Robotic Surgery for Bladder Cancer and Transitional Cell Cancer

For patients with muscle invasive bladder cancer or aggressive bladder cancer, radical cystectomy—surgical removal of the entire bladder plus the regional lymph nodes—remains the gold standard for treatment. It may also be done to treat transitional cell cancer (cancer that occurs in the lining of the urinary tract) where the malignancy involves the bladder and has invaded the bladder wall.  Occasionally, this procedure requires removal of nearby organs as well, in order to provide cancer control. In women, this may include removal of the cervix, ovaries, fallopian tubes, uterus and part of the vagina. In men, it may include removal of the prostate, seminal vesicles and part of the vas deferens. In the past, radical cystectomy also involved removing the adjacent nerves that control erections in men. Today, however, a “nerve sparing” technique can be performed with male patients, in which the surgeon carefully navigates around these nerve bundles to preserve sexual function.

Open surgery, requiring an incision stretching from the belly button (or higher) down to the pubic bone, has traditionally been considered preferable to laparoscopy for radical cystectomies, due to the technically challenging nature of the surgery. But robotic radical cystectomy is now emerging as a viable alternative for bladder cancer patients, since the enhanced visualization and control of the da Vinci Si surgical robot affords the surgeon a level of precision comparable, or even superior, to that of open surgery. Robotic surgery also offers other advantages, particularly in terms of less intra-operative blood loss. And because the robotic procedure involves operating through a number of small incisions instead of a single large incision, it also offers the trauma-sparing benefits of minimally invasive surgery. Most robotic radical cystectomy patients are able to resume their normal activities within 6 to 8 weeks.

Depending on the stage of the bladder cancer, treatment may also include chemotherapy or radiation therapy. In treating bladder cancer, our robotic surgeons always work closely with medical oncologists and radiation therapists at the NYU Cancer Institute, employing a team approach.

How Robotic Radical Cystectomy is Performed

During a robotic radical cystectomy, the patient’s abdomen is inflated with gas and the robot’s camera and operating arms are inserted through quarter-inch incisions in the abdomen. The surgeon then uses the robot’s instruments to excise the bladder and surrounding organs en bloc (all together). These organs are then removed through a separate, 2- to 3-inch midline incision. A pelvic lymph node dissection is also performed as part of the procedure. Removing lymph nodes helps determine whether cancer is present in the lymph nodes and provides more accurate information about the stage of the cancer.  Robotics is ideally suited to this important staging procedure, since it allows the delicate dissection of the lymph nodes from important nerves and blood vessels with minimal blood loss and high accuracy.

Urinary Reconstruction

Since radical cystectomy involves removal of the entire bladder, patients are required to undergo urinary reconstruction as part of the procedure. In urinary reconstruction, the surgeon uses tissue from the patient’s intestine to fashion a new means of expelling urine form the body. Our surgeons are highly skilled at the full range of innovative reconstructive techniques, including:

Creation of an ileal conduit (urostomy). In this approach, the surgeon uses part of the patient’s intestine to create a channel that connects the ureters to a surgically created opening in the abdomen (stoma). In robotic radical cystectomy, the stoma site is created using one of the quarter-inch incisions employed during the original robotic procedure—meaning that no new incision is required. The urine passes through the conduit and out the stoma into an external plastic appliance, which is then emptied 3 or 4 times a day.

Creation of an orthotopic neobladder. In properly selected patients, an orthotopic neobladder may be fashioned to allow the patient to pass urine out through the urethra, in the same way he or she did prior to surgery. In this procedure, intestinal tissue is used to create a “neo” or new bladder, which is then attached to the ureters at one end and the urethra at the other—avoiding the need for an external appliance.

Creation of a continent catheterizable reservoir. Patients who aren’t candidates for an orthotopic neobladder but still wish to avoid the need for an external appliance may be eligible for this procedure. In this approach, intestinal tissue is used to create a reservoir for the urine, which the patient then empties every few hours by passing a catheter through a small opening (stoma) that is typically “hidden” in the belly button.

Advantages of Robotic Radical Cystectomy

Improved surgical visualization. One of the most important advantages of robotic radical cystectomy is the suberb, 3-D high-definition view of the pelvic organs offered by the da Vinci Si surgical robot. In the hands of an experienced robotic surgeon, this capability can greatly facilitate the delicate dissection and suturing required in this procedure.

Less blood loss than open surgery—reducing the need for blood transfusions.

Decreased pain and minimal scarring of the skin surface. A robotic radical cystectomy is performed through a series of small incisions, which are less painful, heal faster, and produce significantly less surface scarring than the larger incision associated with open surgery.

The da Vinci Si surgical robot improves the ability to perform lymph node dissection. In radical cystectomy, removal of the lymph nodes is an integral part of the procedure for both therapeutic and diagnostic purposes. By utilizing the da Vinci Si surgical robot, with its superior range of motion, urologic surgeons at NYU’s Robotic Surgery Center can perform a more extensive lymph node dissection than was previously possible with less-advanced robotic systems.

Other advantages: There is emerging data that suggests the robotic approach can improve recovery time as well as functional outcomes for patients undergoing radical cystectomy.