SCIENTIFIC ARTICLES
HYPERBILIRUBINEMIA AFTER SINGLE-STAGE RADICAL CYSTECTOMY AND ILEAL LOOP DIVERSION EDWARD B. RUBENSTEIN, M.D. MYRNA KHAN, M.S. PRISCILLA ALFARO, B.S. DOUGLAS E. JOHNSON, M.D. From the Departments of Medical Specialties and UrologT. The University of Texas M. D. Anderson Cancer Center, Houston, Texas
and il•Eii!oop R AhundredCninety-twoT patients- underwent - single-stage O nradical cystectomy e diversion over a three-year period. Postoperative hyperbilirubinemia occurred in 21 paII}~ts(lO.9 %) within the first ten days. Early hyperbilirubinemia occurred in 11 patients by posti~iative day 5, accounting for 52 percent of the hyperbilirubinemic patients and 5.7 percent of the ~[,idy~population. Elevation persisted into the six to ten-day postoperative period for 9 at which ~ i ~ a total of 18 patients had bilirubin levels elevated above their presurgical values (P < 0.001). S!blinical observation appears to be benign and worthy of further investigation.
¢ with an ileal loop diversion Lment for invasive carcinoma •y tract. 1 We have previously ~ions of this procedure in 214 ee and one-half-year period. 2 is included wound infection, :liac problems, prolonged il3f other surgical and medical 9mplications included pyelo~ral ureteral obstruction, 2 Ld intestinal obstruction. We ~ilirubinemia as an expected ; procedure in a significant (P tage of patients. We also aanges in liver enzymes that lsequence of radical cystec,wledge, hyperbilirubinemia ~tomy has not been reported amatic jaundice, which octients, warrants little investi~iated with other symptoms. Material and Methods ~ i O n e hundred ninety-two patients underwent ~ d i e a l cystectomy with ileal loop diversion
D
OLOGY
]
MAI:ICII 1990
;
V O L U M E XXX\q NUMBER 3
from January, 1983, through December, 1985, at The University of Texas M. D. Anderson Cancer Center. We have retrospectively reviewed the charts, looking at certain variables believed related to or predictive for the development of postcystectomy hyperbilirubinemia. These included preoperative age; levels of serum glutamic oxaloacetic transaminase (SGOT), total bilirubin, and alkaline phosphatase; history of prior liver or gallbladder disease; and the number of units of blood transfused during surgery. We then looked at the levels of SGOT, alkaline phosphatase, and bilirubin two to five days postoperatively and six to ten days after surgery. For purposes of our study we considered total bilirubin >__ 2.0 mg/dL as the operational definition of hyperbilirubinemia.
Statistical analysis Data were analyzed using the computerized Statistical Package for the Social Sciences (SPSSX). Linear regression and discriminate analysis were used to evaluate whether or not any of the variables was a significant predictor of hyperbilirubinemia. The paired Student 205
10 r
7O
Mean = .393 Median
~0
N =
=
9 "
.300
Mean = 3.52 ~ledl~n = 2.8 N = 21
i
192
~i
50 4o
[4
.: 3o 13"
5
P t,. 20
i
=
2
i
=
=
•
lO~, i
As"
.2
.3
.4
.5
= .7
.6
4 .8
1 I .9
2.1
2.2
2.3
2.5
2.7
Blllrubln Levels
2.8 3.2 3.5 Blllrubln Levels
,5.8
~.9
6~6.! , 'i
5
5 Mean = 2.44 Median = 2.3 N =7
Moo. = 6 . s s 4
k4ed[an = 6.~ / N = 4 ....;:.
il I
it
O"
.=
P
ta.
b-
1
1
Co
---
2.1
2.2
2.3 BIHrubln Levels
2.8
Do
3.2
5.8
6.0 6.8 91llrubln Levels
5 F ~ean = S.02 ~;) t~,edlon = 4.9 5
Mean = 2.71 Median = 2.7 N = 13
tT t~
1
Eo L l
2.2
2.3
2.5
lille
2.7 2.8 3.0 BIIIrubln Levels
3.2
3.4
*t nun_un n ,o
3.5
.
.
.
3.8
.
.
.
4.1
.
4.9 Blllrubln Levels
7.4
9:9, ;: ;
.2 2
Bilirubin levels: (A) precystectomy, (B) two days pos~cystectomy, (C) two to five days tomy (range: 2.0 to 3.5), (D) two to five days postcystectomy (range: >3.5), (E) six to ten day,s tomy (range: 2.0 to 3.5), (F) six to ten days postcystectomy (range: >3.5).
F 1 G U R E 1.
t-test was used to determine significant differences between preoperative, two to five-day, and six to ten-day postoperative levels of bilirubin, SGOT, and alkaline phosphatase. P values were calculated for each analysis and were considered statistically significant when P < 0.05. Results The overall incidence of postcystectomy hyperbilirubinemia was 10.9 percent (21/192; Fig. 1A, B). Of the 21 patients in whom hyperbilirubinemia developed postoperatively, it occurred by postoperative day 5 in 11 (52 %) (Fig. 1C, D). Hyperbilirubinemia persisted in 9 of 206
these 11 patients into postoperative days 6i~ 10; the tenth patient's bilirubin level r e t u r ~ to normal, and data were not available f o r i ~ eleventh. Late postcystectomy hyperbilirub:i~i~ mia occurred in 9 patients (43 %). One patie~ bilirubin level at six to ten days after surge was 3.5 mg/dL, but no value was recorde~[-! two to five days, and therefore this patient c~ not be included in the exclusively late group, ~ other words, 18 of the 21 patients had h ~ bilirubinemia almost one week after surg (Fig. 1E, F). ~':i~ In analyzing the variables possibly relatea~ hyperbilirubinemia, we found that the rne~ UROLOGY
/
M A R C H 1990
/
VOLUMI~" XXXV, NUMBE~?~:;~
TABLE I, ~t
Patient Group ients ~- ---- -i-92)
Analysis' oJ variables --Level Mean
of Variable Range
64.2 yrs 79.8 U/dL 9.8 0.365 mg/dL
36.6-83.8 yrs 0.5-188 U/dL 2-71 0.1-0.9 mg/dL
~Pl:eop alkaline phosphatase level ::::No. units blood : )Preep bilirubin
65.7 yrs 83.4 U/dL 11.9 0.518 mg/dL
55.1-76.1 yrs 40-126 U/dL 6-39 0.2-0.8 mg/dL
~t0p day 6-10 )~flirubin > 2.0 mg/dL (n = 18) ::!:Age :i~Preop alkaline phosphatase level ~:! :No. units of blood ~!:!i~!;.Preopbilirubin
57.2 yrs 81.4 U/dL 14.4 0.461 mg/dL
36.6-74.5 yrs 47-126 U/dL 6-39 0.2-0.8 mg/dL
days 2-10 ~bihrubin > 2.0 mg/dL (n = 21) [~).: age ~,:;;~!!~reop aklaline phosphatase level [i:~)iNo. units blood '~ ~.Treop bilirubin
59.2 yrs 79.4 U/dL 13.8 0.457 mg/dL
36.6-76.1 yrs 40-126 U/dL 6-39 0.2-0.8 mg/dL
Age Wpreop alkaline phosphatase level ~i:N0, units blood l:~reo ~ bilirubin level
~
ostop days 2-5 Nlirubin > 2.0 mg/dL (n = 11)
Paired Student t-test analysis of bilirubin levels Bflirubin Level (mg/dL) Mean + SD t df TAm~F.II.
~,~:_.,',L,~./tjy!mr'~'" i
MAI~CH t990
/
Whole group (n -- 192) Preop 2-5 days postop Preop 6-10 days postop 2-5 days postop 6-10 days postop
0.365 0.942 0.362 1.13 0.939 1.16
_ 0.161 +__ 1.11 _+ 0.160 _+ 1.17 _ 1.12 ± 1.19
Nonelevated group (n = 171) Preop 2-5 days postop Preop 6-10 days postop 2-5 days postop 6-10 days postop
0.352 0.733 0.351 0.949 0.737 0.977
± 0.150 ___ 0.398 _ 0,153 +_ 0.698 _+ 0.391 ___ 0.711
Elevated group (n = 21) Preop 2-5 days postop Preop 6-10 days postop 2-5 days postop 6-10 days postop
0.455 2.57 0.440 3.40 2,56 3.39
__. 0.211 _ 2.46 _.+ 0.196 _+ 2.04 +_ 2.52 _ 2.10
V O L U M E XXXV, N U M g E R 3
P
6.73
157
< 0.001
8.81
169
< 0.001
3.25
151
0.001
11.39
147
< 0.001
10.98
159
< 0.001
4.06
143
< 0.001
3.99
19
0.001
6,60
19
< 0.001
i.89
18
0.074
207
Pre-Cystectomy Values 160
1.5 1.~, 1.2 1.1 t~
_.E2
t
1.3
1.0
-LIO0 ' 80 O
,~
so
.J~ a. R O tO.
,, 20
ao
g
40
n.
2O
"~
.D
3
•> ~
.~
2
2
Bo
1
2
3
4
5
S 7
8
9 10 11 12 13 14 15 16 17 18
°
age of the patient population was 64.2 years (range 36.6-83.8 years). Age did not seem to correlate with bilirubin level. The mean number of blood units transfused was 9.8 (range from 2-71 units), and the correlation between blood units transfused and the development of postcystectomy hyperbilirubinemia was significant (P < 0.001). The mean preoperative alkaline phosphatase level was 79.8 U/dL (range 0.5-188 U). In the patients with bilirubin levels > 2 mg/dL at two to five days after surgery, the mean preoperative alkaline phosphatase level was 83.4 U/dL (range 40-126). In the patients with bilirubin > 2 mg/dL at six to ten days after surgery, the mean preoperative alkaline phosphatase level was 81.4 U/dL (range 47-126) (Table I). Levels of bilirubin were higher in the entire group of patients at two to five and six to ten days posteystectomy than they had been preoperatively. Student t-test paired analysis of the patients whose bilirubin levels did not exceed 2 mg/dL postoperatively showed significant dif-
208
~
1
C"
ferences between oreoDerative and two to five~ day postoperative bilirubin levels (P < 0.001)i~ This correlation also held true for the six to teri~i day postoperative group (P < 0.001) (Table IIi;~ Results were similar for levels of SGOT and ~ kaline phosphatase. Figure 2 shows paire~ values for the 18 patients with hyperbilirubin~!! mia during the two to five and six to ten-dayi postoperative period. :i~ None of the 192 patients had a history of hver • e'i~:~ disease. Sixteen had had gallbladder dlseas but none of these had bilirubin levels > 2.0 mgi:!i dL postcystectomy. :~ : :? Comment
: : Postcysteetomy hyperbilirubinemia occurredi in 10.9 percent of the patients investigated• Be~'il cause we employed a strict criterion for repor ~;: ing hyperbflirubinemia, i, e., a bilirubin level o}: 2.0 mg/dL or greater, we are underestimatirl~ the actual incidence of this development. AI~'~ though there was a correlation between the:~i UROI,OGY
/
MARCH
1990
/
V O I , U M E XXXV; NU MBEtt~!!
of hyperbilirubinemia and the Nod units transfused, this was not evated levels of SCOT and biliru;xplained by the metabolism of the Ilood cells transfused during sursignificant rise of alkaline phos~ially in those without elevated Lds to indicate a different mechae to consider anesthetic agents, lrgery, and preoperative and post]ications limits our ability to draw bout the pathophysiology of postyperbilirubinemia. Furthermore, division of data into two sampling nd to skew our findings by repretrly and late phase of postcystecilirubinemia. Nevertheless, jauna a significant number of patients radical eystectomy with ileal loop occurrence should be anticipated, not be considered an indicator of
.-",*,-,i
] MARCH 1990 i
VOLUME XXXV, NUMBER 3
serious hepatobiliary disease unless the patient's condition warrants further investigation. Section of General Internal Medicine Box 40 UT M. D. Anderson Cancer Center 1515 Holcombe Boulevard Houston, Texas 77030 (DR. RUBENSTEIN) References 1. BredinHC, andProutGR: One-stageradical cysteetomy for bladder carcinoma: operative mortality, cost~benefit analysis, J Urol 117:447 (1977). g. Johnson EE, and Lamy SM: Complications of a single stage radical cysteetomy and ileal conduit diversion: review of 214 eases, ] Urol 117:171 (1977). 3. Bracken RB, McDonald M, and Johnson DE: Complications of single-stage radical eystectomy and/lea/conduit, Urology 17: 141 (1981). 4. Skinner DG, Crawford ED, and Kaufman jJ: Coraplications of radical eysteetomy for carcinoma of the bladder, J Urol 19.3:640 (1980).
209
HYPERBILIRUBINEMIA AFTER SINGLE-STAGE RADICAL CYSTECTOMY AND ILEAL LOOP DIVERSION EDWARD B. RUBENSTEIN, M.D. MYRNA KHAN, M.S. PRISCILLA ALFARO, B.S. DOUGLAS E. JOHNSON, M.D. From the Departments of Medical Specialties and UrologT. The University of Texas M. D. Anderson Cancer Center, Houston, Texas
and il•Eii!oop R AhundredCninety-twoT patients- underwent - single-stage O nradical cystectomy e diversion over a three-year period. Postoperative hyperbilirubinemia occurred in 21 paII}~ts(lO.9 %) within the first ten days. Early hyperbilirubinemia occurred in 11 patients by posti~iative day 5, accounting for 52 percent of the hyperbilirubinemic patients and 5.7 percent of the ~[,idy~population. Elevation persisted into the six to ten-day postoperative period for 9 at which ~ i ~ a total of 18 patients had bilirubin levels elevated above their presurgical values (P < 0.001). S!blinical observation appears to be benign and worthy of further investigation.
¢ with an ileal loop diversion Lment for invasive carcinoma •y tract. 1 We have previously ~ions of this procedure in 214 ee and one-half-year period. 2 is included wound infection, :liac problems, prolonged il3f other surgical and medical 9mplications included pyelo~ral ureteral obstruction, 2 Ld intestinal obstruction. We ~ilirubinemia as an expected ; procedure in a significant (P tage of patients. We also aanges in liver enzymes that lsequence of radical cystec,wledge, hyperbilirubinemia ~tomy has not been reported amatic jaundice, which octients, warrants little investi~iated with other symptoms. Material and Methods ~ i O n e hundred ninety-two patients underwent ~ d i e a l cystectomy with ileal loop diversion
D
OLOGY
]
MAI:ICII 1990
;
V O L U M E XXX\q NUMBER 3
from January, 1983, through December, 1985, at The University of Texas M. D. Anderson Cancer Center. We have retrospectively reviewed the charts, looking at certain variables believed related to or predictive for the development of postcystectomy hyperbilirubinemia. These included preoperative age; levels of serum glutamic oxaloacetic transaminase (SGOT), total bilirubin, and alkaline phosphatase; history of prior liver or gallbladder disease; and the number of units of blood transfused during surgery. We then looked at the levels of SGOT, alkaline phosphatase, and bilirubin two to five days postoperatively and six to ten days after surgery. For purposes of our study we considered total bilirubin >__ 2.0 mg/dL as the operational definition of hyperbilirubinemia.
Statistical analysis Data were analyzed using the computerized Statistical Package for the Social Sciences (SPSSX). Linear regression and discriminate analysis were used to evaluate whether or not any of the variables was a significant predictor of hyperbilirubinemia. The paired Student 205
10 r
7O
Mean = .393 Median
~0
N =
=
9 "
.300
Mean = 3.52 ~ledl~n = 2.8 N = 21
i
192
~i
50 4o
[4
.: 3o 13"
5
P t,. 20
i
=
2
i
=
=
•
lO~, i
As"
.2
.3
.4
.5
= .7
.6
4 .8
1 I .9
2.1
2.2
2.3
2.5
2.7
Blllrubln Levels
2.8 3.2 3.5 Blllrubln Levels
,5.8
~.9
6~6.! , 'i
5
5 Mean = 2.44 Median = 2.3 N =7
Moo. = 6 . s s 4
k4ed[an = 6.~ / N = 4 ....;:.
il I
it
O"
.=
P
ta.
b-
1
1
Co
---
2.1
2.2
2.3 BIHrubln Levels
2.8
Do
3.2
5.8
6.0 6.8 91llrubln Levels
5 F ~ean = S.02 ~;) t~,edlon = 4.9 5
Mean = 2.71 Median = 2.7 N = 13
tT t~
1
Eo L l
2.2
2.3
2.5
lille
2.7 2.8 3.0 BIIIrubln Levels
3.2
3.4
*t nun_un n ,o
3.5
.
.
.
3.8
.
.
.
4.1
.
4.9 Blllrubln Levels
7.4
9:9, ;: ;
.2 2
Bilirubin levels: (A) precystectomy, (B) two days pos~cystectomy, (C) two to five days tomy (range: 2.0 to 3.5), (D) two to five days postcystectomy (range: >3.5), (E) six to ten day,s tomy (range: 2.0 to 3.5), (F) six to ten days postcystectomy (range: >3.5).
F 1 G U R E 1.
t-test was used to determine significant differences between preoperative, two to five-day, and six to ten-day postoperative levels of bilirubin, SGOT, and alkaline phosphatase. P values were calculated for each analysis and were considered statistically significant when P < 0.05. Results The overall incidence of postcystectomy hyperbilirubinemia was 10.9 percent (21/192; Fig. 1A, B). Of the 21 patients in whom hyperbilirubinemia developed postoperatively, it occurred by postoperative day 5 in 11 (52 %) (Fig. 1C, D). Hyperbilirubinemia persisted in 9 of 206
these 11 patients into postoperative days 6i~ 10; the tenth patient's bilirubin level r e t u r ~ to normal, and data were not available f o r i ~ eleventh. Late postcystectomy hyperbilirub:i~i~ mia occurred in 9 patients (43 %). One patie~ bilirubin level at six to ten days after surge was 3.5 mg/dL, but no value was recorde~[-! two to five days, and therefore this patient c~ not be included in the exclusively late group, ~ other words, 18 of the 21 patients had h ~ bilirubinemia almost one week after surg (Fig. 1E, F). ~':i~ In analyzing the variables possibly relatea~ hyperbilirubinemia, we found that the rne~ UROLOGY
/
M A R C H 1990
/
VOLUMI~" XXXV, NUMBE~?~:;~
TABLE I, ~t
Patient Group ients ~- ---- -i-92)
Analysis' oJ variables --Level Mean
of Variable Range
64.2 yrs 79.8 U/dL 9.8 0.365 mg/dL
36.6-83.8 yrs 0.5-188 U/dL 2-71 0.1-0.9 mg/dL
~Pl:eop alkaline phosphatase level ::::No. units blood : )Preep bilirubin
65.7 yrs 83.4 U/dL 11.9 0.518 mg/dL
55.1-76.1 yrs 40-126 U/dL 6-39 0.2-0.8 mg/dL
~t0p day 6-10 )~flirubin > 2.0 mg/dL (n = 18) ::!:Age :i~Preop alkaline phosphatase level ~:! :No. units of blood ~!:!i~!;.Preopbilirubin
57.2 yrs 81.4 U/dL 14.4 0.461 mg/dL
36.6-74.5 yrs 47-126 U/dL 6-39 0.2-0.8 mg/dL
days 2-10 ~bihrubin > 2.0 mg/dL (n = 21) [~).: age ~,:;;~!!~reop aklaline phosphatase level [i:~)iNo. units blood '~ ~.Treop bilirubin
59.2 yrs 79.4 U/dL 13.8 0.457 mg/dL
36.6-76.1 yrs 40-126 U/dL 6-39 0.2-0.8 mg/dL
Age Wpreop alkaline phosphatase level ~i:N0, units blood l:~reo ~ bilirubin level
~
ostop days 2-5 Nlirubin > 2.0 mg/dL (n = 11)
Paired Student t-test analysis of bilirubin levels Bflirubin Level (mg/dL) Mean + SD t df TAm~F.II.
~,~:_.,',L,~./tjy!mr'~'" i
MAI~CH t990
/
Whole group (n -- 192) Preop 2-5 days postop Preop 6-10 days postop 2-5 days postop 6-10 days postop
0.365 0.942 0.362 1.13 0.939 1.16
_ 0.161 +__ 1.11 _+ 0.160 _+ 1.17 _ 1.12 ± 1.19
Nonelevated group (n = 171) Preop 2-5 days postop Preop 6-10 days postop 2-5 days postop 6-10 days postop
0.352 0.733 0.351 0.949 0.737 0.977
± 0.150 ___ 0.398 _ 0,153 +_ 0.698 _+ 0.391 ___ 0.711
Elevated group (n = 21) Preop 2-5 days postop Preop 6-10 days postop 2-5 days postop 6-10 days postop
0.455 2.57 0.440 3.40 2,56 3.39
__. 0.211 _ 2.46 _.+ 0.196 _+ 2.04 +_ 2.52 _ 2.10
V O L U M E XXXV, N U M g E R 3
P
6.73
157
< 0.001
8.81
169
< 0.001
3.25
151
0.001
11.39
147
< 0.001
10.98
159
< 0.001
4.06
143
< 0.001
3.99
19
0.001
6,60
19
< 0.001
i.89
18
0.074
207
Pre-Cystectomy Values 160
1.5 1.~, 1.2 1.1 t~
_.E2
t
1.3
1.0
-LIO0 ' 80 O
,~
so
.J~ a. R O tO.
,, 20
ao
g
40
n.
2O
"~
.D
3
•> ~
.~
2
2
Bo
1
2
3
4
5
S 7
8
9 10 11 12 13 14 15 16 17 18
°
age of the patient population was 64.2 years (range 36.6-83.8 years). Age did not seem to correlate with bilirubin level. The mean number of blood units transfused was 9.8 (range from 2-71 units), and the correlation between blood units transfused and the development of postcystectomy hyperbilirubinemia was significant (P < 0.001). The mean preoperative alkaline phosphatase level was 79.8 U/dL (range 0.5-188 U). In the patients with bilirubin levels > 2 mg/dL at two to five days after surgery, the mean preoperative alkaline phosphatase level was 83.4 U/dL (range 40-126). In the patients with bilirubin > 2 mg/dL at six to ten days after surgery, the mean preoperative alkaline phosphatase level was 81.4 U/dL (range 47-126) (Table I). Levels of bilirubin were higher in the entire group of patients at two to five and six to ten days posteystectomy than they had been preoperatively. Student t-test paired analysis of the patients whose bilirubin levels did not exceed 2 mg/dL postoperatively showed significant dif-
208
~
1
C"
ferences between oreoDerative and two to five~ day postoperative bilirubin levels (P < 0.001)i~ This correlation also held true for the six to teri~i day postoperative group (P < 0.001) (Table IIi;~ Results were similar for levels of SGOT and ~ kaline phosphatase. Figure 2 shows paire~ values for the 18 patients with hyperbilirubin~!! mia during the two to five and six to ten-dayi postoperative period. :i~ None of the 192 patients had a history of hver • e'i~:~ disease. Sixteen had had gallbladder dlseas but none of these had bilirubin levels > 2.0 mgi:!i dL postcystectomy. :~ : :? Comment
: : Postcysteetomy hyperbilirubinemia occurredi in 10.9 percent of the patients investigated• Be~'il cause we employed a strict criterion for repor ~;: ing hyperbflirubinemia, i, e., a bilirubin level o}: 2.0 mg/dL or greater, we are underestimatirl~ the actual incidence of this development. AI~'~ though there was a correlation between the:~i UROI,OGY
/
MARCH
1990
/
V O I , U M E XXXV; NU MBEtt~!!
of hyperbilirubinemia and the Nod units transfused, this was not evated levels of SCOT and biliru;xplained by the metabolism of the Ilood cells transfused during sursignificant rise of alkaline phos~ially in those without elevated Lds to indicate a different mechae to consider anesthetic agents, lrgery, and preoperative and post]ications limits our ability to draw bout the pathophysiology of postyperbilirubinemia. Furthermore, division of data into two sampling nd to skew our findings by repretrly and late phase of postcystecilirubinemia. Nevertheless, jauna a significant number of patients radical eystectomy with ileal loop occurrence should be anticipated, not be considered an indicator of
.-",*,-,i
] MARCH 1990 i
VOLUME XXXV, NUMBER 3
serious hepatobiliary disease unless the patient's condition warrants further investigation. Section of General Internal Medicine Box 40 UT M. D. Anderson Cancer Center 1515 Holcombe Boulevard Houston, Texas 77030 (DR. RUBENSTEIN) References 1. BredinHC, andProutGR: One-stageradical cysteetomy for bladder carcinoma: operative mortality, cost~benefit analysis, J Urol 117:447 (1977). g. Johnson EE, and Lamy SM: Complications of a single stage radical cysteetomy and ileal conduit diversion: review of 214 eases, ] Urol 117:171 (1977). 3. Bracken RB, McDonald M, and Johnson DE: Complications of single-stage radical eystectomy and/lea/conduit, Urology 17: 141 (1981). 4. Skinner DG, Crawford ED, and Kaufman jJ: Coraplications of radical eysteetomy for carcinoma of the bladder, J Urol 19.3:640 (1980).
209
