Physical agents in the treatment of bladder tumors

Abstract During recent years there has been a great change in the outlook of patients suffering from bladder neoplasm, owing to the introduction of physical agents. Though much has been accomplished, especially in benign growths there is still considerable work to be done in the malignant growths, especially in the infiltrating non-resectable carcinomata. Our experiences in over 400 cases are detailed in the printed report, and here I shall attempt to give a brief resume. Amongst the physical agents employed are: 1. 1. Various modalities of the high frequency currents through the cystoscope. 2. 2. The use of these currents through the opened bladder combined with alcohol to prevent implantations. 3. 3. Resections of the bladder with the radio-knife actuated by a very rapidly oscillating (1,200,000) high frequency current. 4. 4. The use of radium seeds (emanations) 4.1. (a) through the cystoscope 4.2. (b) through the open bladder 4.3. 5. The use of deep roentgen ray 1. 1. The trans-cystoscopic use of the high frequency currents has given excellent results. Both the original growths and any possible recurrence are readily destroyed. There are well-recognized differences in the effect of both the so-called monopolar and bipolar currents, the former being more explosive and of higher tension, while the latter is of higher amperage. The distant action of the bipolar is of great use in producing a massive coagulation in the pedicle, as can be demonstrated on a piece of raw beef properly shaped so as to simulate a pedunculated growth, or when the bladder is open and the papilloma is seized and raised with a blunt forceps and the bipolar current is allowed to run down this forceps into the growth. It produces an extensive coagulation at the pedicle and adjacent bladder wall. The monopolar current has a similar distant effect but much less marked. The ideal treatment through the cystoscope would be by means of a forceps electrode, which could be as readily applied as the above forceps through the open bladder. Only benign growths should be treated with these currents, and if in doubt as to the cystoscopic accuracy of diagnosis, a biopsy, occasionally a cystogram, will aid in establishing the nature of the growth. Lack of adequate response to the current speaks against its benign nature. There are benign cases which do not lend themselves to cystoscopic treatment, e.g., extensive papillomatoses, tumors at the neck, or in inaccessible situations, tumors that bleed profusely at every examination, etc., and these are treated better by open operation. The trans-cystoscopic treatment has given us in over 158 cases excellent results. In about 20 per cent we see recurrences in a new situs or in loco, the latter due to incomplete destruction and the former to possibly overlooked growths or to new growths resulting from the original causative agent. 2. 2. In the operative treatment everything must be done to avoid implants. Good exposure by extraperitonealizing the bladder in the Trendelenberg position, careful packing-off of the wound, and operating on the empty bladder assist us in reaching our goal. The bladder is opened with the radio-knife and as the growths present, they are coagulated with the current and removed with the cutting needle (curved). We used to use the Paquelin, later the electrocautery, but for two years we have been using the radio-knife. We have had 33 cases in which this procedure was necessary, and our apparent end-results with this technique are excellent though there is a primary and considerable mortality. Eighty-five per cent of the survivors are apparently cured. We say apparently, for it is difficult to tell when a case is to be classed as cured, having seen, five years after a total cystectomy and apparent health, carcinoma in the iliac glands. Cystoscopic control is essential and it is notorious how difficult it is to persuade patients to submit to regular reexaminations. We are convinced that flooding the wound with strong alcohol, which coagulates potential implants (free tumor cells), has been of greatest value. 3. 3. In carcinoma cases, the papillary and the infiltrating, we use practically the same technique as under (2) coagulating the growth and then resecting. We always have radium present so that in case the growth cannot be resected, we can try to destroy it with this physical agent. Of this group we have had 65 cases (28 plus 37) with apparent good results in 60 per cent of the papillary carcinomata and 35 per cent of the infiltrating carcinomata. 4. 4. Radium emanations we have employed in 16 cases trans-cystoscopically, with apparent successes in 50 per cent; whereas radium applied through the open bladder in non-resectable growths, usually at or near the sphincter, has given us our highest mortality (33 per cent), and only 6 cases (30 per cent) of the total of 31 cases seemed to be cured. 5. 5. In 17 cases of carcinoma, we tried the deep roentgen ray without any curative effect, though occasionally there was some amelioration of the symptoms. From this summary, it is evident that the picture has changed materially, and instead of advising “Hands off!” in these growths, we are now getting results that we can be proud of, even though we are far from the goal at which we are aiming.