Though questions around its ability to completely remove a tumor and surrounding cancerous cells dogged it in its early days in the mid-2000s, robotic cystectomy — a surgery to remove all or part of the bladder — is now a common treatment for bladder cancer. One of the foremost practitioners of the procedures is Janet Kukreja, MD, director of urologic oncology and associate professor of urology in the University of Colorado Department of Surgery.
“People were very skeptical of robotic surgery at first — of negative margins and recurrence rates vs. doing an open surgery,” says Kukreja, also a member of the CU Cancer Center. “Multiple clinical trials were performed, and eventually it was demonstrated that robotic has the same cancer outcomes, the same yield of removal for lymph nodes, and actually decreases the need for transfusions. It also leads to decreased hospital stay and decreased complications.”
The smaller incisions used for robotic surgery take a shorter time to heal, Kukreja says, which means that, on average, patients receiving the surgery from CU Surgery providers spend just three to four days in the hospital, instead of the seven to 10 days required for a traditional open surgery.
Technological advances
Kukreja, who has been performing robotic cystectomies for the past seven years, says she has only seen the technology get better.
“The newer generations of the surgical robot are even more surgeon-friendly,” she says. “It's easier for us to attach the robot to the patient and it's easier for us to take it off, and the vision is getting better and better too. The robotic technology continues to improve and continues to make our jobs easier.”
Urinary alternatives
One of the most important parts of her job as a bladder surgeon, Kukreja says, is counseling patients on what sort of urinary diversion — or way to collect and dispose of urine — to use once their bladder is gone.
“They have a few choices,” she says. “One is called an ileal conduit, which is a small piece of intestine that sits on their abdomen and collects urine, which then collects in an external bag. There's something called a neobladder, which we re-create in the same spot where the old bladder was, and the patient uses their pelvic muscles to empty. Then there's something called an Indiana pouch, where the patient has a stoma on their abdomen that they have to periodically connect to a catheter to empty. All these methods have advantages and disadvantages, and not one is right for every single patient.”
It can be a daunting change for patients, but Kukreja says most adjust to their new arrangement within four to six weeks and get back to their normal quality of life.
“It’s all done at the same time, and it’s all done robotically,” she says. “That's something that we offer here that no other place in Colorado offers. We are unique in that most do the neobladders with an open incision. We're one of the only places that does everything robotically, no incision, just little laparoscopic ports.”
Road to cystectomy
For most people, bladder cancer is first detected when they see blood in their urine; some people also experience unusual frequency or urgency of urination. The presence of cancer is confirmed through a special biopsy called a transurethral resection of bladder tumor, which is done through the urethra. This can be done with white light and a special technology called blue light to detect even more cancer. Kukreja can perform the procedures, but by the time she sees a patient, they typically have had the biopsy elsewhere and are now ready to discuss treatment.
“Depending on what the cell type of their bladder cancer is, a lot of patients will get four cycles of chemotherapy first, so it ends up being a couple of months until they have surgery,” she says. “Some people will get surgery and then have chemo afterward. And some people will have had a different type of bladder cancer, where they got treatments in their bladder and didn't respond, and they get no chemo. They're ready for surgery when they first come in.”
Patient-first approach
In an addition to surgery, there are recently FDA-approved treatments for bladder cancer that Kukreja makes it a point to keep up on, so she can tailor a personal treatment plan for each patient.
“It really depends on where patients are in their life,” she says. “I see a very broad spectrum of patients — from people in their 30s all the way up to people in their 90s. And a 90-year-old’s values are different than a 30-year-old's values.”
No matter their age, patients can trust the CU Department of Surgery to give them the best treatment for their situation, Kukreja says.
“The University of Colorado is a leader in this area, and we do a lot of these surgeries,” she says. “We have a great program around the surgery too — our inpatient nurses, our after-care nurses, our nurses in clinic — we have a comprehensive multidisciplinary program.”
