Learn About Surgical Treatments for Different Cancers:
Bladder Cancer
Bladder cancer occurs in approximately 350,000 patients annually worldwide and there are 145,000 deaths every year from this disease. The most common risk factor for developing bladder cancer is a history of smoking. Other risk factors include exposure to certain chemicals and dyes.
About 50- 70 % of bladder cancers diagnosed are superficial with the cancer being confined to the mucosal layer of the bladder. They are usually treated with transurethral resection using a telescope that is inserted into the bladder through the urethra. The urethra is the tube attached to the bladder in which the urine is voided out from. The tumor is then scraped out. Sometimes chemotherapy is inserted directly into the bladder to lower the risk of recurrence.
Localized invasive bladder cancer occurs when the cancer invades and grows deeper into the bladder muscle. This is a serious condition and is associated with a high risk of metastasis and death from the cancer. The most common way to treat this stage of cancer is a radical cystectomy in which the bladder is removed surgically. In men, the prostate is also removed and in women most of the time the uterus and ovaries are removed.
When the bladder is removed, the ureters (the tubes that drain the urine from the kidneys into the bladder) are disconnected from the bladder and the urine is diverted. The most common diversion is the ileal conduit in which a short segment of ileal intestine is isolated and separated from the rest of the intestine. One end of this segment is attached and brought through a created hole in the abdominal wall. The ureters are sewn to the segment of ileum and the urine drains into the piece of intestine and then out the abdominal wall. A bag is attached to the open end of the conduit and the urine is collected in the bag.
Another diversion is the continent urinary pouch. There is still a small hole in the abdomen called a stoma but since the pouch in continent, or in other words doesn’t leak, there is no need to wear a drainage bag. A segment of intestine is isolated and separated from the rest of the intestines and then reconstructed into a pouch in which the ureters are attached to. This pouch is attached to the stoma but the pouch is continent. In order to get the urine out of the pouch, a catheter or small tube is inserted through the abdominal stoma and urine is then drained out.
Another type of diversion is the intestinal neobladder. A segment of intestine is again isolated and detached from the rest of the intestine. It is reconstructed into a pouch and the ureters are attached to the pouch. The pouch is then sewn back to the urethra. Using the abdominal muscles, the intestinal neobladder is able to empty through the urethra.
Radical cystectomy is a large operation with a long recovery period. Most of the time it is performed with a large midline abdominal incision. However the surgery can be performed in a minimally invasive manner laparoscopically. The benefits of this include potentially less blood loss, shorter hospital stays and faster recovery. However laparoscopic radical cystectomy can be a technically demanding and challenging surgery.
The surgery can also be done robotically. The robotic laparoscopic cystectomy utilizes a few small incisions instead of a large open incision. The visualization is superior due to the use of a high definition, 10x magnified, 3 dimensional vision camera that is introduced into one of the port sites. The robotic arms have special wristed instruments that bend and rotate like a human wrist. As a result, the surgery has enhanced vision, precision, dexterity and control. In the case of cystectomy and creation of a neobladder, the robotic procedure has the distinct advantage that the attachment of the neobladder to the urethra can be done precisely under complete visualization.
As a result, Robotic laparoscopic radical cystectomy offers the following potential benefits:
- Precise bladder removal
- Precise suturing of neobladder to the urethra
- Less post operative pain
- Less blood loss
- Low rate of operative complications
- Shorter hospital stay
There are some risks of having a robotic laparoscopic radical cystectomy. They include possible bleeding, bowel injury and inability to remove the cancer completely. There is a possibility for the need to convert the surgery to an open surgery in cases of difficulty or complications.
Rare complications include but are not limited to deep vein thrombosis, pulmonary embolism, heart attack, stroke and death.
Kidney Cancer
About 190,000 people will be diagnosed with kidney cancer worldwide every year. In the United States, there is an estimated 30,000 new cases annually with about 12,000 deaths. There are several possible risk factors for kidney cancer. They include smoking, high blood pressure, obesity, and chronic kidney failure. Some patients may have a rare hereditary form of kidney cancer that is seen in diseases like Von Hippel Landau syndrome. However, most patients have “sporadic” kidney cancers in which there is no known cause.
Most people have two kidneys located in the back of the upper abdomen. The role of the kidneys is to filter the toxins out of our bloodstream, maintain fluid and electrolyte balance in our body and to release certain hormones that regulate blood pressure, red blood cell production and calcium levels.
In the past the most common symptoms of kidney cancer were blood in the urine, a mass in the abdomen or abdominal pain. Usually the cancer was found in a more advanced stage. However today, most kidney cancers are found early before the development of symptoms. This is because of the common use of imaging in modern medicine such as CT or ultrasound.
There are different effective treatments for localized kidney cancer. The stage of the art treatment is the Robotic laparoscopic partial nephrectomy.
The benefits of a partial nephrectomy are preservation of most of the normal kidney while removing the cancer growth with a rim of normal kidney tissue. There is less risk of developing kidney failure with a partial nephrectomy compared to a complete nephrectomy. This is important especially for patients who have smaller cancers, medical kidney disease or only one kidney.
Minimally invasive surgery such as laparoscopic partial nephrectomy is attractive because there is potentially less pain, shorter hospitalization and faster recovery. However laparoscopic partial nephrectomy can be a technically challenging operation due to need to remove all the cancerous tissue out completely, precisely sew bleeding blood vessels and close the defect created in the kidney when removing the cancer.
These challenges can be overcome with a robotic assisted partial nephrectomy. The robotic surgical system allows excellent visualization with a high definition, 10x magnified 3-diminensal vision camera. The robotic arms have specialized instruments with a hinged wrist that allow 7 degrees of motion. Complex maneuvers can be done precisely and efficiently.
As a result, Robotic Laparoscopic Partial Nephrectomy offers the following potential benefits:
- Precise tumor removal and kidney reconstruction
- Excellent chance of preserving the kidney, where indicated
- Shorter warm ischemic time (shorter is better for kidney function)
- Less blood loss
- Low rate of operative complications
- Shorter hospital stay
- Faster recovery
There are some risks of having a robotic laparoscopic partial nephrectomy. They include possible bleeding, bowel injury and inability to remove the cancer completely. There is a possibility for the need to convert the surgery to an open surgery in cases of difficulty or complications. Sometimes a partial nephrectomy will have to be converted to a complete nephrectomy.
Rare complications include but are not limited to deep vein thrombosis, pulmonary embolism, heart attack, stroke and death.
Prostate Cancer and Robotic Laparoscopic Radical Prostatectomy
Prostate cancer is the most common type of cancer in men. Approximately 280,000 men in the United States will be diagnosed with prostate cancer annually with an approximate death rate of 30,000. Approximately one of six men will develop prostate cancer in their lifetime.
The prostate is a male sexual gland located deep in the pelvis. Its function is to produce the seminal fluid that is ejaculated during sexual activity.
When the prostate cancer is diagnosed in the early stages, there are different therapies which are effective in treating the cancer.
One of the mainstays of treatment is the radical prostatectomy in which the prostate is removed surgically. The current state of the art for prostatectomy is the robotic assisted laparoscopic approach. In the robotic laparoscopic radical prostatectomy (RLRP), the surgeon sits at a console nearby the patient. The robot is at the bedside next to the patient and the robot arms in which specialized instruments are attached are inserted into the patient’s abdomen through the port sites. The middle port site is for the high definition, magnified 3 dimensional laparoscopic camera. The surgeon has excellent visualization of the abdominal structures. The robot arms are inserted into the abdomen through the other tiny port sites. Specialized instruments can be attached to the robot arms. The robot is a master-slave system. The robot mimics the motion of the surgeon who is at the console. The benefit of the robotic system is the precision in which the surgery can be performed in a minimally invasive manner. The specific benefit in robotic prostatectomy is that the camera can get to hard to see locations like underneath the pubic bone. There is less blood loss, less post operative pain and shorter recovery.
The advantage of surgical removal of the prostate is the complete pathologic analysis of the prostate, which provides important staging information and allows additional therapy to be planned.
The major advantage of surgery over radiation is that if cancer recurs after surgery, then radiation is still a treatment option. If radiation is done first, usually surgery is not a good option due to a high risk of complications seen when operating on irradiated tissue.
Prostatectomy has possible side effects. The two most common side effects are urinary incontinence and erectile dysfunction.
Urinary incontinence is the inability to control your urination after surgery. This typically happens to all patients after surgery but in the great majority slowly go away. In the beginning, leakage is severe but improves week by week. Patients wear depend diapers and later pads. Sometimes they are referred to a physical therapist to do biofeedback. Most patients have significant improvement 2 to 3 months after surgery. Fortunately only a small percentage of patients may have long-term incontinence that can affect their quality of life. If necessary this can be surgically corrected.
Erectile dysfunction occurs more frequently. This is due to injury to the neurovascular bundles near the prostate. The neurovascular bundles contain the cavernosal nerves for erections. A nerve sparing surgery can be done. Results depend on the type and location of the cancer, medical condition of the patient, age of the patient and the skill of the surgeon. Also there is an Erectile Preservation Program after surgery.
Rare complications include but are not limited to bleeding, infection, deep vein thrombus, pulmonary embolism, heart attack, stroke and death.