A technique for radical total cystectomy

obvious attack upon cancer is its T gross excision. It limited excisions fail, wider removals are usually next consideretl. Rf iich appears to tiepelid upon the removal of an adequate margin of grossly normal tissue in order to excise unrecogniLed extensions of the cancer. With witlening of the margin until procedures initst 1 x classed as radical, the risks ancl serious scquelae usually increase. Since all surgical procedures niust be judged as ;I halance between the good and the l ~a t l , these disadvantages may, nevertheless, be justified. While it is probable that, technically, arnputation at the level of the lumbosacral joint might be accomplished, there are limitations other than technical.5 Although, in our opinion, these moral, humane, or philosophical limits do not include such an amputation, they tlo permit a more extensive removal oE the blatltler than is accomplished by the usual simple total cystectomy. Taking many of our plans from Brunschwig, we decided to remove the bladder by following the pelvic walls rather than by merely circumscribing the viscus locally. T h e satellite lymphatic chains, as well as any unessential pelvic organs, would be re-~noved. Thus, the plan was to excise en niasse all the pelvic viscera (pelvic exenteration) or all the viscera except the rectum (radical cystectomy or anterior pelvic exenteration). 111 spite of the fact that a wider excision of tissue under and beside the bladder base could certainly be obtained if the rectum were also excised, the obvious advantages of retaining a lunctioriing rectum were so great that we hesitated to rc'n~ove it routinely.