[Total cystectomy in the treatment of infiltrative bladder tumors. The conclusions of an analysis of postoperative results in a series of 269 nonselected patients at late follow-up].

Abstract

The authors report their experience with 341 radical cystectomies, and 61 anterior pelvectomies for infiltrating urinary bladder tumours, of which 269 were followed at long periods of time after surgery. In 56% of the patients there was tumoural involvement of lymph nodes at the time when cystectomy was performed. In 88% of the cases the tumours were of G3 stage. Fifty-one percent of the patients had had one previous surgical procedure, and in 75% of the cases surgery was performed when the upper urinary apparatus was already dilated by tumoural obstruction, or when high serum nitrogen was present. Planned radical cystectomy was possible in only 26% of the patients. The technical procedure implies a significant change consisting in the exclusive use of the urethropelvic drainage, and this had excellent results. The urinary derivation used was adapted to the stage of development of the tumour, and after consideration of the condition of the upper urinary apparatus. In 130 cases cutaneous urethrostomy was performed, in 95 patients urethrocolic derivation, in 23 cases cutaneous transurethral ureterostomy, and in 6 patients substitution bladder was achieved. The global postoperative mortality of 16.6% was mainly due to the advanced age of patients, the advanced stages of the tumours, to high serum nitrogen, infections, and to operatory indications that were not always justified but were determined by clinical complications and the extreme discomfort of patients. The most frequent early postoperative complications included an association of toxic shock and high serum nitrogen. In the authors' experience preoperative radiotherapy did not have satisfactory results, and chemotherapy only resulted in inconstant improvement of the patients' condition The late results were not satisfactory, the deaths in the first two years after surgery being the result, almost in exclusivity, to a continued evolution of the neoplastic tissue remaining in the pelvic cavity, and that was due to the fact that the patients had been operated at a very advanced stage of the disease. Total cystectomy has an elective indication in urinary bladder tumours of the T2, T2a, or T3b type, with N0 and M0. It should be carried out as planned surgical intervention and presumes a mandatory urinary derivation that should provide a maximal renal protection.