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ROBOTIC CYSTECTOMY
OKAY WHAT ARE THE THOUGHT ABOUT THIS FOLKS.???????
DAVID SAMADI HEAD AT MOUNT SANAI
Robotic surgical systems have thrust minimally invasive surgical options into a new era. For years now, surgeons and urologic oncologists have relied on the minimally invasive nature and nerve-sparing virtues of the procedure known as laparoscopic cystectomy to offer their patients the most effective treatment for bladder cancer. Not so long ago at all, cystectomy was performed using a traditional open surgical procedure; and therefore usually involved notable tissue and nerve damage, significant blood loss and carried a greater risk of post-operative infections and complications. By comparison, the robotic-assisted laparoscopic cystectomy, (also known as Da Vinci Robotic Cystectomy) may seem a bit like a kind of state-of-the-art miracle.In reality, the robotic cystectomy is simply a newer and more effectual minimally invasive bladder cancer surgical method. It that makes use of the Da Vinci Robotic Surgical System and imitates a surgeon’s movements—and amplify their precision, and in so doing, it offers bladder cancer patients the prospect of a more effective surgical and less problematic post-surgical outcome. It is fast becoming the favored surgical answer to cancer of the bladder. A minimally invasive surgical procedure will allow your surgeon, oncologist or urologist to operate without making large incisions; the result spares vital but delicate nerve and muscle tissue and facilitates a faster recovery time, fewer complications and a shorter hospital stay.
Just as with a standard laparoscopic cystectomy, the robotic-assisted version of cystectomy may call for urinary diversion followed by reconstruction once a bladder has been removed.
For men and women alike, such reconstruction would include a continent reservoir to hold urine within the abdomen until a patient has been fitted with a either a catheter—to empty urine or a bladder replacement and an ileal conduit—a urinary diversion that will collect urine in an external bag. More importantly, using the Da Vinci Robotic Surgical System will provide your physician with a superior visualization plane and more surgical dexterity during bladder removal, as well as during any necessary reconstructive procedure.
By offering your surgeon, urologist or oncologist a high-definition 3-D view, the Da Vinci Surgical Robot allows the vital muscles and delicate nerve tissues, surrounding the operative area to be more easily identified – and spared. The Robot’s unique EndoWrist Instruments offer physicians surgical dexterity that is simply not available to them when they’re using conventional laparoscopic instruments. By taking advantage of the Da Vinci Robot, surgeons are able to surgically dissect and reconstruct the bladder with relative ease.
SUMMARY OF ROBOTIC-ASSISTED CYSTECTOMY:
The advantages of a procedure designed to spare delicate nerve and muscle tissue.
Keyhole sized incisions distributed across you abdomen.
A brief 4 to 7 day hospital stay.
Less risk of blood loss …and a lower chance that you’ll need a blood transfusion.
Reduced scarring, minimal discomfort and less need for major pain medication.
Only one to three months’ worth of recovery time before you’ll regain your normal level of urine control.
*The benefits of da Vinci Robotic Prostatectomy cannot be guaranteed as surgery is both patient and procedure specific.BENEFITS OF ROBOTIC-ASSISTED CYSTECTOMY:
Minimal damage to vital muscle and delicate nerve tissue as a result of the surgery.
A shorter hospital stay and an even faster return to your normal level of activity.
Fewer noticeable scars.
Minimized risk of blood loss.
Minimized chances of post-operative infections.
Minimized chances of post-operative incontinence or impotence.
Minimized chances of other complications commonly associated with cystectomy.
Minimal post-operative pain and discomfort
You’ll have the unprecedented capacity of the Da Vinci Robotic Surgical System to offer surgeons, oncologists and urologists a high-definition, three-dimensional view of the procedure as well as robotically assisted suturing and stitching, at your disposal.
TYPICAL OPEN SURGICAL CYSTECTOMY:Greater risks associated with any procedure that requires a larger surgical cut-in
Potentially greater discomfort and a longer post-operative hospital stay
Potenntially more postoperative scarring, muscle damage and nerve damage
Potentially more postoperative soreness and a greater need for perscription pain medication
Longer post operative recovery time
Before you decide on which course of action would be right for you, it may help you to know that open surgery patients can experience five times the loss of blood, have four times the risk of other complications, a high chance of infection, incontinence or impotence and are forced to spend roughly three times as much time in the hospital as patients who opt for robotic-assisted surgery.Robotic-Assisted cystectomy also offers patients a cancer removal rate that’s 14% higher … as well as increased prospects that they’ll be able to engage in normal sexual activity in as little as 11 months — by comparison, patients who opt for open surgery are often unable to for years.
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16 Replies
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Yes i did see that..only he didn’t single me out as his Star Indiana Pouch person…i expected to go on Oprah or at least get a by-line in the National Enquirer! Geez! And i was in the extracorporal group which explained the 3″ incision to the right of my abdomen…but he has a great whipstitch! Pat
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Holly, thank you so much for your wisdom and understanding. I send you a big fat virtual hug.
Hey…Pat, I bet you caught this recent review from Dr. Gill about laparoscopic cystectomies?
http://www.urotoday.com/browse_categories/bladder_cancer/laparoscopic_radical_cystectomy_for_cancer_oncological_outcomes_at_up_to_5_years.htmlI also bet you are included in this follow up!
“Drs. Georges-Pascal and Gill detail the oncologic findings and short-term recovery from laparoscopic radical cystectomy for clinically organ confined bladder cancer. The authors evaluated 37 patients who underwent laparoscopic radical cystectomy from 1999 to 2005.
There was equal distribution of patients receiving a neobladder and an ileal conduit. The initial 17 patients had laparoscopic cystectomy and urinary diversion done intracorporeally and the subsequent 20 patients had the urinary diversion done extracorporeally. A limited node dissection was done on the initial 11 patients by the subsequent 26 patients had an extended lymph node dissection.
The authors reported that the disease free survival after the laparoscopic radical cystectomy appeared to be similar to historical controls of open radical cystectomy for similarly staged patients. Obviously the small number of patients included in this study limits the ability to make definitive considerations but importantly there was no evidence of a pelvic or port site recurrence. The complication rates are significantly higher in patients who underwent an intracorporeal urinary diversion and this prompted the change to an extracorporeal formation of the urinary diversion. The length of hospital stay and pain management was similar to the open technique. Pathologically, there were two patients who had positive surgical margins: one with T3a and one with T4a disease. Whether these patients would have had a negative surgical margin with the open surgical technique is unknown.
This article demonstrates the feasibility of performing laparoscopic radical cystectomy and urinary diversion. Important information from this study is that even in expert hands the intracorporeal urinary diversion is problematic and should be done extracorporeally. Further data with more patients and longer term follow-up is required to determine the oncological benefit or equivalence to the open radical cystectomy however, the major concern of pelvic or port site recurrence was not found in this study.
Georges-Pascal H, Gill IS
BJU International. 100(1):137-142, July 2007
doi:10.1111/j.1464-410X.2007.06865.x -
Hi Wendy :)
Please – you have absolutely nothing to apologize for! This website has literally saved my life. Without this website I would have had BCG treatments for Stage3 grade 3 micropapillary bladder cancer and they would not have found the urachal cancer until my autopsy. I am grateful for the accurate and timely info here delivered with hugs and compassion – Bless you always.
Mayo’s and Dr Blute are indeed top notch and if I had it to choose over again – I would make the same choices in surgeon, hospital and choice of diversion. But I have had a very difficult time in finding info on recurrance and survival rates for my path in recovery – now I know why. Again – it would not have changed my choices, it just explains alot.
In all honesty, I have had no idea how rare a breed those of us are. It certainly was not presented as a trial, but rather as the best option I had available to me (which I believe it was). It is to say the least – sobering. To realize that treatment for this cancer is so lacking. The cancer has caused my distress – not your honesty. And thank you for the forthrightedness.
God bless all us pioneers, Holly
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There it is…The Learning Curve…..I didn’t want nor did i seek anyone still on the learning curve highway. And as for the reduction in length of skin incisions it was quite a reduction for me…Dr. Stein usually goes from the sternum down to the Netherlands and thru the muscle…Dr. Gill i kid you not..3 incisions of maybe l/2″ on the abdomen nowhere near a muscle and the longer 3″ one to the right of the navel and just a tad lower. I know he travels all over the world teaching this but i don’t think there is much interest in it in the U.S….much tougher to learn. I know one of his fellows at the time of my surgery is now in pediatric urology here at Childrens Hospital..but the rest of the residents and members of his team are in other fields. I will try to get some follow up information from him…i don’t know how he would have time to publish…he’s in surgery 4 days a week and seeing patients the other day. I do know his criteria is not a single tumor preferably T2…i know of one patient that was already in Stage 4 that waited and was in denial about the serverity of his condition…he didn’t make it…another woman an 84 yr old who had other problems….she died of heart disease……
And yes stuff like this does make you wonder about your particular course and second guess what you thought was a most thorough and incredible and exaustive search. I’m in absolute terror of what my Ct scan of Friday showed. I think i’ll name my book “When Can You Breathe Again”…………Pat -
[quote author=mznoregrets link=topic=1197.msg8269#msg8269 date=1190550521]
Hi Wendy and Pat and all, Please do not think I am trying to be difficult here, I just am confused by the last few posts and what I thought I had an understanding of in regaurds to the Da Vinci…
My procedure was done at Mayo’s with the DaVinci – and it wasn’t presented in a fashion of “qualifying” for having an excellant prognosis. Dr Micheal Blute was my surgeon – he has been doing neobladders on women for quite some time. I would find it very hard to believe that this procedure was not available by him 4 years ago. I do intend to find out for sure when I go for recheck on Oct 8. I will post what I learn.
Also I would like to ask where the stats are showing worse survival for DaVinci. I have not seen these and it does conflict with information I was given prior to surgery. Again – I will also address this at Mayo’s and share what I learn.
Again, please know that I am questioning as my understanding doesn’t agree. I merely want to be sure of what I know and how it has/could impact me.
God Bless us all, Holly
[/quote]Dear Holly,
First off, never second guess your path once you’ve taken it as believing in your chosen treatment is half the battle (at least, I think so). You went to a top notch hospital, one of the best in the world, and your surgeon is too. He would not have done robotic surgery unless he thought it would benefit you-this I’m 100% positive about.
It’s true that not every person would qualify just as not every blc patient qualifies for bladder sparing, or for neobladders (for example).
There are no stats on Da Vinci for cystectomy yet, it’s just too new. Laparoscopic cystectomy is also extremely new and the 4 yr stats are coming back and I’m sorry to say that the results have been less than expected, given the fact that they do hand pick people with single tumors, preferably stage 2 and in good general health, which would normally mean that the results should be outstanding.
I’m very reluctant to say something like this–not only has Pat had a laparoscopic RC but others as well (and doing fine, I might add). There are only something like 200 people on which to do follow up with after 4 yrs.
Both laparoscopic RC and DaVinci RC’s are still highly experimental procedures and the long term benefits of Da Vinci is not yet defined. If your doctor didn’t tell you this then he was remiss. Best would be if you were part of a clinical trial…but even if that wasn’t the case, believe me, your experience will count. Actually, you’re a pioneer making history and defining what may be the future of RC. Pat too.
The hardest part about doing this site, discussion group and this forum is the risk that I will upset or worry someone by reporting to the best of my knowledge, honestly about the state of things. I hope you accept my apology for causing you worry.
Please do ask lots of questions to your doctor and let us know what he says if you can.
Dan reported John Stein’s and USC’s review of laparoscopic RC’s just coming in, I had this one as well, both are very recent, if you want I can send you the whole article in pdf form; an excerpt:
JULY 2007 VOL 4 NO 7 PUPPO ET AL. NATURE CLINICAL PRACTICE UROLOGY 393
http://www.nature.com/clinicalpractice/uro
Most series in which LRC has been studied
have included patients with fewer comorbidities
and lower-stage cancers than participants in
ORC[open RC] studies. Also, publications on LRC often do
not report the number of lymph nodes retrieved
during the procedures; consequently, there is a
dearth of that type of information. Some later
papers report a median number of nodes excised
within the range fixed as standard for ORC.
Overall, most of the information published
on LRC is devoted to the description of the
operative technique; follow-up data and
survival rates are generally lacking. In addition,
given the more favorable inclusion criteria for
participants in LRC than in ORC studies, the
disease-free survival of 80% at follow-up seems
to be inferior to that reported by major series
of ORC. Obviously, to assess adequately the
surgical safety and the extent of cancer control
achieved with LRC, studies must be done with
more-homogeneous cohorts and with cohorts
comprising a broader range of patients, along
with longer follow-up periods than those that
have been used to date.
LRC is expensive and time-consuming [again, most people getting LRC and/or DaVinci spend just as long on the table as with regular RC, it is not a shorter surgery in spite of Pat’s experience, and yours–w}, and
surgeons endure a long learning curve to master
the technique; therefore, the choice of urinary
diversion becomes limited. Meanwhile, advances
in ORC techniques have reduced blood loss and
duration of surgery. Before LRC can be advocated
for integration into clinical practice, the
effect of the degree of invasiveness on outcomes
needs to be compared for LRC and ORC. The
reduction in length of skin incisions by a few
centimeters in LRC does not justify an overhaul
of established urological surgical practice.
Further reductions in blood loss, consumption
of analgesics, and length of hospitalization,
might overcome the high cost of LRC instruments,
long operating times and the need for
dedicated teams of surgeons. So far, however,
the main advocated advantages of LRC—low
transfusion rate and short hospital stay—are
at best similar to those of ORC. Disadvantages
of LRC, such as worse oncologic outcomes and
the excessive use of nonorthotopic types of
diversion, might outweigh these advantages. (what he is saying here is that more people undergoing LRC get pouches or ileal conduits rather than neobladders, and neobladders are considered state of the art at this point in time)
■ The proportion of patients with orthotopic
neobladders and who remain disease free
seems to be suboptimal compared with
ORC, and might actually represent major
disadvantages of LRC -
Yes its interesting to know where the stats are coming from…in the hands of what inexperienced surgeons. Here’s where the exaustive research comes in….You just have to find out who’s the best and get his or hers stats. My Laproscopic surgeon is considered the best in the World..now there may be a difference between time on the table for women vs. men. Its much easier to get the female organs out than the nerve sparing prostatectomy. My time on the O.R. table was 4hrs 20mins..no blood loss..3 bandaid size incisions on my abdomen and one about 3″ long on the right side where the bladder was removed and new Indiana Pouch placed in. Post op pain i would say was right up there with the conventional surgery unless i have an extremely low pain tolerance level..it didn’t help that my morphine pump wasn’t working…but by day 3 i was uncomfortable, couldn’t stand up straight yet, but more aggrevated by the nasal gastic tube. Day 5 i went home.
I know Holly’s DaVinci surgery was under 4 hrs with a neo-bladder.
As for some of the stats…its possible that some candidates are at risk for other complications as they have heart disease or some other medical condition that would put them at great risk for a longer surgery and blood loss. Their prognosis may not be the best to begin with so who knows what those stats include. I know my surgeon just worked in tandem with a conventional surgeon at The Cleveland Clinic (which is a first)..He quickly removed the bladder laproscopically with no blood loss and got a good cross section of lymph nodes and the conventional surgeon proceeded with the ilial conduit.
Again it boils down to really doing your homework on your surgeon and your hospital…and i agree time will tell but there are excellent surgeons available in this field… not a lot agreed..the rest may have to catch up but they will is my guess. I love progress. Pat -
Hi Wendy and Pat and all,
Please do not think I am trying to be difficult here, I just am confused by the last few posts and what I thought I had an understanding of in regaurds to the Da Vinci…
My procedure was done at Mayo’s with the DaVinci – and it wasn’t presented in a fashion of “qualifying” for having an excellant prognosis. Dr Micheal Blute was my surgeon – he has been doing neobladders on women for quite some time. I would find it very hard to believe that this procedure was not available by him 4 years ago. I do intend to find out for sure when I go for recheck on Oct 8. I will post what I learn.
Also I would like to ask where the stats are showing worse survival for DaVinci. I have not seen these and it does conflict with information I was given prior to surgery. Again – I will also address this at Mayo’s and share what I learn.
Again, please know that I am questioning as my understanding doesn’t agree. I merely want to be sure of what I know and how it has/could impact me.
God Bless us all, Holly -
I have done some research on this. I have a friend that had it done 5 years ago . I think one of the first. It was done at Henry Ford Hospital in Detroit by Dr Menion and another surgeon as a team. One does the removal and one builds the Neo. He has done so well normal sexialy. His surgery was longer than convetional I think 9 hours. His recovery time was much shorter and hardly any pain meds.I was going to have mine done this way but insurance at the time would not pay and said it was concidered experamental. This was July of 06. I went for interferon and so far have dodged the bullit on surgery. So for 9 months I have been clear till last Monday. I will post on that later. If I need to have it done I would only have it done by robotics. Don
Hanging in there!
About robots and laparoscopic cystectomies…I agree with Dan that it’s not quite ready for prime time. The stats coming in are showing worse survival even though the candidates are hand picked for having excellent prognoses. The robotic technique is coming off better than the laparoscopic technique, but I’m not convinced that either technique is an advancement yet.
They still need to make a large incision, it takes just as long on the O.R. table (pat’s doctor excepted).
Shorter hospital stays, less blood loss and less pain post-op is the only proven benefit at this time.
WendyWell supporting data is not going to exist since #1 the DaVinci is only being used by a few for cystectomy….and #2 there was at the time of my laproscopic cystectomy only one surgeon doing it in the world and he happens to be also the head of the Transplant division at the Cleveland Clinic…i doubt that there are many out there doing it today..it requires amazing surgical skills. The conventional surgeon whether it be in urology or cardiology or whatever division is going to poo pooh the laproscopic surgeon and the DaVinci surgeon…they don’t like one another for obvious reasons.
With the large screen available to the laproscopic or DaVinci surgeon they have an amazing view which the human eye cannot see with the same clarity.
Just my opinion and i have the utmost respect for Dr. Stein.
Pat
The article is interesting but comes across as a promotional piece (e.g. isn’t technology wonderful!).
One thing this article fails to mention is that there are several studies showing that for patients with muscle-invasive blc (and that’s if the patient/surgeon know this for sure BEFORE surgery – keep in mind that cancer is upstaged quite often and that what is thought to be superficial cancer often turns out to be muscle and/or lymph node invasive AFTER surgery), oncologic outcomes are better when extended lymph node removal is done. 25 nodes removed may be better than 5, or 35 vs 25 or 65 vs 35. By selectively omitting such important information, it seems to me that that this cancer center is trying to increase patient volume to cover the considerable overhead associated with the purchase of their “state of the art miracle” machine.
Instead, today, I’d feel much more comfortable choosing the surgeon over Da Robot (and I don’t mean to minimize the benefits of technology). But especially if one has muscle-invasive blc, go with a top surgeon who remove lots of lymph nodes rather than focus on shorter time on the operating table…
Also, why the scare tactics when comparing laparaoscopie to open surgery (e.g. loss of five times the blood, greater chance of infection and incontinence and impotence…). The statistics quoted by the author of the article may be all too real for some, but I don’t believe they are representative of the top surgeons at the top institutions. None of this happened to me – plus I had nerve sparing surgery and (to my relief), it worked (no pills/shots needed…).
Here’s what Dr. Stein has to say about laparaoscopic RC:
PURPOSE OF REVIEW: Radical cystectomy with an appropriate lymph node dissection… is the standard treatment for muscle-invasive transitional cell carcinoma… Optimal outcomes following radical cystectomy require an extended lymph node dissection, negative surgical margins… There has been an increasing number of reports describing initial experiences with laparoscopic radical cystectomy.
RECENT FINDINGS: Intermediate and long-term oncologic outcomes with laparoscopic radical cystectomy remain undefined, and appropriate lymph node dissections laparoscopically have not been uniformly performed. Furthermore, the long-term functional outcomes associated with laparoscopically performed urinary diversions also remain undefined. There appears to be a recent trend toward performing the urinary diversion portion of the procedure extracorporeally, after laparoscopic removal of the bladder. Some studies suggest a decrease in postoperative analgesic requirements and quicker recovery of bowel function in those undergoing laparoscopic radical cystectomy, but these observations have not been corroborated by others.
SUMMARY: In the absence of long-term functional and oncologic outcome data, laparoscopic RC should be considered an investigative technique, and potential candidates for this operation should be appropriately counseled.
His summary is prudent and reasonable. It’s great to use laparaoscopic surgery, one’s results may be great, it may be one’s best option given the choice of doctors… it’s just that all of the supporting data does not yet exist.
Dx 7/04, CIS + T1G3, Age 50
2 TURBTs
12 BCGs
Cystectomy 8/05 USC/Norris
So far, so good (kow)
I think I agree with Zach on this one something more common down the road, but I don’t see it being common for us here baby boomers oh well at least we have the opt for the regular surgery. I was thinking back in my hippie days early 70’s you wouldn’t even think about surviving bladder cancer so things have come a long way. Joe ;)
Hi Star,
I have been following your posts and saying prayers for you as you navigate thru the bladder cancer. Just thought I would let you know I had cystectomy/neobladder done in March at Mayo’s in Minnesota by Da Vinci. My surgery was 3.5 hours to do the removal, neo and take 35 lymphnodes. Another surgeon from the University of Wis Madison was offering to do it traditionally with on the table time of 7-9 hours. I did need 2 units of blood within 2 days of the surgery – I think that would have happened regaurdless tho. I was pleased with the robotic and I would highly recommend it. Best wishes and God bless, Holly
[quote author=Patricia link=topic=1197.msg8239#msg8239 date=1190482829]
Actually the DaVinci is in about 500 hospitals now … only problem is they’re using it for heart surgery, prostate surgery, and you name the surgery ..everything but cystectomy. [/quote]That’s what I meant. For cystectomies it’s not a real viable option unless you want to travel. My own opinion is that, as it is right now, I would choose the surgeon over method. I’d rather have Dr. Stein or Dr. Schoenberg operating on me conventionally than someone less experienced using a Da Vinci.
Your mileage, as always, may vary.
Don’t misunderstand me–this is a thrilling technology. At the moment, for most of us, it’s just a little too far around the corner.
“Standing on my Head”––my chemo journal
T3a Grade 4 N+M0
RC at USC/Norris June 23, 2006 by Dr. John SteinActually the DaVinci is in about 500 hospitals now … only problem is they’re using it for heart surgery, prostate surgery, and you name the surgery ..everything but cystectomy. However, having said that there are a few major centers that are using it for cystectomy…Mayo Clinic for one..and Mt. Sinai…….I’ll have to do a little research to find out the others if any. Its still a learning curve and the young docs coming up who were weaned on video games are whizes at mastering this system. In my major city where there is noone doing Indiana Pouches and maybe there is one neo-bladder floating around…it’s not going to happen anytime soon…but they are using it for bypass surgery at one of the major hospitals..interestingly enough not the major heart hospital here. Pat
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