Bladder Cancer and Robotic Bladder Cancer Surgery


Bladder cancer is a type of malignancy arising out of the urinary bladder in which abnormal cells multiply without control. A bladder is a hollow and a muscular organ about the size of a grape fruit that stores urine and is located in the pelvis. Bladder cancer causes blood in the urine.

According to statistics, bladder cancer is the 4th most common cancer in men and 9th most common cancer in women in the world with 350,000 new cases registered every year. It roughly claims of 145,000 lives annually. Men are 3/4th times more prone to bladder cancer compared to women. Genetic factors, family history, lifestyle such as rate of smoking or drinking are some of the issues causing bladder cancer. It is most common among certain ethnic groups such as South and East European countries, parts of Africa, the Middle East and North America. In USA also bladder cancer is the 4th most common cancer among men and 9th most in women.


Bladder Cancer – Symptoms

Some of the common symptoms for Bladder cancer are:

  • Blood in the urine (making the urine slightly rusty to deep red)
  • Pain during urination
  • Frequent urination or feeling the need to urinate without results
  • Low back pain

Above symptoms are not the sure sign of Bladder cancer. All these above symptoms can also be the sign of Infection, Benign tumors, Bladder stones or other health problems.

Any person with the above sign or symptoms of bladder cancer should visit their family doctor or a specialized urologist.

 
 

Stages of Bladder Cancer

Staging of cancer is based on how cancer develops in the body. The nature of the cancer is that, it divides and grows to form a mass of tissue called a tumor, and as it grows, it can invade nearby organs and tissues. These cells may also break away from the tumor and enter the bloodstream or lymphatic system. These cells moves through the bloodstream or lymphatic system, and cancer can spread from the primary site and form new tumors in other organs. These new site of cancer is called metastasis 2.

The reason to define stages of cancer:

  • Staging helps the cancer diagnosis and treatment process.
  • Any particular stage of cancer helps to estimate the person's Prognosis (outcome or course of the disease).
  • Knowing the stage help to identify clinical trials that may be suitable for patient.
  • It helps researches and health care providers to share information about patients, and help to improve treatment option by doing so.

Read more for some of the common tests to determine Bladder Cancer stages:

Tests to determine Bladder Cancer stages

Cystoscopy: A cystoscope is a thin, tube-like instrument with a light and a lens for viewing. Cystoscopy is a procedure to look inside the bladder and urethra to inspect the problem area. It can also be used to remove the sample of the tissues to test under microscope.

CT scan (CAT scan): A procedure that makes several detailed pictures of areas inside the body taken from different angles. The pictures are created by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly.

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to take several details of the body from inside.

Physical exam: An exam of the body to check general signs of health, including signs of disease such as lumps or anything else that seems unusual.

History: History of the patient's health habits and past illnesses and treatments will also be taken.

Chest x-ray: An x-ray of the organs and bones inside the chest.

Bone scan: A procedure to check for rapidly dividing cells such as cancer cells in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.

Treatment options will depend on the stage of your disease. The following is a description of the various stages of bladder cancer:

Stage 0: In this stage, abnormal cells are found in tissue that lines the inside of the bladder. These abnormal cells may become cancer and spread into nearby normal tissue. In stage 0, tumors look like a tiny mushrooms going from the lining of the bladder.

Stage I: In stage I, cancer has formed and spread to the layer of tissue under the inner lining of the bladder.

Stage II: In stage II, cancer has spread to either the inner half or outer half of the muscle wall of the bladder.

Stage III: In stage III, cancer has spread from the bladder to the fatty layer of tissue surrounding it, and may have spread to the reproductive organs (prostate, uterus, and vagina).

Stage IV: In stage IV, cancer has spread from the bladder to the wall of the abdomen or pelvis. Cancer may have spread to one or more lymph nodes or to other parts of the body.

 
 

Risk factors

There are numerous risk factors, including:

Smoking: Smoking is the greatest risk factor. Smokers are twice at risk to get bladder cancer than people who don't smoke.

Chemical Exposure: People who are exposed to chemicals are at risk to get bladder cancer such as chemicals used in the making of dyes or Aromatic Armines which is used to make rubber, leather, printing materials, textiles, and paint products.

Race: Asians have the lowest rate of bladder cancer.

Age: The risk of bladder cancer increases with age.

Gender: While men are more prone to bladder cancer than women however, recent statistics reveal an increase in the number of women being diagnosed with the disease.

Chronic bladder inflammation: Urinary infections, kidney stones and bladder stones don't cause bladder cancer, but they have been linked to it.

Personal history of bladder cancer: Those who already suffered from this disease have a higher chance of getting another tumor. People with a family history are also at risk to suffer from bladder cancer.

Birth defects of the bladder: Very rarely, a connection between the belly button and the bladder doesn't disappear as it should before birth and can become cancerous.

Arsenic: Arsenic in drinking water has been one of the causes of bladder cancer.

Earlier Treatment: Some drugs or radiation used to treat other cancers can increase the chances of bladder cancer.

 
 

Treatment Options:

It totally depends on the stage of the bladder cancer (0 to 4 stages) and there are four standard treatment options of the disease such as:

  1. Surgery
  2. Radiation
  3. Chemotherapy
  4. Biologic Therapy

The type of treatment that will be recommended by physicians will depend on the type of each patient's case and the stage he/she belongs. It is important to discuss all the treatment options with the doctor before making a decision best fitting the individual's situation.

 
 

Robotic Bladder Cancer Surgery (Cystectomy)

A cystectomy is the removal of all or part of the bladder, as well as the removal of nearby lymph nodes and organs that may contain cancer. If the bladder is removed, the surgeon creates a new way or path for urine to be stored and to leave the body.

Cystectomy is traditionally performed using an open approach, meaning the surgeon must make a large abdominal incision to access the bladder. Another approach is conventional laparoscopy, which is less invasive but due to the usage of surgical instruments, laparoscopy limits the doctor's dexterity, vision, and control in comparison to open surgery.

Da Vinci® Cystectomy:

If the doctor recommends surgery then the patient is the candidate of minimally invasive Da Vinci Cystectomy. Da Vinci uses state-of-the-art technology to help doctors perform a precise operation through a few tiny incisions with enhanced vision, precision, dexterity and control. Further, it also offer potential benefits to bladder cancer over traditional open surgery, including:

  • Significantly less pain
  • Less blood loss
  • Fewer occurrences of major complications
  • Shorter hospital stay
  • Quicker recovery of bowel function
 
 

Robotic Bladder Cancer Surgery at CRS

Bladder Cancer SurgeryRobotic bladder surgery, bladder reconstruction surgery and other bladder related conditions has come a long way in the last few decades. From open to laparoscopic to now robotic — bladder cancer surgery has become safer and more effective thanks to the technological advancements involving robotic surgery in India.

At Centre for Robotic Surgery – A leading bladder cancer treatment center in India, the innovative robotic surgery technique is used to conduct various bladder related surgeries including:

  • Robotic Cystectomy and Partial Cystectomy
  • Cystectomy with Neobladder
  • Nephro-Ureterectomy
  • Uretero-Calycostomy
  • Ureterolysis
  • Cystectomy with Ileal Conduits

And more…

Robotic Cystectomy and Partial Cystectomy

With the help of a robotic surgical system such as the da vinci surgical system used at Centre for Robotic Surgery – A bladder cancer surgery center in India, even complicated bladder cancer surgery can be performed effectively. Robotic bladder cancer surgery offers various advantages to the robotic surgeons during operation due to which vital and delicate nerves and muscle tissues are spared, leading to faster recovery of the patients.

Bladder Reconstruction Surgery

The da Vinci Robotic Surgery System is especially useful in bladder reconstruction surgeries which may sometimes be required after a cystectomy. With the help of the da vinci robotic surgical system , the robotic surgeon gets enhanced dexterity and visualization required during the reconstruction process, which has significant advantages over the traditional open and laparoscopic surgeries.


Benefits of Robotic Bladder Cancer Surgery

The state-of-the-art da Vinci Surgical System provides several advantages to both the robotic surgeon and the patient in a robotic cystectomy as well as other robotic bladder surgeries.

For Robotic surgeons, the benefits include:

  • A high-definition, 3-D view of the ongoing procedure
  • Better dexterity
  • Better precision due to filtering of hand tremors
  • More degrees of freedom compared to human hand

As a result of the above, bladder cancer treatment offers the following benefits to the patients:

  • Spares delicate nerves and muscle tissue
  • Small keyhole-sized incisions and hence, fewer scars
  • Shorter hospital stay
  • Quicker return to normal activity level
  • Reduced risk of blood loss as well as blood transfusion
  • Reduced risk of post-operative infections
  • Much less pain post the surgery
  • Faster regain of normal urine control and sexual functions compared to open surgery

Bladder Cancer Surgery : Post-Operative Care

  • After the robotic bladder surgery operation, patient is usually kept in the postoperative ICU for 48 to 72 hours.
  • The patient is actively monitored during this period for any complications.
  • Usually we advise patient to move lower limbs and actively do chest physiotherapy exercises within the same evening.
  • The patient is asked to sit on the next postoperative day.
  • He is ambulated fully on the second postoperative day.
  • Depending on the abdominal fullness, the tube that is placed in the stomach through the nostrils is removed on either 2nd or the 3rd postoperative day.
  • The bladder catheter tube is washed with saline water to get rid of mucus every eight hourly interval.
  • Once the patient is comfortable, he is shifted out of the ICU and kept in the rooms before discharge.
  • A drain is monitored for output and is generally removed once the output is less than 100 ml.
  • Usually patient starts tolerating food on the 3rd day. If the treating Robotic surgeon delays it, then he/she is supplemented with intravenous energy fluids.
  • The patient normally goes out of the hospital with a bladder tube on 5th or 6th postoperative day.
  • The catheter remains for a period of 3 weeks and then is removed after a small procedure under fluoroscopy.
  • We ask the patient to be admitted for a day or two after catheter removal in the 3rd postoperative week. Patient is again monitored for normal voiding and any deviation thereby.

Bladder Cancer and Robotic Bladder Cancer Surgery: Frequently Asked Questions

 

1. What are the signs and symptoms of bladder cancer?


The most common sign of bladder cancer is blood in urine that can be easily seen
. Sometimes it may be that the tumors do not produce enough blood for a patient to see (microscopic hematuria) and are only detected with the help of special chemicals and a microscope after a urine test is done by a physician.The overwhelming majority of patients who have microscopic hematuria do not have cancer. Irritation while urinating, as well as urgency, frequency and a constant need to urinate may be symptoms a bladder cancer patient initially experiences.

 

2. What types of tests will the doctor conduct to determine if I have bladder cancer?

Ultrasound, CT IVU scans (computed tomography), can detect irregularities in the bladder wall, which would suggest a possible cancer. The urologist will also look inside the bladder with a Cystoscope to visually examine your bladder and remove samples of any suspicious areas for biopsy. Urine cytology will be performed to detect cancer cells in the urine.

 

3. What is a Cystoscopy?

The Cystoscope is inserted through the urethra. Today with the widespread use of the flexible Cystoscope most of the diagnostic Cystoscopies are done in the outpatient setting with little or no discomfort.

As the Urologist looks through the Cystoscope, the locations where abnormal features appear are noted and recorded. During the cystoscopy, the Urologist may choose to take a small piece of what appears to be an abnormal tissue (biopsy) and send it to the Pathologist to read and analyze. In addition, a urine sample is frequently sent for analysis (cytology) to determine if there are any cancer cells. The biopsy specimen as well as the urine sample will help the doctor make recommendations about the patient’s future care.

 

4. What is meant by ‘staging and grading’ a tumor?

If bladder cancer is diagnosed, the doctor needs to know the stage or extent of the disease to plan the best bladder cancer treatment. Staging is a careful attempt to find out whether the cancer has invaded the bladder wall, whether the disease has spread, and if so, to what parts of the body. Grade refers to what the cancer cells look like, and how many cells are multiplying. The higher the grade, the more uneven the cells are and the more cells are multiplying. Knowing the grade can help your doctor predict how fast the cancer will grow and spread.

Urologists typically send the sample of cancer tissue to a Pathologist, who specializes in examining tissue to determine the stage and grade of the cancer. The Pathologist writes a report with a diagnosis, and then sends it to your Urologist.

 

5. What types of treatments are available?

Knowing the stage and grade helps your doctor decide which methods are most suitable for treating your cancer.

Ta papillary tumors are usually low grade (most closely resemble normal cells) and, even though a large majority will recur multiple times after the initial diagnosis and removal, 85-90% will never invade the bladder wall and become life-threatening. Further treatment beyond removal may not be necessary, but regular follow-up is required.

Ta non-invasive tumor will probably be treated with more aggressive therapies, including immunotherapy. Once the tumor has invaded the lamina propria, it is considered an invasive tumor with the potential of spreading through the muscle wall and ultimately affecting organs that border the bladder (prostate, uterus, etc.) or other organs such as the lung, bone, and liver. Intravesical therapy and surgery may be considered.

 

6. What is a Trans Urethral Resection of a Bladder Tumor (TURBT)?

Generally, after the diagnosis of a bladder tumor, the urologist will suggest that the patient have an outpatient procedure in the hospital to examine the bladder more completely under anesthesia (general or spinal) as well as to remove, if possible, those tumors which are suitable for resection. The doctor may refer to this procedure as a TURBT (transurethral resection of a bladder tumor).

The TURBT is “incision-less” surgery usually performed in the hospital as an outpatient procedure. It is the first-line surgical treatment for bladder tumors. Like the cystoscope, the resectoscope or the instrument used to remove the tumor in the TURBT. It is also introduced through the urethra into the bladder. Attached to this scope is a small, electrified loop of wire which is moved back and forth through the tumor to cut and remove the tissue.

All the specimens from the TURBT will be sent to the pathologist for review. The pathologist will confirm the type of bladder cancer and the depth of invasion into the bladder wall, if any. These findings, along with results from x-rays, will determine if further treatment is necessary.

 

7. What is intravesical therapy?

There are two principal drugs that are used as intravesical chemotherapy or immunotherapy.

Mitomycin C is an intravesical, anti-cancer drug that has been shown to be effective after the TURBT in reducing the number of recurrences of bladder tumors by as much as 50%. This drug may be delivered into the bladder immediately after TURBT.

Bacille Calmette-Guerin or BCG is intravesical immunotherapy which causes an immune or allergic reaction that has been shown to kill cancer cells on the lining of the bladder. The Urologist may also suggest maintenance therapy using BCG. The rationale for maintenance therapy is that the initial therapy plus intermittent therapy for 2 to 3 years may provide a decreased likelihood that the tumors will recur.

 

8. When is surgery to remove the bladder necessary?

If a bladder tumor invades the muscle wall or if CIS or a T1 tumor still persists after BCG therapy, the urologist may suggest removal of the bladder or a radical cystectomy. Before any radical surgery is performed, a series of CT scans will be ordered to exclude the possibility of metastatic or “distant” disease in other parts of the body. If the patient has metastatic disease, chemotherapy will be prescribed.

A complete radical cystectomy requires complete bladder removal, and in men, it always involves removal of the prostate as well. For women, in addition to removing the bladder, the Robotic surgeon may also remove the uterus, fallopian tubes, ovaries and cervix. In addition, the Robotic surgeon will remove lymph nodes surrounding the bladder, and perhaps even more, to determine whether the cancer has progressed to the lymph nodes, which then could result in metastasis. The lymph node removal is an important method of accurately staging the progression of the disease.

 

9. What are the types of urinary reconstructions available if I need to have my bladder removed?

An ileal conduit is the easiest and most common reconstruction performed by the urologist. A small portion of the ileum or small intestine is disconnected. One side of the piece of ileum is attached to a skin opening on the right side of the abdomen and a small stoma or mouth is created. A plastic appliance or ostomy bag is placed over the stoma to collect the urine. The ureters are sewn or re-implanted near the other end of the ileum. Because the nerves and the blood supply are preserved, the conduit is able to propel the urine into the appliance.

A neo-bladder is also a type of internal reservoir for storing urine. Using a portion of small intestine, the urologist reconstructs the tubular shape of the intestine and creates a sphere. The Robotic surgeon then connects the pouch to the urethra, creating a neo-bladder, in which case the patient can void (pass urine out of the body) normally. By tensing the abdominal muscles and relaxing certain pelvic muscles, the patient is able to push the urine through the urethra.

A radical cystectomy is considered major surgery and at least 20% of patients have complications as a result of either operation. The choice of which type of reconstruction to utilize is a highly-individualized decision between the patient and the doctor, and depends on a variety of factors, including the patient’s overall health, age, and extent of disease. There are advantages and disadvantages to each type of reconstruction.

 

10. When is chemotherapy used?

Chemotherapy refers to drugs used to treat cancer systemically. These drugs are administered by injection directly into the patient’s veins, and attack cancer cells anywhere in the body. Chemotherapy is typically used to treat bladder cancer that has metastasized, which means the cancer cells have spread beyond the bladder to other organs.

Neo-adjuvant chemotherapy is the term used for chemotherapy prior to surgery. Adjuvant chemotherapy is the term used for chemotherapy following surgery. Typically, removal of the bladder also involves removal of a number of lymph nodes surrounding the bladder, which are then sent to the pathology lab for analysis. If the pathology results indicate that the cancer has spread to the lymph nodes, the doctor may recommend chemotherapy to help prevent any cancer recurrence.