Robotic Surgery For Bladder Cancer

Robotic Versus Open Radical Cystectomy For Bladder Cancer In Adults

Review question

For patients with bladder cancer that involves the deep muscle wall, does use of a robotic device lead to better or worse outcomes than open surgery?

Background

Patients with bladder cancer that involves the deep muscle wall are best treated by an operation that removes the entire bladder and creates an artificial bladder or channel from the bowel to allow urine to drain to the outside world. This has been done traditionally through open surgery using one large incision. Recently, this operation has been performed with robotic assistance using several small incisions. It is uncertain which approach is better.

Study characteristics

We performed a comprehensive literature search until 1 July 2018. We found five trials comparing robotic assisted versus open surgery. The total number of participants in these trials was 541. Four studies were conducted in the USA and one in the UK.

Key results

There may be little to no difference in the time to recurrence, the rate of major complications or minor complications, quality of life, and rates of positive margins . Robotic surgery probably results in fewer blood transfusions and may lead to a slightly shorter hospital stay when compared with open surgery.

Certainty of evidence

Reviewers rated the certainty of evidence as low for most outcomes, except for minor complications and transfusions . This means that the true results for these outcomes could be quite different.

Primary outomes

Secondary outcomes

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Southmead Hospital Surgeons Use Robot To Create A New Bladder For Cancer Patients

Surgeons at Southmead Hospital are robotically constructing new bladders for cancer patients in a UK first.

The procedure, known as a radical cystectomy and neo-bladder, used to be performed manually in open surgery by surgeons creating a new bladder for cancer patients who had to have the organ removed.

Now Southmead Hospital, in Bristol, are making neo-bladders robotically from the patients own bowel tissue inside their body for the first time.

The keyhole surgery is less invasive, has a faster recovery time for patients.

A radical cystectomy involves removal of the bladder, prostate, seminal vesicles in men, and in women, also the uterus, cervix, urethra, anterior vaginal wall, and often the ovaries.

Traditionally this was performed using open surgical methods which could lead to more tissue and nerve damage, more blood loss and carry a greater risk of post-operative infection.

Robotic cystectomy is minimally invasive using our Da Vinci robot which has greater precision.

In 2008 Southmead Hospital became the first hospital in the South West to use a Da Vinci robot to carry out prostate removal for cancer patients.

Since then the hospital has carried out more than 600 of these prostectomies.

It is now being used for radical cystectomy and partial nephrectomy .

Robotic neo-bladder procedure is being carried out by Southmeads consultant urologists Edward Rowe and Anthony Koupparis.

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Three Loyola Medicine Urologic Oncologists Are Co

Date:

Loyola University Health System

Summary:

Robotic surgery is as effective as traditional open surgery in treating bladder cancer, according to a new study.

Robotic surgery is as effective as traditional open surgery in treating bladder cancer, according to a landmark study published in the journal Lancet.

Three Loyola Medicine urologists, Marcus Quek, MD, Gopal Gupta, MD, and Alex Gorbonos, MD, are co-authors of the study. First author is Dipen Parekh, MD, of the University of Miami.

Loyola is among 15 centers that participated in the nationwide trial of 350 patients, who were randomly assigned to undergo robotic surgery or open surgery to remove cancerous bladders.

After two years, there was no significant difference between the two groups in survival without disease progression. Robotic surgery was associated with less blood loss and shorter hospital stays, but longer surgeries. There were no significant differences in complication rates or in patients’ quality of life. The study is called RAZOR and was funded by the National Cancer Institute.

A robotic system allows a surgeon to perform operations through a few small incisions. Movements by the surgeon’s hand or wrist are translated into highly precise movements of the surgical instruments. Every maneuver is directed by the surgeon, in real time, as the surgeon views a magnified, 3D, high-definition image of the surgical site.

Story Source:

Risk Of Bias Evaluation

The results of the risk of bias evaluation are shown in Fig. . All studies but one were considered High risk in Random sequence generation and Allocation concealment as they were retrospective studies. Blinding of participants and personnel was considered Low risk because blinding cannot be achieved in operation theatre settings, and allocation does not affect outcomes. Four articles were considered High risk in Selective reporting because of missing primary outcomes or cost data. For example, Martin et al. did not publish the exact cost data in their article for proprietary reasons , and Smith et al. did not include surgeon fees in their analysis .

Fig. 2

Result of risk of bias evaluation. The results of risk of bias assessment conducted using the Cochrane Risk of Bias Tool

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This Video Represents An Actual Prostate Sparing Robotic Cystectomywarning Content Is Graphic

A robotic cystectomy or cystoprostatectomy will utilize the same laparoscopic port placement as for a robotic prostatectomy, but the ports are shifted slightly higher in the abdomen. The case is comprised of five major operations: removal of the bladder, an extensive lymph node dissection, a bowel resection so as to harvest a long piece of ileum, and then extensive reconstruction of the bowel, bladder and ureters.

A robotic cystectomy or robotic cystoprostatectomy offers similar advantages to what is seen with prostate cancer surgery. The robotic approach allows for a superior nerve-sparing operation which aids in the hopeful recovery of erections in men, and it provides for a much better ability to dissect the urethra and leave a very long stump to sew a neobladder to. Blood loss is far less with the robotic approach. Only the resection portion of the case is performed robotically by Dr. Engel the urinary diversion, either an ileal conduit, a Studer ileal neobladder in men, or an Indiana pouch in women, is performed through a small incision. Once created, the neobladder is sewn robotically to the urethra, or the prostatic capsule if the prostate is spared as described below.

Creation Of An Ileal Conduit:

As the entire bladder is removed through robotic radical cystectomy, the body needs another means to collect and drive out the urine from the system. To achieve this, a urinary reconstruction is performed by creating an ileal conduit as a part of the procedure. During the creation of an Ileal conduit, the surgeon uses a portion of the small intestine called the ileum and creates a channel that connects the ureters to a surgically constructed opening in the abdomen called stoma. Now the urine from the kidney passes through the ureters and the newly constructed ileal conduit, enters the stoma and empties into an external collecting pouch. As the entire procedure is robot-assisted, the patient experiences less post-surgical pain and quick recovery.

What are its advantages?

Besides less scarring, shortened hospital stay and quick recovery, the Robotic Radical Cystectomy with Ileal Conduit has two unique advantages.

• The da Vinci Si surgical robot facilitates delicate dissection and paves the way for minimal blood loss. This eliminates the need for blood transfusions.
• Since the procedure involves the creation of an ileal conduit, it stamps out the need for occasional catheterization.

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Robotic Surgery As Effective As Open Surgery For Bladder Cancer

Three Loyola Medicine urologic oncologists are co-authors of landmark study

Loyola Medicine

MAYWOOD, IL – Robotic surgery is as effective as traditional open surgery in treating bladder cancer, according to a landmark study published in the journal Lancet.

Three Loyola Medicine urologists, Marcus Quek, MD, Gopal Gupta, MD, and Alex Gorbonos, MD, are co-authors of the study. First author is Dipen Parekh, MD, of the University of Miami.

Loyola is among 15 centers that participated in the nationwide trial of 350 patients, who were randomly assigned to undergo robotic surgery or open surgery to remove cancerous bladders.

After two years, there was no significant difference between the two groups in survival without disease progression. Robotic surgery was associated with less blood loss and shorter hospital stays, but longer surgeries. There were no significant differences in complication rates or in patients’ quality of life. The study is called RAZOR and was funded by the National Cancer Institute.

A robotic system allows a surgeon to perform operations through a few small incisions. Movements by the surgeon’s hand or wrist are translated into highly precise movements of the surgical instruments. Every maneuver is directed by the surgeon, in real time, as the surgeon views a magnified, 3D, high-definition image of the surgical site.

Journal

Transurethral Resection Of Bladder Tumor

A transurethral resection of bladder tumor or a transurethral resection is often used to find out if someone has bladder cancer and, if so, whether the cancer has spread into the muscle layer of the bladder wall.

TURBT is also the most common treatment for early-stage or superficial bladder cancers. Most patients have superficial cancer when they’re first diagnosed, so this is usually their first treatment. Sometimes, a second, more extensive TURBT is done to better ensure that all the cancer has been removed. The goal is to take out the cancer cells and nearby tissues down to the muscle layer of the bladder wall.

Read Also: Turbt Treatment For Bladder Cancer

What Has Been Your Experience In Clinical Practice

Although the randomized trials did not show a significant difference between the open and robotic approaches, our experience at Cleveland Clinic has been a little bit different. We’ve definitely found significant differences between the intracorporeal urinary diversion technique compared with both open and robotic cystectomies using an extracorporeal technique. With the latter technique, the bladder, prostate, and lymph nodes are removed robotically, but then the surgeon makes an incision in the middle of the abdomen to perform the urinary diversion in a more traditional way. We found that there are fewer complications with the intracorporeal diversion technique compared with the open technique, as well as the extracorporeal technique.

Treatment Of Bladder Cancer

Badder cancer is treated according to the stage of the disease. 70-75% of the patients are in the stage 1 at the time of diagnosis and there is superficial cancer. The treatment in these patients is the removal of the tumor from the bladder, which we call TUR-tm. If the disease has progressed to the muscle layer of the bladder, then stage-2 disease develops and the treatment is removal of the bladder. In stages 3 and 4, chemotherapy, radiotherapy may be administered or the bladder may need to be removed, depending on the disease and the condition of the patient.

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What Types Of Tests Will The Doctor Conduct To Determine If I Have Bladder Cancer

Ultrasound, CT IVU scans , can detect irregularities in the bladder wall, which would suggest a possible cancer. The urologist will also look inside the bladder with a Cystoscope to visually examine your bladder and remove samples of any suspicious areas for biopsy. Urine cytology will be performed to detect cancer cells in the urine.

What Is Meant By Staging And Grading A Tumor

If bladder cancer is diagnosed, the doctor needs to know the stage or extent of the disease to plan the best bladder cancer treatment. Staging is a careful attempt to find out whether the cancer has invaded the bladder wall, whether the disease has spread, and if so, to what parts of the body. Grade refers to what the cancer cells look like, and how many cells are multiplying. The higher the grade, the more uneven the cells are and the more cells are multiplying. Knowing the grade can help your doctor predict how fast the cancer will grow and spread.

Urologists typically send the sample of cancer tissue to a Pathologist, who specializes in examining tissue to determine the stage and grade of the cancer. The Pathologist writes a report with a diagnosis, and then sends it to your Urologist.

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Live Life On Your Terms

When abnormal cells grow out of control in your body, they can form a cancer tumor that crowds out your healthy cells. When this occurs in the bladder, it’s known as bladder cancer.

Bladder cancer can occur at any age, but usually affects older adults and men more than women. However, a large majority of cases are diagnosed at an early stage when the disease is highly treatable. Unfortunately, bladder cancer is also likely to re-occur. Because of this survivors of the disease often undergo follow-up tests for years.

In advanced stages, bladder cancer cells can spread to other parts of your body. This is known as metastasis, and can be very serious. Thats why its important to begin treating the cancer as early as possible.

Find hope in knowing the compassionate, expert teams at the AdventHealth Cancer Institute and Global Robotics Institute are here to help.

Sexual Effects Of Radical Cystectomy In Women

This surgery often removes the front part of the vagina. This can make sex less comfortable for some women, though most of the time it’s still possible. One option is to have the vagina rebuilt . There’s more than one way to do this, so talk with your surgeon about the pros and cons of each method. Whether or not you have reconstruction, there are many ways to make sex more comfortable.

Radical cystectomy can also affect a womans ability to have an orgasm if the nerve bundles that run along each side of the vagina are damaged. Talk with your doctor about whether these nerves can be left in place during surgery.

If the surgeon takes out the end of the urethra where it opens outside the body, the clitoris can lose some of its blood supply, which might affect sexual arousal. Talk with your surgeon about whether the end of the urethra can be spared.

For more on ways to cope with these and other sexual issues, see Sex and the Woman With Cancer.

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What Is A Cystoscopy

The Cystoscope is inserted through the urethra. Today with the widespread use of the flexible Cystoscope most of the diagnostic Cystoscopies are done in the outpatient setting with little or no discomfort.

As the Urologist looks through the Cystoscope, the locations where abnormal features appear are noted and recorded. During the cystoscopy, the Urologist may choose to take a small piece of what appears to be an abnormal tissue and send it to the Pathologist to read and analyze. In addition, a urine sample is frequently sent for analysis to determine if there are any cancer cells. The biopsy specimen as well as the urine sample will help the doctor make recommendations about the patients future care.

Narrative Results And Discussion

A total of 803 articles resulted from the initial search. After removal of duplicates, primary review, and initial screening of 287 abstracts, 37 articles with full texts comparing RARC and ORC outcomes were identified and selected. Three additional manuscripts were added after reference list review. Therefore, a total of 40 articles were included to specifically address the stated purpose. Figure 1 contains the flowchart of study selection. A total of 34 observational , and 6 RCT comparative studies were included in this descriptive analysis and reported on at least one complication and perioperative outcome. Most important characteristics of included studies are depicted in Table 1.

Figure 1Table 1

Oncologic outcomes

Retrospective reports on oncologic outcomes following RARC were promising but were mostly limited due to significant patient selection bias, short term follow-up, and limited number of patients included in most series . Most of these retrospective analyses focused on rate of positive margins and lymph-node yields, with nearly all studies suggesting very similar outcomes for any type of dissection. Positive surgical margins has been largely related to stage of disease, with early reports demonstrating no significant increase in risk of PSM following RARC, which could be due to the fact that this might have been the preferred approach for less advanced cancers .

Table 2

Perioperative parameters and complications

Table 3

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Sexual Effects Of Urostomy

Its normal for both men and women to be concerned about having a sex life with a urostomy. Having your ostomy pouch fit correctly and emptying it before sex reduces the chances of a major leak. A pouch cover or small ostomy pouch can be worn with a sash to keep the pouch out of the way. Wearing a snug fitting shirt may be more comfortable. Choose sexual positions that keep your partners weight from rubbing against the pouch. For more tips, see Urostomy Guide.

Our Expertise In Robotic Gynecologic Cancer Surgery

Our gynecologic oncologists have vast experience in performing robotic-assisted surgery to manage gynecologic cancers, including early cervical cancer, endometrial cancer, fallopian tube cancer, and ovarian cancer. Robotic surgery approaches result in faster recovery time for patients. This helps patients to return to their normal activities more quickly or begin chemotherapy or radiation treatment sooner, if it is recommended.

Our surgeons use advanced techniques, such as near-infrared imaging when performing sentinel node biopsies in women who have cervical cancer, which allows them to better identify lymph nodes, remove only the most necessary lymph nodes, and reduce the short- and long-term side effects from lymph node dissection. We also play a key leadership role in the training of other surgeons to perform safe robotic surgical procedures.

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