When bladder cancer invades deep into the wall of the bladder, it is usually necessary to surgically remove the bladder (radical cystectomy). Although many methods of removal exist today, the goals are always the same – remove the entire bladder and create an alternate route for urine flow and storage. Traditionally this procedure has been performed through a large incision in the abdomen, resulting in a potentially long recovery. Robotic removal using small “button-hole” size incisions can reduce the operative risk and recovery time. This technique can also be used to remove an abnormal bladder for reasons other than cancer.
Robotic technology enhances the expertise of the surgeon during bladder removal. Robotic instrumentation not only allows very precise separation of the bladder and lymph nodes from surrounding tissues, but also eases the meticulous suturing during reconstruction of the urinary reservoir. Of course the daVinci robotic system is only a tool; like any instrument, it is only as good as the surgeon behind it. In 2002, Scott D. Miller, MD performed the first laparoscopic radical cystectomy in the state of Georgia. After developing this technique and achieving results superior to open surgery, Dr. Scott Miller applied this expertise to the first robotic cystectomy in Georgia. By combining the experience of more than 3,500 major laparoscopic and robotic surgeries since 1995, state-of-the-art technology meets the ultimate in technique.
Robotic cystectomy is a laparoscopic procedure, only with an added layer of technology. As with other laparoscopic procedures, the surgeon makes a button-size incision in the abdominal cavity for the insertion of a telescope (in this case near the belly button). After expanding the abdominal cavity with carbon dioxide gas, five additional small incisions are made to place narrow tubes used for interchangeable instruments. The robotic device is then wheeled up to the patient and the robotic arms are attached to the telescope and three of the instruments. The surgeon then sits at the control console a few feet from the patient, leaving the surgical assistant and scrub nurse at the patient’s side.
The surgeon then views a highly magnified, three-dimensional image of the instruments and the patient’s interior structures. All movements of the camera and robotic instruments are precisely performed in real-time by the surgeon with ergonomic finger controls. The tips of these instruments can make any wrist-like turn that the surgeon so desires. The bladder and lymph nodes are carefully separated from the delicate surrounding structures using tweezers and scissors the size of a fingernail (although these scissors appear to be the size of hedge clippers to the surgeon). The bladder and lymph nodes are placed in small plastic bags, later to be removed in one piece through a small abdominal incision – or in the case of a female, through the vagina. Using a segment of intestine, a urinary reservoir is constructed. Dr. Scott Miller will discuss which method of reconstruction is best for each individual. In some cases, a “new” bladder can be constructed and placed in the previous location of the original bladder. In other cases, it is best to have the urine flow into an external bag placed on the abdomen. The skin openings are closed with shower-resistant glue as a substitute for both stitches and bandages.
Results & More
Robotic cystectomy facilitates quicker recovery, less pain, and a lower complication rate as compared to the typical open-incision bladder removal. Obviously, the primary goal is cancer cure. Our cure rates have either matched or surpassed any other published series for open-incision bladder removal. A vast experience and a world-class surgical team help ensure this high level of success.
Most patients are discharged from the hospital 5-10 days following surgery. Risk of transfusion, urinary leak, damage to surrounding organs, blood clots, pneumonia, and wound infection are each under 5%.
Q: How much pain can I expect after the procedure?
A: Pain is typically less with laparoscopic procedures when compared to open-incision surgery. Some abdominal cramps and shoulder discomfort can occur from the carbon dioxide gas used during surgery. This type of pain is best treated with anti-inflammatories rather than narcotics. Although everyone is different, post-operative discomfort is usually easily managed and short-lived.
Q: Is bruising normal after a laparoscopic procedure?
A: When a narrow tube is placed through a button-size skin incision, a small blood vessel just below the skin can break. However, since the snug fit of this tube will compress the blood vessel during surgery, bleeding will often not occur. If this blood vessel were to re-open at a later time, a small amount of blood could track over a large surrounding area (including the genitalia). This is not a true bruise but will have the same appearance. Most important, this finding is not an indication of internal problems.
Q: When can I return to work or other normal activities following my surgical procedure?
A: Dr. Scott Miller recommends at least four weeks away from work. Very few jobs would require more than six weeks of leave. In many cases, a small amount of light work-related duties are acceptable during the first three weeks. All patients should move around frequently from the time of surgery and resume light exercise at one week (gradually increasing to a normal routine by four weeks). Driving a car is often reasonable in approximately ten days if reaction time is good. Of course, Dr. Miller will provide guidance for each individual situation.
Q: How long does the surgery take Dr. Scott Miller to perform?
A: Although many variables can affect the time necessary for Dr. Scott Miller to meticulously perform the surgery, he usually completes the procedure in five to six hours. However, the time away from family members also includes preparation (30-40 minutes), anesthetic reversal (15-20 minutes), and recovery room stay (2 or more hours). Dr. Scott Miller asks patients to arrive two hours prior to this process, during which time family members can remain present. Occasional updates are given to the family by the operating room nurse. Dr. Scott Miller will come to the waiting area when the patient is ready for transfer to the recovery room.
Q: How long do I stay in the hospital following surgery?
A: Most patients are ready for discharge 5-10 days following surgery.
Q: How long will I need drainage tubes following surgery?
A: The number and duration of drainage tubes vary based on the individual patient and the type of urinary reconstruction.
Q: Should I donate blood prior to my procedure?
A: Since the risk of needing a blood transfusion is less than 5%, blood donation is not necessary.
Q: When can I shower or bathe following my surgery?
A: Since shower-resistant glue was used as a substitute for both stitches and bandages, showering is acceptable once discharged from the hospital. Although water will not harm the surgical areas, mechanical cleansing of the incisions should be avoided for two weeks to prevent premature removal of the glue. Dr. Scott Miller will discuss complete immersion such as bathing or swimming.
Q: What long-term follow-up care will I need?
A: In cases of bladder removal for cancer periodic x-rays and blood tests will be necessary on a long-term basis.
Q: How will bladder removal affect my overall quality of life?
A: Once fully healed and educated, you should be able to return to most of your normal activities.
Q: How does the cure rate with robotic cystectomy compare to open-incision bladder removal?
A: The cure rate for robotic cystectomy is equal to open-incision bladder removal.
Q: Will I need chemotherapy or radiation following bladder removal?
A: For more extensive or aggressive disease, Dr. Scott Miller usually consults a medical oncologist (cancer specialist) for recommendations for additional treatments when needed.
Q: Does robotic cystectomy affect bowel function?
A: Typically robotic cystectomy has very little long-term effect on bowel function.
Q: What happens if the robot experiences mechanical failure?
A: Dr. Scott Miller will disconnect the robotic arms and complete the procedure laparoscopically through the same narrow tubes. Unlike most robotic surgeons, Dr. Scott Miller acquired a vast experience with laparoscopic prostate removal prior to the availability of robotic technology.
Q: Does the robot perform the surgery?
A: No. Dr. Scott Miller performs all robotic instrument and camera movements in real time with the controls at the surgeon’s console. By no means is the robotic device programmed to execute any maneuver on its own.