0022-5347/78/1192-0216$02. 00/0 Vol. 119, February
THE JOURNAL OF UROLOGY
Printed in U.SA.
Copyright © 1978 by The Williams & Wilkins Co.
RADICAL CYSTECTOMY FOR BLADDER CANCER HARPER D. PEARSE,* RICHARD R. REED
AND
CLARENCE V. HODGES
From the Department of Urology, University of Oregon Health Sciences Center, Portland, Oregon
ABSTRACT
We reviewed 52 consecutive patients who had undergone radical cystectomy for bladder cancer prior to 1962 and have been followed for 15 to 23 years. The over-all survival rates at 5! 10 and ;5 years were 38, 27 and 17 per cent. Pathologic staging was the most important prognostic factor m the series. The 52 consecutive patients reviewed had undergone radical cystectomy for bladder cancer prior to 1962 and have been followed for 15 to 23 years. All patients had been subjected to radical cystectomy, lymph node dissection and removal of the pelvic peritoneum. The women had en bloc removal of the uterus, while the men underwent complete removal of the prostate and seminal vesicles. Total urethrectomy was not included routinely. Essentially, we evaluated radical cystectomy only as treatment for invasive bladder cancer. However, 3 patients were irradiation failures and underwent salvage cystectomy, resulting in l long-term survivor.
Tumor Stage A-Bl B2 C D
% Survival
5Yrs.
10 Yrs.
15 Yrs.
64 50 20 18
50 42 13 0
36 25 7 0
After 2 years the survival curve is the same as the agecorrected population in general. However, patients still died of bladder cancer 5 to 10 years postoperatively (2 of 6). None of the patients dying between 10 and 15 years postoperatively died of bladder cancer (4 of these 6 patients are known to STATISTICS have died, while the other 2 have been lost to followup and The patients ranged in age from 44 to 82 years, with a are presumed dead). mean of 59.5. The ratio of male to female patients was 3 to 1. Pathologic stage was more important from a prognostic An ileal conduit urinary diversion was used in 40 patients, standpoint than was histologic grade, although grade does while the other 12 diversions included 5 cutaneous ureterosto- correlate with survival in a less precise manner. A significant mies, 4 sigmoid conduits, 2 ureteroileal urethrostomies and 1 difference was noted in the long-term surviv~l of patients ureterosigmoidostomy. with pathologic stage B2 tumors when compared to those The over-all survival rates at 5, 10 and 15 years were 38, 27 with stage C disease, 42 and 13 per cent, respectively, at 10 and 17 per cent (see table). Survival figures are shown for years and 25 versus 7 per cent at 15 years. Since this fact has male and female patients in figure 1 and the relationship of been reported in other series any system attempting to classify pathologic stage to survival is shown in figure 2. bladder tumors should include a distinction between stages B2 and C tumors (fig. 2). DISCUSSION Frozen sections should be done on the distal ureteral marIn this series operative-related mortality was significant. gins to eliminate the _possibility of carcinoma in situ or frank Five patients (9.5 per cent) died in the first 30 days postopera- tumor prior to ureteral intestinal diversion. If a urethrectomy tively and another 5 (9.5 per cent) died within the first 90 is not part of the planned procedure frozen section study of days. Better selection and technique as well as better preop- the urethral margin also is essential. erative and postoperative care have reduced this figure to 6 The denuded pelvis should be reperitonealized, if possible, per cent. in an attempt to lessen late small bowel complications. OmenAnother significant group of patients died in the first 2 tum or an omental pedicle graft can be considered in the high years postoperatively, most with recurrent or persistent blad- risk irradiated patient to support the ureteral intestinal der cancer (17 of 18 patients). Some patients probably had anastomosis and to fill the empty pelvic space. undetected metastatic disease at the time of cystectomy but The ileal conduit remains our diversion of choice after dissemination at operation is a possibility that needs more radical cystectomy. The right colon should be mobilized, investigation. Would adjuvant chemotherapy (systemic and/or allowing placement of the ileal cecal segment over the conduit. regional perfusion) and immunotherapy be beneficial in the This procedure places the conduit posteriorly, adjacent to the preoperative and postoperative periods? retroperitoneum, and allows easier re-exploration if needed. Preoperative radiotherapy has been used as an adjunct to In our opinion this technique is associated with fewer late cystectomy in an attempt to sterilize the primary tumor, to bowel obstructions. stabilize micro-nodal metastases and, possibly, to prevent We favor the standard Bricker type ureteral intestinal viable implantation related to cystectomy. Preoperative radio- anastomosis rather than the conjoined technique that has therapy has been shown to decrease the stage of tumor in gained popularity. The Bricker technique allows the bowel to approximately two-thirds of the patients and, according to be brought to the in situ ureter in an attempt to minimize several studies, has resulted in an increased 5-year survival. dissection and preserve its blood supply. We have not used the sigmoid colon for a conduit in many . . Accepted for publication May 20, 1977. cases believing the combination of irradiation, in many of Read at annual meeting of Western Section, American Urological our l~ter cases, and dissection close to the rectum and sigmoid Association, San Francisco, California, March 13-17, 1977_. . * Requests for reprints: Department of Urology, Umvers1ty of dictated use of another bowel segment. Use of the transverse colon in selected irradiated patients deserves consideration. Oregon Health Sciences Center, Portland, Oregon 97201. 216
217
RADICAL CYSTECTOMY FOR BLADDER CANCER
RADICAL CYSTECTOMY FOR BLADDER CANCER 15 Year Survival ( males)
A 100 ,
...........
90 ', 80 80% (32) ' , 70 \
ti
.
60
~ 50
:::::...
....
~
~
·--
/Expected Survival
' , , 68%
·--
- - - - - - 58°'JO
49%(19)
40
-----
-----~8%(15)
~
30
\ 20
-·
i8_._1/._(1_1l_ _ _ __ ~ Observed Survival
47%
21%(8) •
10 QL.L__ _ _ _ _ _____j__ _ _ _ _ _ _J _ __ _ _ _ _ _
( 2 month)
5
10
~
15
Years
B
RADICAL CYSTECTOMY FOR BLADDER CANCER 15 Year Sur viva I (females)
100]--- ..... 90 - - ..... 77 % ( 10) ._ 80 70
-._:o----J %
Expected Survival
73%
----·-----
~
..........
--
60 ~ .... 50
~ ~
40
38%(5)
-----.
63%
.
•~Observed Survival
30
~ 3 % (3)
-----------~%
20 10
(I)
QLL---------'--------'--------~ (2month) 5 10 15
Years Fm.l
RADICAL CYSTECTOMY FOR BLADDER CANCER Survival by Stage •-A, 81 ( 14 pis) o- 82 ( 12 pis) • - C (15pts) AD ( 11 pis)
80 70
...... I::,
60
....
50
-~::,,,; ~ ~
40 30 20 10
64%(9) : ~ 0 % (7) 0
~~~~6%(5) - - - - - O25%(3)
20% (3)
!------~ 1•3%(2) I ------.
18%(2)'-.
7%(1)
0 L---------'-----~A.----'-------~ 5 10 15
Years Fm.2
218
PEARSE, REED AND HODGES CONCLUSIONS
Therapy for invasive bladder cancer remains less than satisfactory. Radical cystectomy is effective treatment for p~tients with pathologic stages Bl and B2 tumors but patients with stages C and Dl disease will require a combination of
radiotherapy, chemotherapy and immunotherapy in a yet undefined protocol. Such selective combination therapy should also benefit patients with less deeply invasive tumors since all invasive stages are associated with an unacceptabl~ level of tumor-related mortality during the first 2 years.
THE JOURNAL OF UROLOGY
Printed in U.SA.
Copyright © 1978 by The Williams & Wilkins Co.
RADICAL CYSTECTOMY FOR BLADDER CANCER HARPER D. PEARSE,* RICHARD R. REED
AND
CLARENCE V. HODGES
From the Department of Urology, University of Oregon Health Sciences Center, Portland, Oregon
ABSTRACT
We reviewed 52 consecutive patients who had undergone radical cystectomy for bladder cancer prior to 1962 and have been followed for 15 to 23 years. The over-all survival rates at 5! 10 and ;5 years were 38, 27 and 17 per cent. Pathologic staging was the most important prognostic factor m the series. The 52 consecutive patients reviewed had undergone radical cystectomy for bladder cancer prior to 1962 and have been followed for 15 to 23 years. All patients had been subjected to radical cystectomy, lymph node dissection and removal of the pelvic peritoneum. The women had en bloc removal of the uterus, while the men underwent complete removal of the prostate and seminal vesicles. Total urethrectomy was not included routinely. Essentially, we evaluated radical cystectomy only as treatment for invasive bladder cancer. However, 3 patients were irradiation failures and underwent salvage cystectomy, resulting in l long-term survivor.
Tumor Stage A-Bl B2 C D
% Survival
5Yrs.
10 Yrs.
15 Yrs.
64 50 20 18
50 42 13 0
36 25 7 0
After 2 years the survival curve is the same as the agecorrected population in general. However, patients still died of bladder cancer 5 to 10 years postoperatively (2 of 6). None of the patients dying between 10 and 15 years postoperatively died of bladder cancer (4 of these 6 patients are known to STATISTICS have died, while the other 2 have been lost to followup and The patients ranged in age from 44 to 82 years, with a are presumed dead). mean of 59.5. The ratio of male to female patients was 3 to 1. Pathologic stage was more important from a prognostic An ileal conduit urinary diversion was used in 40 patients, standpoint than was histologic grade, although grade does while the other 12 diversions included 5 cutaneous ureterosto- correlate with survival in a less precise manner. A significant mies, 4 sigmoid conduits, 2 ureteroileal urethrostomies and 1 difference was noted in the long-term surviv~l of patients ureterosigmoidostomy. with pathologic stage B2 tumors when compared to those The over-all survival rates at 5, 10 and 15 years were 38, 27 with stage C disease, 42 and 13 per cent, respectively, at 10 and 17 per cent (see table). Survival figures are shown for years and 25 versus 7 per cent at 15 years. Since this fact has male and female patients in figure 1 and the relationship of been reported in other series any system attempting to classify pathologic stage to survival is shown in figure 2. bladder tumors should include a distinction between stages B2 and C tumors (fig. 2). DISCUSSION Frozen sections should be done on the distal ureteral marIn this series operative-related mortality was significant. gins to eliminate the _possibility of carcinoma in situ or frank Five patients (9.5 per cent) died in the first 30 days postopera- tumor prior to ureteral intestinal diversion. If a urethrectomy tively and another 5 (9.5 per cent) died within the first 90 is not part of the planned procedure frozen section study of days. Better selection and technique as well as better preop- the urethral margin also is essential. erative and postoperative care have reduced this figure to 6 The denuded pelvis should be reperitonealized, if possible, per cent. in an attempt to lessen late small bowel complications. OmenAnother significant group of patients died in the first 2 tum or an omental pedicle graft can be considered in the high years postoperatively, most with recurrent or persistent blad- risk irradiated patient to support the ureteral intestinal der cancer (17 of 18 patients). Some patients probably had anastomosis and to fill the empty pelvic space. undetected metastatic disease at the time of cystectomy but The ileal conduit remains our diversion of choice after dissemination at operation is a possibility that needs more radical cystectomy. The right colon should be mobilized, investigation. Would adjuvant chemotherapy (systemic and/or allowing placement of the ileal cecal segment over the conduit. regional perfusion) and immunotherapy be beneficial in the This procedure places the conduit posteriorly, adjacent to the preoperative and postoperative periods? retroperitoneum, and allows easier re-exploration if needed. Preoperative radiotherapy has been used as an adjunct to In our opinion this technique is associated with fewer late cystectomy in an attempt to sterilize the primary tumor, to bowel obstructions. stabilize micro-nodal metastases and, possibly, to prevent We favor the standard Bricker type ureteral intestinal viable implantation related to cystectomy. Preoperative radio- anastomosis rather than the conjoined technique that has therapy has been shown to decrease the stage of tumor in gained popularity. The Bricker technique allows the bowel to approximately two-thirds of the patients and, according to be brought to the in situ ureter in an attempt to minimize several studies, has resulted in an increased 5-year survival. dissection and preserve its blood supply. We have not used the sigmoid colon for a conduit in many . . Accepted for publication May 20, 1977. cases believing the combination of irradiation, in many of Read at annual meeting of Western Section, American Urological our l~ter cases, and dissection close to the rectum and sigmoid Association, San Francisco, California, March 13-17, 1977_. . * Requests for reprints: Department of Urology, Umvers1ty of dictated use of another bowel segment. Use of the transverse colon in selected irradiated patients deserves consideration. Oregon Health Sciences Center, Portland, Oregon 97201. 216
217
RADICAL CYSTECTOMY FOR BLADDER CANCER
RADICAL CYSTECTOMY FOR BLADDER CANCER 15 Year Survival ( males)
A 100 ,
...........
90 ', 80 80% (32) ' , 70 \
ti
.
60
~ 50
:::::...
....
~
~
·--
/Expected Survival
' , , 68%
·--
- - - - - - 58°'JO
49%(19)
40
-----
-----~8%(15)
~
30
\ 20
-·
i8_._1/._(1_1l_ _ _ __ ~ Observed Survival
47%
21%(8) •
10 QL.L__ _ _ _ _ _____j__ _ _ _ _ _ _J _ __ _ _ _ _ _
( 2 month)
5
10
~
15
Years
B
RADICAL CYSTECTOMY FOR BLADDER CANCER 15 Year Sur viva I (females)
100]--- ..... 90 - - ..... 77 % ( 10) ._ 80 70
-._:o----J %
Expected Survival
73%
----·-----
~
..........
--
60 ~ .... 50
~ ~
40
38%(5)
-----.
63%
.
•~Observed Survival
30
~ 3 % (3)
-----------~%
20 10
(I)
QLL---------'--------'--------~ (2month) 5 10 15
Years Fm.l
RADICAL CYSTECTOMY FOR BLADDER CANCER Survival by Stage •-A, 81 ( 14 pis) o- 82 ( 12 pis) • - C (15pts) AD ( 11 pis)
80 70
...... I::,
60
....
50
-~::,,,; ~ ~
40 30 20 10
64%(9) : ~ 0 % (7) 0
~~~~6%(5) - - - - - O25%(3)
20% (3)
!------~ 1•3%(2) I ------.
18%(2)'-.
7%(1)
0 L---------'-----~A.----'-------~ 5 10 15
Years Fm.2
218
PEARSE, REED AND HODGES CONCLUSIONS
Therapy for invasive bladder cancer remains less than satisfactory. Radical cystectomy is effective treatment for p~tients with pathologic stages Bl and B2 tumors but patients with stages C and Dl disease will require a combination of
radiotherapy, chemotherapy and immunotherapy in a yet undefined protocol. Such selective combination therapy should also benefit patients with less deeply invasive tumors since all invasive stages are associated with an unacceptabl~ level of tumor-related mortality during the first 2 years.
