“Robotic Radical Cystectomy’’ in treatment of Bladder Cancer and Ileal Neobladder Reconstruction
Patients with bladder cancer are being offered different treatments depending on stage of the cancer. In superficial bladder cancers, when there is no spread into muscle tissue, patients are firstly offered protective treatment of the bladder – TUR (BT) and if necessary, intravesical biologic therapy or chemotherapy drugs will be used. Thanks to these intravesical therapies, side effects are minimized and tumor recurrence risk is reduced considerably.
For the cancer stages with muscle-invasive tumors, or for cancers diagnosed while they are still superficial but tumor has grown seriously and composed of aggressive cancer cells, the primary treatment is a more radical option, which is total removal of the bladder. This procedure is called ‘’Radical Cystectomy’’.
After removal of this urine storing organ – bladder, today the best alternative to store the urine is reconstructing a new bladder from a part of small intestine, and sewing it back to urinary canal. This surgical procedure is called ‘’Orthotopic Neobladder Reconstruction from Small Intestine’’- Ileal Neobladder Reconstruction.
For a long time, Radical Cystectomy and Ileal Neobladder Reconstruction had been performed with open surgery approach. In many centers, it is still being performed using open surgery. However, Prof. Dr. Tibet Erdogru, following his Conventional Laparoscopic experience of 30 cases, presented his experiences to his colleagues in his scientific articles and during conferences. Thanks to advantages of daVinci Robotic System, now he can perform this extremely challenging and long procedure via Robot, too.
While using open surgery technique, an incision starting at 10-15 cm’s above the belly button and ending at penis root is being made to perform this surgery; however, during an operation through daVinci Robotic and Conventional technique, surgery is performed via small trocars and robot arms inserted into body through 5 or 6 holes. While using daVinci Robotic and Conventional Laparoscopic techniques, patient whose abdominal wall is not open throughout the operation will not face temperature, fluid and electrolyte losses, so he/she will have many advantages during recovery period in terms of metabolism. The metabolic disturbances caused by fluid, temperature and electrolyte losses during surgeries, which are seen especially following open surgeries, are the primary factors negatively affecting recovery phase and increasing risk for complications. Additionally, blood loss is significantly less during daVinci Robotic and Conventional Laparoscopic surgeries when compared to open surgeries. Lesser blood loss is also another factor effecting post-operative recovery period.
While performing daVinci Robotic Cystectomy without opening abdomen, and with no serious blood, fluid and electrolyte losses, nerves controlling sexual function can also be preserved perfectly if condition of the bladder cancer allows us.
After totally removing the cancerous bladder by preserving erectile nerve bundles, lymph nodes on main veins are also being removed thoroughly via daVinci Robot. These dissected lymph nodes are very important for proper staging and control of cancer.
In pelvic space which is totally cleaned off by removal of cancerous bladder and lymph nodes, a 45-60cm’s long portion cut from small intestine is opened and reshaped with a special technique to look like a ‘’sphererical’’ shape, which will become the new bladder. At this stage, I perform Abol-Enein Diversion in my patients, which allows to form an exact sphere, protects kidneys by causing minimal pressure and prevents urine flow back up to kidneys.
With help of a perfect high-definition, three-dimensional (3D) vision system that magnifies the view 10-20 times, and thanks to multi-directional maneuver capability of robot arms, ureters arising from kidneys are anastomosed to neobladder. At that point, a particular importance should be placed on ‘’antireflux’’ mechanism, which prevents urine flow back to kidneys. Because, urine flow backs may cause recurrent inflammation of the kidneys in the future. Firstly, ureters arising from kidneys are completely anastomosed to neobladder, and then it is time for neobladder – penile urethra anastomosis. I complete this second phase by using robotic arms inserted into body through holes, too, without opening abdomen. Then a catheter is being placed in neobladder through urethra, which will stay in there during recovery period.
Advantages of Robotic Radical Cystectomy and Ileal Neobladder Reconstruction Surgeries when compared to Open Surgery:
- Operations are being performed with 3 Dimensional, magnified (10-20 times) and very clear displays
- Since abdominal wall is not being opened with a big incision, patients do not face fluid, temperature and electrolyte losses, which are very important for body
- Cosmetically more advantageous
- Nerves for potency are being spared much more effectively
- No risk of developing urinary incontinence
- Very little or no bleeding
- Very little or no post-operative pain
- Since there are no fluid, temperature and electrolyte losses as in open surgery, recovery is much faster, and risk for complications is significantly reduced.
- Urinary canals can be sewed to neobladder in a very delicate way with multi-directional, steady robot arms, and no urine flow back up to kidneys.
Please CLICK HERE to watch video of Robotic Radical Cystectomy and Orthotopic Diversion surgery performed by Prof. Dr. Tibet Erdogru