Historical Contribution: 1958, Jewett, Surgical Treatment of Bladder Cancer

1958
Jewett HJ. The Surgical Treatment of Carcinoma of the Bladder. J Urol. 1958. 79; 1: 87-93.


 
In the follow-up to his 1946 manuscript on the staging of bladder cancer, Dr. Hugh Jewett reviews the surgical management of bladder cancer stratified into the staging system he proposed. The purpose of this 1958 manuscript was to determine who most benefits from radical cystectomy, or as Jewett puts it,

"to steer a course between what may prove excessively radical on the one hand and ineffectually conservative on the other."

Jewett provides a wonderful summation and timeline of the understanding of bladder cancer in the first half of the 20^th century. Investigators at that time realized that tumor grade provided valuable information and a mechanism for invasive disease, but stage (i.e. depth of invasion) was most correlated with the presence of metastases. In 1951, the first update of his 1946 manuscript, Jewett reviews 80 cystectomy cases and demonstrates an extremely poor survival rate for advanced, infiltrative disease.

Jewett was quick to point out, "that intramural or even extravesical metastasis cannot occur until infiltration is well along. Such a concept would be naive since it is well known that metastasis can occur at any stage of infiltration…" Recognizing that superficial tumors were potentially curable through local excision he came up with the following criteria:

SUPERFICIAL INVASION

• Absence of palpable induration

• Only a "sprinkling" of carcinoma cells only

• Cancer involving only the submucosa, or superficial muscle layer

DEEP INVASION

• Palpable induration after resection

• Massive, invasion of the muscle bundles

Jewett used these criteria to define his staging system (and related survival statistics):
O: Mucosa
A: Submucosa
B1: Superficial muscle
B2: Deep muscle
C: Perivesical fat

Note the similar survival rates for patients with superficial disease undergoing segmental resection and cystectomy. Conversely, observe the potential survival benefit for patients undergoing cystectomy with invasive disease.

Therefore Jewett urged,

"A conscientious attempt to use this classification will prove rewarding. It will enable one-to avoid radical and mutilating surgery when it is unnecessary, to employ more effective instead of less effective measures when the tumor is deeper, and to compare intelligently the results of different kinds of treatment for tumors having roughly the same degree of potential curability."

 

To read the entire manuscript: follow the link above, visit the Centennial Website or click here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy!