CARCINOMA OF THE BLADDER: THE IMPORTANCE OF RECTO-

ABDOMINAL PALPATION UNDER ANESTHESIA IN THE

SELECTION OF CASES FOR TOTAL CYSTECTOMY
HUGH J. JEWETT
From the James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore
After it had been established experimentally and clinically that a new pro-
cedure for the simultaneous implantation of the intact ureters into the sigmoid
in two stages was followed by no significant damage to the upper urinary tract, 1 • 2
a number of patients with extensive carcinoma of the bladder were referred to
me for ureteral transplantation and total cystectomy. During the past 2 years
I have carried out the first stage of this operation on 31 patients, 26 of whom
had extensive cancer of the bladder. The majority of these 26 patients had been
under conservative treatment elsewhere for ·many months, sometimes years,
before they were referred for cystectomy. In 15 of these I was impressed with
the fact that palpation of the bladder from within the peritoneal cavity at
laparotomy revealed a much larger tumor than had been suspected on cystoscopic
examination; in 4, the tumor mass was found to be fixed to the pelvic wall and
obviously inoperable. The second stage of this operation has been carried out
so far in 20 cases, but combined with cystectomy in only 16. In 4 of these
cystectomy cases in which the tumor was large and slightly adherent to the
perivesical structures, recurrences or metastases already have occurred.
From this, it is evident that total cystectomy will not cure carcinoma of the
bladder when it is no longer completely confined to the vesical wall. In these
26 cases of extensive carcinoma, the usual methods of examination, including
rectal palpation, cystoscopy, biopsy, and urography, were not sufficiently ade-
quate to determine the total size of the mass in the bladder wall in 15, nor to
detect perivesical extension in 8. It is imperative, then, that these fundamental
diagnostic procedures be supplemented by some other method of pre-operative
examination in order to determine more accurately the extent of infiltration
and the suitability of the case for radical cure.
Despite admonitions in the literature never to neglect, especially in women,
bimanual examination of the bladder in cases of tumor, recto-abdominal pal-
pation in the male usually has not proved very helpful. A tense, heavily muscled
or obese abdominal wall and perineum prevent accurate delineation of the
tumor mass, and under such circumstances little if any additional information
can be acquired beyond that already obtained on simple rectal examination.
It occurred to me that the principle of the "ether examination," employed by
gynecologists in difficult cases or in obscure pelvic conditions, might be ap-
plicable, in a somewhat modified form, to all cases of tumor of the bladder, in
males as well as in females, in which infiltration is suspected. The newer and
1 Jewett, Hugh J.: Uretero-intestinal implantation: Experimental and clinical results with
a new method. South. Med. J., 36: 1-11, 1942.
2 Jewett, Hugh J.: A new method of ureteral transplantation for cancer of the bladder:
A report of 15 clinical cases. J. Urol., 48: 489-509, 1942.
34
 CARCINO~IA OF BLADDER 35

more innocuous methods of anesthesia, such as spinal and intravenous, produce

the necessary muscular relaxation without subsequent disturbance, even to
elderly patients. vVith anesthesia deep enough to secure complete muscular
relaxation, recto-abdominal palpation of the bladder can become surprisingly
thorough and satisfactory. Information thus yielded may establieh two im-
portant facts: (1) infiltration of the bladder wall; (2) operability.

fres5ure on abdomen forcin.o

bladder doV,fft.Wal:'d

Tumoi:-- with area

at "tn:ti \tration

FIG. 1. Technique of recto-abdominal palpation in the male under anesthesia. Relax-

ation of abdominal wall and perineum makes possible thorough digital exploration of bladder.
Infiltration of bladder muscle is felt as a hard mass and its size determined in 3 dimensions.
A, Cystoscopic appearance of small papillary carcinoma. Although infiltration is apparent,
its extent can be determined only by bimanual palpation.

TECHNIQ-C-E OF RECTO-ABDOMINAL PALPATION

Bimanual palpation of the bladder in the male is not difficult. The method
I have used to great advantage is as follows:
After cystoscopy under spinal or, preferably, intravenous sodium pentothal
anesthesia, the bladder is emptied, the cystoscope removed, and, with the patient
still on the table with thighs flexed, the index finger is placed in the rectum.
The anal sphincter ·will be markedly relaxed, and the perineal musculature to
a lesser extent, facilitating a very high digital exploration. The opposite hand
exerts firm pressure in the hypogastrium, pushing the posterior bladder ,rnll
downward towards the rectal finger which, passing the upper border of the
prostate, palpates the seminal vesicles and most of the posterior wall of the
36 HUGH J. JEWETT

bladder (fig. 1). The abdominal hand next exerts pressure deep in the lower
quadrants, first on one side, then on the other, enabling the rectal finger to
explore the lateral bladder walls and also the infero-lateral ligaments of the
bladder. The anterior wall of the bladder, however, which lies behind the
symphysis, does not lend itself so readily to this method of examination because
the posterior wall covers it and acts as a cushion.
REPORT OF ILLUSTRATIVE CASES

The following case reports illustrate the immense value of recto-abdominal

palpation under anesthesia deep enough to achieve complete muscular relax-
ation.
Case 1. BUI 31165. E. C. K., a large, heavily muscled man of 65, entered
the hospital with pain in the right lower quadrant and marked vesical irritabil-
ity. Five years previously the right kidney had been removed elsewhere be-
cause of intermittent hematuria from the right ureter persisting 2 years after
a renal injury. The removed kidney was said to have shown only subacute
pyelonephritis. Hematuria continued, and 2 years before admission, cystoscopy
elsewhere disclosed 2 papillary tumors, one projecting from the right ureteral
orifice. The only treatment given during this interval was deep x-ray therapy.
Physical examination here disclosed tenderness along the course of the re-
maining portion of the right ureter. Rectal palpation revealed no indura-
tion of the base of the bladder, but a cystogram showed a filling defect on the
right side.
Cystoscopy under pentothal sodium anesthesia disclosed an irregular, rather
flat, somewhat ulcerated tumor involving a large portion of the right half of
the bladder, surrounding and obscuring the right ureteral orifice. Members
of the staff agreed that the case was suitable for total cystectomy.
Recto-abdominal palpation, after emptying the bladder and removing the
cystoscope, was carefully made. A hard, fixed mass, somewhat cylindrical in
shape, which had not been revealed by the previous diagnostic procedures, was
found extending upward and outward from the tip of the right seminal vesicle.
The pre-operative diagnosis, then, was carcinoma of the right ureter, with in-
vasion of the adjacent bladder wall.
At laparotomy the right ureter was found to be 2 cm. in diameter, thick walled
and markedly indurated. This condition extended from the bladder to the mid-
lumbar region, where it commenced to taper off to its upper end which appeared
fairly normal through the unopened posterior peritoneum. Left uretero-sig-
moidostomy was done, and the patient eventually was discharged free from
pain and vesical irritability.
Comment. The confirmation at laparotomy of these unusual findings by pre-
operative recto-abdominal palpation under anesthesia demonstrated 2 important
points: First, a very high digital exploration of the posterior wall of the bladder
is possible, even in a large, heavily muscled man; secondly, some of the gross
characteristics of an infiltrating carcinoma of the bladder can be determined
more accurately by this method than by any other.
 CARCINOMA OF BLADDER 37

In Case 2 bimanual palpation disclosed a mass extending ,vell beyond the

bladder wall and fixed to the left lateral wall of the pelvis, indicating inoper-
ability.
Case 2. BUI 32564. A. P. E., a 49-year old pipe fitter in a dye works, com-
plained of suprapubic pain, vesical irritability, and hematuria. Ten years
previously he had had some frequency, burning, and gross hematuria. Cysto-
scopy elsewhere disclosed a tumor of the bladder which was treated by fulgura-
tion and suprapubic implantation of radon seeds. All symptoms disappeared
until 3 months before admission here.
Physical examination revealed a loss in weight of 25 pounds. Rectal pal-
pation elicited tenderness at the base of the bladder, but no induration or mass
was felt. On excretory urography the left kidney was not visualized, and the
right renal pelvis and ureter were somewhat dilated.
Cystoscopy showed a gray slough covering the greater part of an ulcerated,
hemorrhagic tumor, -which involved the trigone, and part of the left and poste-
rior walls of the bladder. The tumor failed to respond to fulguration and ap-
plications of radium, and eventually the patient was referred to me for total
cystectomy.
Recto-abclomi11al palpation under spinal anesthesia disclosed a large, hard,
somewhat irregular mass involving the base of the bladder. It was the size of a
lemon and was firmly adherent to the left lateral pelvic wall. There was also
some thickening and induration in the left infero-lateral ligament of the bladder.
These findings showed that the case was unsuitable for total cystectomy.
At laparotomy most of the posterior wall of the bladder was found to be oc-
cupied by a large, irregular, nodular, hard mass which caused wrinkling and
puckering of the bladder peritoneum. This mass extended downward as far
as the hand could reach in the recto-vesical pouch, and laterally, whereit was
fixed to the bony pelvis on the left side. It was obviously inoperable, and palli-
ative transplantation of the right ureter was carried out.
In Case 3 recto-abdominal palpation revealed a mass the size of a lemon,
involving most of the right lateral wall of the bladder. It involved the rectal
muscle and right infero-lateral ligament, indicating inoperability.
Case 3. BUI 32569. H. R. L., a 59-year old man, complained of very slight
transitory hematuria 1 year previously. There was no recurrence of hema-
turia until a week before admission, when gross diffuse hematuria occurred.
Examination elsewhere was said to have disclosed an indurated mass in the
base of the bladder, and an infiltrating carcinoma involving the trigonal area.
Rectal examination on admission here showed some thickening and indura-
tion of the base of the bladder just above the vesico-prostatic juncture, extend-
ing upward on the right side as far as the finger could reach.
Cystoscopy under sodium pentothal anesthesia disclosed a large, flat, irregular
tumor occupying practically the entire right lateral wall of the bladder, extending
upward to within 3 cm. of the air bubble and downward to the vesical orifice.
The case seemed suitable for total cystectomy.
Recto-abdominal palpation, after emptying the bladder and removing the
38 HUGH J. JEWETT

cystoscope, revealed a mass about the size of a lemon, extending nearly to the
mid-line posteriorly and involving practically the entire right lateral wall of
the bladder. It was adherent to the rectal muscle, but was fairly movable along
with the rectum. The extensiveness of the mass, with this evidence of peri-
vesical infiltration, indicated unsuitability for total cystectomy.
In Case 4 recto-abdominal palpation revealed extensive perivesical infiltra-
tion, indicating inoperability, whereas the cystoscopic picture was that of a
small papillary tumor, with only superficial infiltration.
Case 4. BUI 32674. D. S., a 48-year old man, gave a history of having re-
ceived cystoscopic treatments for papilloma of the bladder over a period of 9
months. During this time symptoms of vesical irritability supervened.
Cystoscopy under spinal anesthesia disclosed an irregular papillary tumor
2½ cm. in length and 2 cm. in breadth, occupying the central part of the trigone
and extending upward a short distance above the inter-ureteric ridge. The
surface in some places was covered by a white irregular slough. Superficial
infiltration was evident, but deep invasion was not suspected.
Recto-abdominal palpation, after emptying the bladder and removing the
cystoscope, showed thickening and induration of the upper part of the right
seminal vesicle and a hard, irregular mass the size of a large olive which was fixed
to the perivesical structures and slightly adherent to the lateral pelvic wall.
It was obvious, therefore, that cystectomy would not cure the patient.
In Case 5 recto-abdominal palpation under anesthesia disclosed thickening
and infiltration at the base of the bladder, extending laterally into both infero-
lateral ligaments, indicating that total cystectomy would not result in a radi-
cal cure.
Case 5. BUI 32560. W. F., a 57-year old man, gave a history of intermit-
tent hematuria over a period of 10 months. Rectal examination elsewhere had
disclosed an area of induration barely reached by the finger, high up on the
right side of the bladder.
Cystoscopy elsewhere showed a large, irregular, papillary tumor on the right
postero-lateral wall, involving the ureteral orifice. Adjacent to the tumor there
was some edema of the vesical mucosa. The patient was referred for total 1

cystectomy. I

Bimanual palpation under anesthesia showed marked thickening add indura-

tion of the base of the bladder, just above the prostate, which extended through
the bladder wall, close to the rectum, and into the infero-lateral ligament on
each side. The mass was not freely movable and the case was considered un-
suitable for total cystectomy.
Laparotomy, however, was requested, and exploration within the peritoneal
cavity confirmed the findings on bimanual examination.
In Case 6 recto-abdominal palpation under anesthesia disclosed a large smooth
mass completely confined to the posterior bladder wall which was freely movable,
indicating operability.
Case 6. BUI 29627. H. H., a 60-year old man, had been given endovesical
fulguration for a tumor of the bladder several times in the past 2 years. He had
 CARCINOMA OF BLADDER 39

only slight vesical irritability on admission here. Rectal examination disclosed

some enlargement of the prostate but no induration of the bladder wall.
!}ystoscopy under spinal anesthesia showed a papillary tumor on the left
lateral wall of the bladder measuring about 3 cm. in diameter. There were
also some small papillary tumors near the vesical orifice. It seemed likely that
the tumor would respond to conservative treatment.
Recto-abdominal palpation, after emptying the bladder and removing the
cystoscope, revealed a rather firm mass in the posterior wall of the bladder well
above the prostate, just to the left of the mid-line. This mass was freely mov-
able between rectal and abdominal fingers and was completely confined to the
bladder wall. It was approximately 4 cm. in diameter. Total cystectomy was
recommended.
At laparotomy palpation of the bladder from within the peritoneal cavity
confirmed the findings on pre-operative bimanual examination, and after trans-
plantation of the ureters, cystectomy was carried out.
Comment. From a careful study of these 6 case reports, it is apparent that
recto-abdominal palpation under anesthesia established far more accurately
than any other method of examination the extent of involvement of the bladder
and adjacent structures, the size of the tumor mass in 3 dimensions, and its
suitability for total cystectomy.
SELECTION OF CASES FOR TOTAL CYSTECTOMY
In my series of 26 cases of extensive carcinoma of the bladder, all of which
fulfilled the requirements for total cystectomy, emphasized by Beer, 3 by Hy-
man,4 and by Hinman,5 4 were found to be inoperable at laparotomy, and in 4
others recurrences or metastases developed after cystectomy. It is apparent,
therefore, that the usual methods of examination are inadequate to establish
operability.
No one will deny that a familiarity with the complicated pathologic classi-
fication of tumors of the bladder, and their biologic propensities, is important.
Nevertheless, for practical purposes it is necessary to have a simple working
classification which is based upon the answer to the 2 most important questions
ofall: (1) Has the tumor invaded the bladder muscle? (2) Is it operable? For
determining the most appropriate treatment, I believe tumors of the bladder
should be separated into 3 groups:
Group 1. Non-infiltrating tumors. Cystoscopic examination establishes the
diagnosis in this group. If, however, the intravesical mass is large and its base
not well visualized, so that the possibility of infiltration cannot be excluded,
subsequent recto-abdominal palpation under intravenous or spinal anesthesia
3 Beer, Edwin. Tumors of the Urinary Bladder. Baltimore: William Wood & Co., 1935.
p. 104.
4 Hyman, Abraham: Surgical Treatment of Carcinoma of the Urinary Bladder. In:
Treatment of Cancer and Allied Diseases. New York: Paul B. Roeber, Inc., 1940. vol. 3,
chapt. 108, p. 1852.
6 Hinman, Frank: The technic and late results of uretero-intestinal implantation, and
cystectomy for cancer of the bladder. In: Reports of VII Congress of the International
Society of Urology, 1939, pp. 464-524.
40 HUGH J. JEWETT

should be carried out, usually just before endovesical destruction of the tumor.
It may reveal a softish mass covered by a cushion of normal bladder wall.
Tumors in this group are treated conservatively, usually by fulguration or loop
resection, after which radium or some other treatment may be used, if it seems
indicated.
Group 2. Infiltrating tumors completely confined to the bladder wall. If, in the
absence of marked vesical symptoms, cystoscopy should be undertaken under
local anesthesia, the appearance of the tumor and the surrounding bladder
mucosa will suggest at least some infiltration. A subsequent examination under
intravenous or spinal anesthesia is then indicated for the purpose of making a
more accurate inspection, obtaining a biopsy, and making a bimanual examina-
tion. If the infiltration is only superficial, it cannot be felt on recto-abdominal
palpation. It can be determined only by cystoscopy and biopsy which is deep
enough to show carcinoma cells extending into the submucosa of the bladder.
But when the tumor has deeply invaded the muscular wall of the bladder, on
bimanual examination under anesthesia the infiltration usually can be felt by
the rectal finger as an indurated mass (fig. 1). Oftentimes the mass in the blad-
der wall is muchlarger than that indicated by cystoscopy. Its size and location,
as well as the age and general condition of the patient will determine whether
conservative management or total cystectomy is the procedure of choice.
To be curable by cystectomy this mass must be confined to the bladder wall
and should be freely movable between the abdominal and rectal fingers, unless
it occupies the bladder base, which is always relatively fixed. Perhaps a cor-
relation of the gross characteristics of the tumor with its degree of malignancy,
as demonstrated by biopsy, may aid still further in determining the probability
of cure by radical operation.
Although even some of these cases subsequently may prove to have been
inoperable, because of the finding at laparotomy of involved retro-peritoneal
lymph nodes, or local recurrence or metastases following cystectomy, much has
been accomplished if cystectomy frees the patient from pain in the bladder and
urethra. However, the rigid limiting of cystectomy to cases within this group
should increase the incidence of radical cures.
Group 3. Infiltrating tumors with perivesical extension, with or without metas-
tases. A cure by total cystectomy in the majority of cases in this group is im-
possible. Inoperability is indicated by any one of the following findings: (1)
A large, hard, irregular mass projecting well beyond the bladder wall, which
sometimes can be felt also by the abdominal fingers; (2) thickening and indura-
tion in the infero-lateral ligaments of the bladder when the tumor involves the
base; (3) fixation of the mass to the bony pelvis or to other perivesical structures,
unless such structures can be completely removed with the bladder, such as the
seminal vesicles, or upper vagina in the female; and (4) metastases, which may
be revealed by general physical examination and roentgenograms of the chest,
spine, and pelvis.
In this group, surgical diversion of the urine is indicated only when vesical
symptoms are incapacitating and cannot be controlled by any other means. In
 CARCINOMA OF BLADDER 41

such cases a palliative 1-stage ureteral transplantation without cystectomy

probably is preferable to transplantation of the intact ureters in 2 stages. Al-
though a 1-stage procedure may afford less protection to the upper urinary
tract, radical cure of the carcinoma is impossible, and a patient with a hopeless
prognosis is subjected to only 1 laparotomy. If persistent pain or hemorrhage
cannot be controlled by irradiation or other means, subsequent cystectomy may
become necessary. Many patients, however, will obtain complete relief of
symptoms when the bladder is put at rest by a simple diversion of the urine.
SUMMARY AND CONCLUSIONS

Recto-abdominal palpation under anesthesia is the most satisfactory method

for determining whether the primary carcinoma is confined to the bladder wall.
It is practicable, and is indicated as a routine procedure in all cases of tumor of
the bladder in which there is any question of infiltration, as revealed by cysto-
scopy and biopsy. Infiltration of the bladder muscle is felt on bimanual palpa-
tion as a hard mass in the bladder wall and its size determined in 3 dimensions.
It may be much larger than is suspected on cystoscopy.
Total cystectomy as a means of cure should be considered only when the mass
is completely confined to the bladder wall and movable.
Recto-abdominal palpation under anesthesia in cases of carcinoma of the
bladder gives invaluable aid in establishing 2 facts: (1) Deep invasion of the
bladder muscle, indicating the probable hopelessness of further conservative
management; and (2) suitability of the case for radical cure by total cystectomy.
1201 N. Calvert St., Baltimore, Md.