINOMA OF BLADDER TABLE 2.
Pathological Stage No tumor 0
Comparison of clinical and pathological staging Clinical Stage Totals
B,
0
A
1 [3]
9 8 [27] 3
A B,
B, C
D
4
Totals
4
51
B,
C
6
1 [4] 14
15 13 36 7 15 23 25
22
21
134*
4
1 8 [4] 6 12 1 36
[8] 7
* 7 cases-no clinical stage.
TABLE
3. Effect of preoperative radiotherapy on pathological stage Stage Improved (path. stage < clin. stage) No.
1,600 rads 5,000 rads None Over-all
(%)
Stage Worsened (path. stage > clin. stage) No.
(%)
1/19 (5.2) 21/51 (41.2)
15/51 (29.4)
13/64 (20.3) 35/134 (26. I)
53/134 (39.6)
11/19 (57.9) 27/64 (42.2)
ing in relation to clinical grade was detected but higher grade lesions tended to be understaged (table 4). The over-all 5-year survival rate was 44 per cent. As has been previously described 6 - 8 stage was more important than grade in determining survival (table 5). Although traditional emphasis has been placed on invasion of tumor through more than half of the musculature of the bladder," in this series any invasion of muscle significantly decreased the survival rate, irrespective of pathologic grade (table 6). Patients with dysuria unassociated with infection had a lower 5-year survival rate than did those without dysuria (30.1 as compared to 47.3 per cent). Likewise, those with duration of symptoms for more than 6 months prior to diagnosis had a decreased 5-year survival rate (28.6 versus 44.5 per cent). In neither group was there a difference in distribution among the various stages and grades to account for this lower survival rate. The most common complication encountered was wound infection (24.8 per cent), which was significantly lower (p less than 0.01) in patients with classic Bricker diversions (table 7). High dose irradiation was associated with an increased incidence of wound infection. leakage, en6 Jewett, H. J.: Carcinoma of the bladder: influence of depth of infiltration on the 5-year results following complete extirpation of the primary growth. J. Urol., 67: 672, 1952. 7 Cordonnier, J. J.: Value of cystectomy in management of carcinoma of bladder. J. Urol., 77: 432, 1957. 'Long, R. T. L., Grummon, R. A., Spratt, J. S. and Perez-Mesa, C.: Carcinoma of the urinary bladder (comparison with radical, simple, and partial cystectomy and intravesical formalin). Cancer, 29: 98, 1972.
countered in 11 patients, was fatal in remaining 6 patients had an average of 42 days. A higher incidence of urinary was noted in those patients with stents, as well as those with ureterosigmoidostomies. Although monary emboli developed in 3 patients, 1 undergone node dissection. Addition of node section to radical cystectomy did not increase the incidence of cardiac complications. No significant difference in operative was seen for patients treated by simple cystectomy (10.7 per cent), by radical cystectomy (Hi per cent) or by radical cystectomy plus node dissecticrn (8.7 per cent). In patients most likely to have a difficult postoperative course for reasons of high dose irradiation, marked obesity or associated diseases, a staged procedure of urinary diversion was fol-lowed by cystectomy 3 months later. Although 5 such difficult cases were so treated the mortality was zero and the single complication was a wound infection. This staggered sents a valuable adjunct for certain patients. Three of 12 patients with stage D 1 lesions treated with radical cystectomy and node dissection survived at least 3 years. DISCUSSION
Although low grade and low stage tumors can be treated adequately by conservative methods, the 4. Effect of grading on understaging
TABLE
Grade
TABLE
% Understaged
I
12.5
II III
26.7
34.5
IV
65.2
5. Correlation of pathologic grade and stage with 5-year survival
Grade No tumor I II
78.2
50.0 58.6
III IV
?+.
No tumor 0
78.2 65.6 86.4 39.9
A
B, B,
37.2 36.3 42.6
Squamous
TABLE 6.
Stage
%
40.4
C D
19.1 6.2
Pathologic stages and 5-year survival
Stage Survival(%)
B,,B 2 OA 78.6 40.0 p < 0.01
C
D
19.7
6.2
Stage(%) Grade
All I-II Ill-IV
* 5 patients only.
OA,B,
B,,C. D
74.0 68.9
18.0 0.0*
80.6
15 0
188 TABLE
RICHIE, SKINNER AND KAUFMAN
7. Incidence of postoperative complications in 141 patients: correlation with preoperative and intraoperative parameters Wound Infection Parameters
No.
(%)
Bowel
Cardiac
No.
(%)
No.
(%)
No.
(%)
11 (7.8)
8 (5.6)
11 (7.8)
11 (15.1) 13 (39.4) 11 (39.3)
5 (6.8) 2 (6.1) 4 (14.3)
4 (5.4) 4 (12.1) 0 (0.0)
5 (6.8) 2 (6.1) 3 (10.7) 1 (14.3)
63 78
14 (22.2) 21 (26.9)
7 (11.1) 4 (5.1)
5 (7.9) 3 (3.8)
3 (4.8) 8 (10.1)
28 67 46
9 (32.1) 15 (22.4) 11 (23.9)
5 (17 .9) 3 (4.5) 3 (6.5)
0 (0.0) 4 (6.0) 4 (8.7)
3 (10.7) 5 (7.4) 3 (6.5)
65 20 56
14 (21.5) 4 (20.0) 17 (30.4)
3 (4.6) 1 (5.0) 7 (12.5)
2 (3.1) 2 (10.0) 4 (7.1)
7 (10.8) 1 (5.0) 3 (5.4)
35 (24.8) Type diversion: Classic Wallace Ureterosig. Other Stents: With Without Cystectomy: Simple Radical Rad. plus nodes Radiation: None 1,600 rads 5,000 rads
Urine Leak
No. Pts.
73 33 28 7
natural history of bladder tumors is such that, at some point in time, the relatively innocuous tumor may change and become more aggressive, either by histologic dedifferentiation or by extension into the deeper tissues of the bladder. If the exact moment of this theoretical transformation could be predicted accurately, the question of proper timing for radical cystectomy would be eliminated. Since such is not the case the urologist must decide when to treat by transurethral resection and conservative management, leaving the patient at risk from his tumor, or when to treat radically, placing the patient at risk from operative intervention. One pertinent finding from this series was that higher grade lesions tend to be higher stage and are more frequently understaged. Whitmore and Marshall reviewed 230 cases of radical cystectomy and reported understaging in only 1 of 30 low grade lesions but in 15 of 34 high grade lesions. 9 Prognosis correlated more closely with stage of tumor rather than histologic grade. Although Jewett's classic study demonstrated a marked decrease in survival when the tumor had invaded more than halfway through the muscle layer, 6 the present study reveals a significantly decreased survival with any evidence of muscle invasion. No difference was noted in B 1 versus B 2 lesions. The decreased survival rate in patients with dysuria cannot be explained by differences in stage and grade of lesion. In a previous report 74 per cent of 29 patients with dysuria were found to have carcinoma in situ in their cystectomy specimens. 10 These findings suggest that the symptoms of dysuria may represent some unrecognized infiltration or irritation associated with a tendency to
earlier penetration and spread of tumor or that the carcinoma in situ per se predisposes to recurrence and spread. Certainly patients presenting with dysuria who are found to have bladder tumor should be closely scrutinized, random biopsies taken and consideration given for earlier cystectomy. In our series neither operative morbidity nor operative mortality was significantly altered by radical cystectomy and pelvic lymph node dissection compared to patients treated by simple cystectomy or radical cystectomy without lymph node dissection. Three patients with stage D 1 lesions have survived at least 3 years and lend support to other reports in the literature, suggesting that lymph node dissection can safely improve the prognosis for some patients afflicted with advanced carcinoma of the bladder. 11 , 12 Although the number of patients in the series with squamous cell carcinoma is small, their survival rate of 42 per cent is encouraging. In addition, all of these patients had B 1 or higher stage lesions. We believe that the recent decrease in operative mortality can be attributed to improved fluid management, preoperative digitalization and postoperative anticoagulation therapy. This marked improvement in mortality has allowed a more aggressive attitude toward the management of bladder carcinoma.
: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. 10 Skinner, D. G., Richie, J.P., Cooper, P. H., Waisman, J. and Kaufman, J. J.: The clinical significance of carcinoma in situ of the bladder and its association with overt carcinoma. J. Urol., 112: 68, 1974.
11 Dretler, S. P., Ragsdale, B. D. and Leadbetter, W. F., Jr.: The value of pelvic lymphadenectomy in the surgical treatment of bladder cancer. J. Urol., 109: 414, 1973. 12 DeCenzo, J. M. and Leadbetter, G. W., Jr.: Survival with stage D bladder carcinoma. Surgical improvement. Urology, 3: 221, 1974.
SUMMARY
The records of 141 consecutive patients who underwent simple or radical cystectomy between 1955 and 1971 were reviewed. Symptoms, interval before diagnosis, and stage and grade of lesion were
RADICAL CYSTECTOMY FOR CARCINOMA OF BLADDER
analyzed and correlated with survival rates. Although stage was the most critical determinant of survival, grade, presence or absence of dysuria and delay in diagnosis were also important. Preoperative radiotherapy caused downstaging in 41.2 per cent of patients, with complete disappearance of tumor in some. Postoperative complications from cystectomy
189
and from various forms of urinary diversion were correlated with the type of diversion, type ureteral anastomosis, radiotherapy and stents. Improved operative techniques, method of fluid balance, and preoperative and postoperative care have led to a progressively decreased mortality in patients with carcinoma of the bladder.
