F • CLINICAL ASPECTS OF SPINAL CORD INJURIES
429
the Second World War. Therefore, this potential complication demands, in future,
increasing attention by everyone concerned with the long-term management of these
patients with regard to early diagnosis and early treatment. This applies, in particular,
apart from paraplegics and tetraplegics with long-standing indwelling urethral or supra-
pubic catheters, to those who were subjected to cutaneous vesicostomy. Laskowski &
Brantley-Scott (1965), who performed this operation on 45 patients, as introduced by
Lapides (1960), found squamous metaplasia present histologically in 13 patients selected
at random and cystitis glandularis in 2 of these cases. These changes are due to chronic
irritation and environmental exposure resulting in metaplasia of the bladder epithelium
to a mucus secreting glandular type of cystitis, which may cause development of malig
nancy of adenocarcinoma type. Mclntosh & Worley (1955) reported 2 cases of adenocarci-
noma amongst 25 cases of extrophy of the bladder.
Kawaichi (1960) reported 4 cases of bladder cancer amongst 1,600 paraplegic patients,
3 of transitional and one of squamous cell cancer. The ages of the patients varied from
36 to 49 years and the level of the spinal lesion ranged from T4 to L3. The diagnosis
of cancer was made 18, 24 and 25 years after injury. Melzak (1966) reported 12 cancer
cases (10 men, and two women) amongst 3,800 patients of our material, n of them
involving the bladder and one the ureter. The average age of these patients was 51 years;
the youngest 37, the oldest 68 years old. The level of the spinal lesions varied from
Cj
to
82. There was one cervical, 6 thoracic (Ti-Ti2) and 5 lumbar-sacral lesions, 9 were
complete, 3 incomplete. All patients had long-standing permanent bladder drainage by
suprapubic (the majority) or urethral indwelling catheters. The cancer was diagnosed
during life 13 to 42 years after injury, with the exception of one which was discovered
post-mortem.
The histological examination of our cancer cases revealed the following cell
types: 4 transitional, 4 squamous, 3 mixed transitional and squamous and one papillary.
The time of survival after diagnosis and treatment (cystectomy and cutaneous ureteros-
tomy followed by deep X-ray treatment) varied between 7 days to 5^ years.
Since 1965 regular cytological investigations have been carried out in paraplegics
and tetraplegics, and Melzak reported in his paper of 374 urines examined, only one case
proved positive and in 7 cases atypical smears were found.
Bors & Comarr (1971) found 15 cases of malignancy amongst 2,322 patients. The
sites of the neoplasia in these cases were as follows: one urethra, eleven bladder, four
kidney, one kidney and bladder. The average age of these patients was the fifth decade.
The cancer was diagnosed 10 to 22 years after injury. No details of the histology are
given.
The incidence of malignant tumours of the bladder and other sections of the urinary
tract, published so far, is still too small to allow comparative statistics with those occurring
within the non-paraplegic population in this country, and it remains to be seen whether
or not the incidence is greater amongst spinal cord sufferers. It also remains to be seen
what role chronic infection and long-standing use of indwelling catheters, especially
those of rubber material, play in the aetiology of malignancy developing in the bladder
in comparison to catheter-free paraplegics and tetraplegics.
