Specialists at Mediclinic Durbanville recently performed pioneering simultaneous rectal and prostate surgery with the da Vinci robot.
It is very rare for a patient to present with both colon (rectal) and prostate cancer. And yet in a world first, urologist Dr Gawie Bruwer and surgeon Dr Frikkie Rademan at Mediclinic Durbanville have successfully performed simultaneous robotic surgeries on three patients who required removal of cancer in the prostate and rectum.
“It is extremely rare to have simultaneous cancers such as this,” says Dr Bruwer. “After an extensive search of international literature to find more information about the correct approach for simultaneous robotic surgery, it was confirmed no known cases have been reported. It is pioneering surgery to have removed both cancers at the same time under one setting with the da Vinci robot. Dr Rademan and I worked it out for ourselves and believe we’ve created a blueprint of how to approach these cases in the future.”
Each of the three cases presented its own challenges, and the specialist duo refined their approach and technique after each procedure. In all three patients, colorectal cancer was asymptomatic, and was found incidentally on an MRI following chemical signs of raised PSA levels.
The first case was performed in April 2019. “We suspected possible prostate cancer, so we ordered an MRI of the prostate to see the lesion,” says Dr Bruwer. “By coincidence, we found the patient had a rectal tumour too. The risk involved in this type of surgery is that when you cut the colon and suture it together, and you cut the prostate out and suture the bladder to urethra, these two suture lines are relatively close together. This means there is a risk of a connection forming between the intestine and the urinary tract – called a fistula.”
To minimise this risk, and to give Dr Rademan better access, the team decided to first remove the prostate and put a catheter in the loose bladder. Dr Rademan then removed the colon before Dr Bruwer returned to suture the bladder.
“However, as the patient was lying on his back and the operation happens in front of the rectum, the blood seeping from the open wounds obstructed my view of the nerves,” Dr Rademan explains. “Although his recovery was excellent, with our second patient, in June 2019, we decided I would perform robotic surgery on the bottom side (rectum) first, before Dr Bruwer operated on the bladder and prostate. Despite some swelling, this worked very well.”
The third patient underwent surgery in September 2021. “All three surgeries resulted in no signs of recurrence of the cancer – it was completely removed and showed no positive margins,” says Dr Bruwer. “None of the patients required further treatment, such as chemotherapy or radiation, after the surgery. Importantly, their quality of life was also intact.”
In the past, if a patient underwent a resection of the colon, followed by a prostate operation a few months later – or vice versa – surgeons would have performed an anterior resection, as the pelvic floor is damaged with conventional surgery. This means the patient would probably have ended up with a colostomy bag and a very high risk of 100% urinary incontinence. Dr Bruwer highlights just what the da Vinci surgery means to the patient: “Firstly, these surgeries could be performed together, which reduced theatre time and cost to the patient, but it also enabled us to spare both urinary and faecal continence.”
Dr Rademan, who was the first qualified robotic colorectal surgeon in South Africa, says a patient’s recovery after robotic surgery is advanced in terms of hospital stay, return to normal routine as well as the return of bladder and sexual function.
He further explains that as the pelvis is the size of a cup, space is critical for surgeons. “In the past, if you worked with your hands, you obstructed the whole view of the pelvis. Then we moved onto laparoscopic instruments – but these are straight, and the pelvis has a natural curve, which made it tricky. The da Vinci robot gives us the advantage of working in a confined space with instruments that angulate like a surgeon’s wrists.”
Reduced blood loss during the procedure, accelerated recovery times and enhanced quality of life due to the nerve-sparing precision of the robot are other significant factors in the success of these pioneering simultaneous surgeries.
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