INFILTRATING CARCINOMA OF THE BLADDER: A NEW METHOD OF URETERO-INTESTINAL ANASTOMOSIS EMPLOYED IN 29 CASES; INDICATIONS FOR TOTAL CYSTECTOMY*

A method of uretero-intestinal implantation of the intact ureters in two stages, combined with total cystectomy at the second stage, has been described. When properly done it usually is followed by no permanent obstruction to the upper urinary tract. In my series of 29 cases in which both stages of the ureteral transplantation have been completed, there were only 3 patients who died as the specific result of the uretero-intestinal anastomosis. The causes in 2 of these cases have been determined and subsequently eliminated by improvement in the surgical technique. In 4 other elderly patients with advanced carcinoma there were 2 deaths from coronary occlusion, 1 from pulmonary embolus, and 1 from volvulus. Radical surgery no.w is limited to patients who are good surgical risks, and in whom there is a reasonable chance of cure. To be suitable for radical cure by total cystectomy, metastases must be absent, and the tumor must be completely confined to the bladder wall and freely movable. This latter condition is best determined pre-operatively by recto-abdominal palpation under anaesthesia. The opposition to total cystectomy for cancer of the bladder which is otherwise incurable has been based on two principal considerations: (1) The results of the rerouting of the urinary stream have been too uncertain, and (2) a surgical procedure which contemplates two laparotomies has seemed too formidable. These objections should be largely eliminated by the results obtained in this series of 29 cases. Certain authors have also objected to cystectomy because the incidence of radical cures of the cancer has not been impressive. I believe the principal reason for this is that ureteral transplantation previously has been so hazardous that this operation and cystectomy usually have been postponed until the cancer has become advanced and the patient's condition desperate. When this stage is reached the opportunity for obtaining a radical cure has been missed. The restriction of total cystectomy to cases without metastases in which the primary tumor is completely confined to the bladder wall and freely movable should increase the incidence of radical cures.