Doctors at Mediclinic Durbanville recently completed a groundbreaking minimally invasive bladder cancer surgery using the da Vinci robot.
This surgery not only removed the patient’s cancer but also reduced the risk of complications. In addition, they performed a unique procedure to reroute urine flow with the patient’s body – a first in South Africa.
Why a cystectomy?
A cystectomy is a surgery performed to remove all, or part of, the bladder – usually because of bladder cancer. In the case of 76-year-old patient Jacobus Burger, a radical cystectomy was necessary. During the procedure his entire bladder, nearby lymph nodes, part of the urethra and nearby organs that may have contained cancer cells were removed.
“He presented with blood in his urine,” says Dr Gawie Bruwer, a urologist at Mediclinic Durbanville, who with fellow urologist Dr Danelo du Plessis, performed the surgery. “The main issue was that we diagnosed an invasive bladder cancer, which means it went into the muscle of the bladder. The best treatment for that type of cancer is bladder removal.” As the patient’s type of cancer was relatively rare, chemotherapy which is sometimes administered before surgery, would not have been effective. The only option was to remove the bladder.
Using the da Vinci robot
As a state-of-the-art surgical platform, the da Vinci robot overcomes the limits of both traditional open surgery and laparoscopic surgery. For bladder cancer, a minimally invasive da Vinci cystectomy is a highly recommended treatment option. So, for Jacobus, who was in good health otherwise, the procedure was an obvious choice.
The da Vinci robot was necessary to perform the required urinary diversion. “Once you remove the bladder, you have to decide how you're going divert the urine because you no longer have a storage chamber for urine,” Dr Bruwer explains. There are many ways of doing that, he adds, from making a new bladder out of the bowel, to using a loop of bladder that leads to an external stoma bag.
“In the past, we used to join the ureters to the bowel on the outside,” he says. “Once we’d done the operation laparoscopically or with a robot, we made an incision, and joined them through an open incision. However, this defeated the purpose of the minimally invasive surgery and the advantages it offers. So, a da Vinci cystectomy involves performing an anastomosis [a surgical connection between two structures] on the inside of the abdomen, and then we bring the bowel stoma out through one of the smaller port holes on the side of the abdomen.”
Having trained on the da Vinci system together, Dr Bruwer and Dr Du Plessis often work as a team when using it to perform cystectomies. “As it’s long, complex procedure of around four hours with multiple steps, we each do parts of the of the surgery,” Dr Du Plessis explains. In theatre, the doctors draw on one another’s expertise.
Using the da Vinci robot improves dexterity and precision and lowers the risks of massive complications that are common with open radical cystectomies, say the doctors. “It replicates your open hand but gives you even more ability, as there’s a camera inside,” Dr Du Plessis explains. “It's almost as if you're a mini-Lego surgeon inside the abdomen. With the ultra-HD 3D camera, you can see exactly what you’re doing.”
The robot applies pressure to seal blood vessels, which prevents or minimises bleeding, especially compared to open surgery. “In the seven cases we’ve done so far, we haven't had to transfuse a single unit of blood,” Dr Du Plessis says. Having better control of delicate suturing to connect the ureters to the tube that carries urine to the stoma, reduces complications. Using the robot also decreases the chances of bowel issues, like ileus, which can lead to infections and sepsis because the bowels can’t move out waste properly.
The recovery period is also much shorter after a da Vinci robot cystectomy, with hospital stays reduced from up to two weeks to just five days, Dr Du Plessis adds. Patients are usually immediately placed in a general ward, eliminating the need for ICU admission.
Who is a good candidate for robotic cystectomy?
Being healthy enough to undergo da Vinci cystectomy is vital, Dr Bruwer says. Since bladder cancer is often associated with heavy smokers, some patients have chronic lung disease, and operating on them is not feasible. Jacobus, however, was a good surgery candidate as he’d never smoked, and didn’t have other physical problems. “Anybody who qualifies for open cystectomy would qualify for robotic cystectomy,” Dr Du Plessis adds. “The indications are the same for both.”
Although robotic cystectomy is the gold standard for bladder cancer treatment, the doctors point out that medical aids are not yet providing sufficient cover. “It’s now accepted worldwide as the number one way of performing cystectomies,” says Dr Bruwer.
Jacobus says he’s grateful to the entire Mediclinic Durbanville team. Aside from adapting to having a stoma bag – which is connected to a small bowel tube that transfers urine – he’s living an active, normal life and is cancer-free. “Less than two months later, I’m already working in the garden, driving and doing things around the house,” he says. “I’m glad Dr Bruwer advised me to have the da Vinci surgery. My recovery time was shorter and there was hardly any risk of infection. I’m just a positive, grateful person.”