Currently, the standard of care worldwide for the treatment of patients who have cancer invading the bladder muscle (muscle invasive bladder cancer) is chemotherapy followed by surgery. In men, the surgery is called radical cystoprostatectomy (removal of the bladder, prostate, and the seminal vesicles). In women, the surgery is called anterior pelvic exentration (removal of bladder, uterus, ovaries, and part of the vagina which can sometimes be avoided). In addition, a critical part of the surgery in both men and women is removing the lymph nodes within the pelvis.
Historically, a cystectomy was performed using an “open approach”. This means the surgeon makes a vertical incision from underneath the belly button down to the pubis bone. Over the last few years, as surgeons have become more facile with technology (laparoscopic or da Vinci ® robotic surgery) and have successfully been able to mimic the open surgery techniques such as for removing prostate cancer, kidney tumors, uterine tumors, etc., they have also begun using the robotic technology for the treatment of patients with muscle invasive bladder cancer. Recent scientific studies have shown that in comparison to open cystectomy, robotic cystectomy offers enhanced visualization and precision during surgery which translates to significantly less blood loss and better lymph node dissection, as well as preservation of nerves. Moreover, the incisions with robotic surgery are smaller and result in less pain and shorter recovery time and hospital stay.
Cystectomy is considered one of the most technically challenging surgeries because after removing the bladder, the surgeon reconstructs the urinary tract to divert the urine. Bladder cancer patients often face difficulty choosing the appropriate type of urinary diversion. There are three basic categories of modern urinary diversions:
1) Ileal conduit: the most common urinary diversion which is fastest and simplest to create, and notably is associated with the fewest complications. A short piece of small bowel is connected to the ureters (tubes that transport urine to bladder) and then brought onto the skin. This requires a urinary bag to collect the urine.
2) Indiana Pouch: the surgeon uses part of the right colon to create a pouch which allows the patient to empty the urine by self catheterizing through a small skin-opening on the stomach.
3) Neobladder (new bladder): the surgeon uses about 60 centimeters (24 inches) of small bowel to create a spherical reservoir. The neobladder is then connected to the ureters and to the urethra. The goal is to mimic the native bladder and for the patient to be able to urinate spontaneously by straining abdominal muscles and relaxing the pelvic floor.
It is important to note that with the Indiana Pouch and the Neobladder, life-long catheterization and irrigation regimen are required. A patient and his or her urologist should have a thorough discussion about which type of diversion is most suitable for the patient.
It is important for patients to know that it is not the technology that provides the best possible outcome, but rather it is the surgeon’s experience and the volume of complex surgeries that are being performed at a given hospital. It is always best to care for these complex cancer surgeries with a multi-disciplinary approach, which involves collaborative care and decision-making by medical oncology, radiation oncology, radiology, and pathology teams. I believe the minimal invasive technologies and techniques offer the surgeon the ability to deliver the most effective treatment in a way that patients can have the best cancer care with rapid return to their daily activities.
By Dr. Reza Mehrazin, Assistant Professor of Urology at Icahn School of Medicine at Mount Sinai.