Cystectomy in the Management of Carcinoma of the Urinary Bladder.

SIMPLE cystectomy has proved to be a satisfactory method of treatment for carcinoma of the urinary bladder. We became interested in this method of treatment in 1948 and have performed 265 cystectomies since then. During the period between 1948 and 1953, ureterosigmoidostomy was utilized as a means of urinary diversion. Since then, we have been using the ileal loop as a method of urinary diversion. In our opinion, the morbidity has been decreased and the prognosis for long term survival is definitely enhanced because of improvement in the method of urinary diversion. In our original series reported in 1956, a total of 48 five year cases was analyzed. In this group, there were 2 operative deaths, an operative mortality of 4.2%. Thirty patients died within the five-year period and sixteen survived five or more years, a survival rate of 33.5%. Incorporated in this series was a large number of patients operated upon early in our experience. The criteria for surgical removal were not well formulated, and cystectomy was performed in many cases in whom there was no possibility of ultimate cure. With additional experience, we have developed more rigid indications for cystectomy, resulting in an improvement in five-year survival rates. Cystectomy is now performed on patients in the following categories: lesions of high grade cellular malignancy (Grade III and IV); biopsy evidence of muscle invasion; rapid recurrence of tumours of increasing cellular malignancy; and generalized involvement of the bladder mucosa by tumour, not controllable by other means. Cystectomy has not been performed in those patients in whom, on abdominal exploration, the following conditions were found: extravesical spread of tumour; the presence of positive pelvic lymph nodes; the presence of metastatic disease outside the pelvis. The presence of palpable lymph nodes, demonstrated to contain carcinoma by frozen section, is definitely an indication for palliative diversion without any further surgery on the bladder. In our experience, patients with positive lymph nodes do not survive beyond a year. We do not feel that there is any particular advantage in routinely combining radical lymph node dissection with the cystectomy. The lymph node dissection seems to add materially to both the mortality and morbidity of the surgery; and, since the prognosis is extremely poor if positive nodes are present, it is our belief that the rare case who might be salvaged by this method is more than offset by the added mortality and morbidity involved. A recent review of 99 patients followed five or more years after cystectomy and ileal loop diversion showed an overall survival rate of 40 (41.4%). The immediate operative mortality was 4.2%. An analysis of this group based on both Broder's classification and Jewett's classification is of interest.