Bladder Cancer - Robot-Assisted Laparoscopic Radical or Simple Cystectomy
Once the patient and his physician decide to have surgery for prostate cancer, the conventional option is to undergo open radical cystectomy. At the University Of Chicago Hospitals, we offer an alternative to the open surgical approach. The laparoscopic radical cystectomy is robot-assisted using the DaVinci robot system . 6 key-hole sized incisions distributed throughout the lower abdomen are made. The robot arms are placed through three of these keyhole incisions, the remaining incisions are for placement of instruments to hold and expose tissues in the pelvis during surgery. The surgeon is seated at a separate console a few feet away from the patient. He/she operates the robot arms and hands with a set of complex controls at the console. The surgeon is able to see the inside of the patient's abdomen in a three dimensional fashion. The bladder is separated from the front abdominal wall, and then the blood vessels to the bladder are clipped and divided. The uterus and part of the vagina may need to be taken with the bladder. The vagina is repaired and closed with sutures. The specimen is removed through one of the keyhole incisions that is extended to around 3". In a male patient, the operation starts by dissection of the seminal vesicles. The dissection is carried towards the direction of the feet, separating the back part of the prostate gland from the rectum. Then, the bladder is separated from the front abdominal wall, and the blood vessels to the bladder is clipped and cut. The bladder is further separated from all the adjacent attachments, marching down the pelvis. The prostate gland is then also separated from its side attachments until we reach the urethra. Finally, the urethra is cut. The specimen which includes the bladder and the prostate is removed from one of the keyhole incisions that is extended to around 3". Depending on the decision of the surgeon and the patient prior to the surgery, there are three major types of urinary diversion. The orthotopic neobladder pouch is created by suturing opened small bowel together to form a new bladder. The suturing is performed outside the body through the incision made for specimen retrieval. Both ureters are also connected to the pouch outside the body. The pouch is placed back into the abdomen, and it is connected to the urethra with sutures. The second type of pouch is the continent catheterizable stoma. In this type of pouch, the patient is able to pass a catheter to drain the urine from a continent stoma on the abdomen periodically. Again, the pouch is created outside the body, the ureters are connected to the pouch, then the pouch is dropped back into the abdomen, and the stoma is created on the skin. The third type of pouch is the ileal conduit. In this type of urine diversion, the patient places a urinary bag on the stoma to collect urine. In a similar fashion as the first two pouches described, small bowel is brought out of the body, the conduit is created, placed back into the abdomen, and the stoma is created on the skin. Once the surgery is done, the surgeon makes sure there is no bleeding, and the patient is awakened.
The advantage of the robotic-assisted laparoscopic radical cystectomy is less postoperative pain. This is in part due to the smaller incisions made, and the urinary stream is then diverted using bowel segments brought out through the 3" opening to diversions. No large metal retractors are needed to keep the incision open, which contributes to less pain. In the laparoscopic approach there is usually less blood loss, thus minimizing the chances for blood transfusion. The patients are encouraged to be out of bed and ambulate sooner. With quicker ambulation, many patients also experience quicker return of bowel function. The diet is advanced from clear liquids to regular diet as the patient's bowel function recovers. Once the patient can tolerate regular food and is walking about freely, they are discharged home. A typical hospitalization ranges from 4-7 days. In the laparoscopic approach the patients can expect to experience less pain when they return home. In addition to these advantages, the laparoscopic approach also offers a better cosmetic result due to the small and almost negligible incisional scars over time.