By Leslie A. Deane, MD
Bladder cancer can be a devastating diagnosis, especially when the deep muscle of the bladder is involved. It affects approximately 76,000 people in the United States annually, with 18,000 deaths. Men are affected three times as often as women.
The treatments for this condition are life-changing, to say the least, and the goal of surgeons treating patients is to minimize the morbidity and hasten recovery, attempting to normalize quality of life thereafter.
Robotic surgery has changed the approach to patients with this disease, allowing duplication of open techniques, albeit with a less invasive alternative. We have been able to remove the bladder, remove the lymph nodes and reconstruct the bladder using the small intestine, all inside the body (intracorporeal).
Although these are long operations, blood loss is minimized and the risk of a blood transfusion is 10 times lower than with open surgery. The hospital length of stay is also markedly reduced. The average patient can be expected to spend only three to five days in hospital. Nasogastric tubes have been omitted, as have ureteral stents.
Rush University Medical Center is the only center in Chicago performing these operations using a totally intracorporeal technique. We have performed ileal conduit (small intestine as stoma on the skin and requiring a urine collection appliance) and ileal neobladder (small intestine made into a reservoir in the position where the normal human bladder was, and without the need for an external urine collection appliance) urinary diversions using this technique. This surgery can be expected to take six to eight hours.
It is unnecessary to use any bowel preparation to clean the intestine, and patients are able to drink clear fluids on the day of surgery and can usually eat food and ambulate the day after surgery. Our technique of local anesthetic infiltration of the abdominal wall results in excellent early post-operative pain control. An epidural is rarely, if ever, necessary for pain control and the majority of patients do very well with acetaminophen and ibuprofen.
It is very important for patients to have excellent nutrition leading up to surgery, as this helps with their post operative recovery. We encourage a high protein intake with clear liquid protein drinks daily for the two weeks before the procedure.
Our team works closely with the medical oncologist, as many patients benefit substantially from chemotherapy followed by surgery. Radical removal of the bladder is not the best option for all patients, however, and some will do better with a combination of maximal transurethral resection, followed be chemotherapy and radiation therapy. To this end, we also work in conjunction with our radiation oncology colleagues to optimize outcomes for these individuals.
Leslie A. Deane MD, FRCSC, FACS, is an associate professor of urology and attending urologist at Rush University Medical Center, a fellow of the Royal College of Surgeons of Canada, a fellow of the American College of Surgeons, and a diplomate of the American Board of Urology.