Robot in Bladder Cancer; Robotic Radical Cystectomy, Robotic Partial Cystectomy, Robotic New Bladder, Robotic Orthotopic New Bladder
Bladder cancer
The bladder is the organ that stores the urine filtered from the kidneys and allows the urine to be thrown out of the body by contraction. The inner surface of the bladder is covered with a unique cell layer (figure 1).
Figure 1: Anatomical structure of the bladder and its relationship with neighboring organs
In bladder cancers, these special cells multiply uncontrollably and invade healthy tissues (figure 2). In Turkey, bladder cancer is seen in the 3rd frequency in men and 13th in women. Approximately two-thirds of bladder cancers are non-fatal but tend to recur, while one-third are malignant formations that have the potential to spread (metastasize) to muscle tissue and then to the rest of the body.
Figure 2: Stages of bladder cancer
How is bladder cancer diagnosed?
When a bladder tumor is suspected, the tumor is removed by entering the urethra under general or spinal anesthesia (TUR-MT; transurethral resection of bladder tumor). The removed tumor tissues are sent for pathological examination.
What are the treatment methods in bladder cancer?
Different methods are used in the treatment planning in bladder cancer, depending on whether the disease has spread to the muscle tissue.
How is superficial bladder cancer treated?
TUR-MT can provide a permanent improvement in superficial cancer (Ta, T1) that does not involve the muscle layer of the bladder. However, in the presence of more than one tumor or when the tumor diameter is larger than 4 cm, the risk of recurrence is higher, and these patients are given a tuberculosis vaccine (BCG) or chemotherapy drug once a week for 6-8 weeks.
How is muscle involving bladder cancer treated?
If the cancer has invaded the muscle layer of the bladder (T2, T3), especially in young and in patients with good general condition, complete removal of the bladder (radical cystectomy) or removal of a part of it (partial cystectomy) can be performed. These surgeries can be performed with open, laparoscopic, or robotic methods. In men, removal of the prostate and seminal vesicles is also performed along with the removal of the bladder. In women, the uterus, ovaries, and part of the vagina are also removed during radical cystectomy (figure 3). In addition, lymph nodes are also removed in both sexes. According to the pathological evaluation, chemotherapy may be required as an additional treatment approach to surgery.
Figure 3: The bladder, uterus, ovaries, and part of the vagina that were removed in a female patient who underwent robotic radical cystectomy for bladder cancer are seen in one piece
The treatment method that aims to destroy cancer cells by using high-energy rays is called radiation therapy. Radiotherapy applications come to the fore especially in patient groups who are not suitable for surgical interventions or where surgical interventions are not preferred.
Bladder-sparing treatment approaches are the process of preserving the bladder instead of removing it completely, with the use of chemotherapy and radiotherapy applications, following the reduction of the cancer structure by removing as much as possible with transurethral resection (TUR). Such organ-preserving approaches may come to the fore in appropriate patient groups following the physician's evaluation.
How isurine excreted after bladder removal?
After the bladder is removed, the urinary tract is reconstructed. There are several options for this procedure, called urinary diversion:
- Opening the ureter to the skin (ureterocutaneostomy): Channels called ureters that carry urine from the kidneys are anastomosed to the skin (figure 4). This is the simplest operation that can be used for this purpose. However, the rate of complications such as narrowing over time and the development of urinary tract infection in the places where the ureters mouth to the skin is high.
Figure 4: Schematic view of opening the ureter to the skin
- Ileal canal (loop, conduit): A piece of small intestine of approximately 20 cm is used for this procedure. The ureters are attached to one end of the intestine. The other end is mouthed to the anterior abdominal wall (stoma) and urine is directed to the skin. In this process, urine flows drop by drop through the stoma(figure 5). Therefore, a bag is attached to the abdominal skin to store urine. As this bag is filled, it is emptied by the patient.
Figure 5: Schematic view of the ileal canal in bladder cancer
- Creating a new bladder: Here, a 55 cm piece of small intestine is used to create a new bladder to store the patient's urine. This bladder is placed in place of the original bladder inside the body (orthotopic neobladder) and one end is mouthed to the external urethra (figures 6 and 7). In this way, the patient stores and controls his urine and urinates normally. It is the most ideal treatment method in terms of patient comfort.
Figure 6: Schematic view of the neobladder creation technique
Figure 7: In my patient who had cystoprostatectomy and new bladder from the intestine due to a bladder tumor,the operation technique on the left and the image of the neobladder when I filled the bladder with radio-opaque medication on the right.
What is the difference between robotic bladder cancer surgery and open method?
In the open surgical technique, this surgery is performed with a large surgical incision (approximately 15 cm) above and below the umbilicus. I technically include all the stages of cystectomy, removal of lymph nodes and new bladder from the intestine; I do this by using robot arms with excellent high resolution, 3D and 12 times magnification, with versatile mobility. I use the Studer technique for neobladder. I mouth the ureters with the "anti-reflux" technique that prevents the urine from flowing back into the kidney. I do all these steps without opening the patient in any way. My operation time takes an average of 7 hours.
What are the advantages of robotic radical cystectomy and new bladder from the bowel to open surgery?
- The entire operation is performed in 3D, 12 times magnification and under clear vision.
- The incisions made for robotic arms are quite small and smaller scars remain after the surgery.
- Minimal or zero damage to surrounding tissues is caused by precise maneuvers in very tight spaces. Thanks to this advantage, the nerve and vascular structures that perform sexual function in men and the muscles that control urination are protected.
- The amount of bleeding during the procedure is very small.
- Post-operative pain is minimal.
- The patient's recovery after surgery is faster and the hospital discharge time is shorter.
Is the doctor important in robotic bladder cancer surgery?
As in all urological surgeries, it is very important that the surgeon performing the surgery is experienced. After all, the one who controls the robot is a surgeon. For a successful and smoother operation, it is necessary to have an operation with a doctor who is specialized in robotic surgery.