Retrograde arteriography in the staging an follow-up of bladder tumors.

Abstract

Recent literature shows a significant upsurge of interest in arteriographic demonstration of bladder tumors (4, 5, 9, 10). This method supplies the long needed adjuncts for the proper staging of these tumors and for serial follow-up examinations of patients receiving radiotherapy. Jewett's theory of a correlation between the depth of infiltration of bladder tumors and their curability is now a well accepted fact (6–8). Hence, preoperative staging has become the determining factor for the mode of treatment (8, 12, 13). Until recently, staging of tumors of the bladder has been based largely on palpation under anesthesia, cystoscopy, and selective biopsy through the resectoscope (6–8, 12, 13). Radiographic examination following perivesical air insufflation, plexus angiography, and double-contrast cystography have been of secondary importance and have failed to supply substantial additional information (1–3). Selective arteriography of the hypogastric arteries, however, readily demonstrates the lesion. A characteristic staining quality of the tumor in the capillary phase and the classical appearance of the tumor vessels offered the first specific visualization of bladder tumors in all positions. Neoplastic and inflammatory masses could be readily differentiated; particularly, tumors in the anterolateral position that are habitually difficult to evaluate by bimanual examination could now be easily demonstrated and staged (9, 10). A modified Seldinger technic has been advocated for the demonstration of these bladder tumors (9, 10, 14). In addition, carbon dioxide or nitrous oxide insufflation is used as an intravesical medium. Retrograde arteriography has been employed in the diagnosis and preoperative staging of bladder tumors and for the follow-up examination of those patients subjected to radiation therapy. The observations were confirmed by histologic examination of the specimen or suprapubic cystotomy in 14 cases. In the remainder, serial biopsy through the resectoscope and typical findings on bimanual examination under anesthesia were felt to suffice as clinical proof for the arteriographic staging. The arteriographic diagnosis of bladder tumors relies on the demonstration, in the arterial phase, of increased size of the vesical arteries supplying the tumor-bearing area and massive vessels in the pedicle of the tumor. The late arterial phase may show the characteristic corkscrew vessels reminiscent of the tumor vessels of a meningioma. These vessels are usually seen within one and one-half to three seconds after the beginning of the injection. There is probably a correlation between the capillary stain of the tumor and its histologic grade. In poorly differentiated tumors, a very early and dense capillary stain was encountered. The draining veins from these tumors appeared to fill earlier than those from more differentiated neoplasms. This is apparently related to the presence or absence of arteriovenous shunts in the tumors.