The Country’s First Robot-assisted Radical Cystectomy to Treat Bladder Cancer performed at The Medical City

Premier health institution The Medical City (TMC) recently hosted the country’s first robot-assisted radical cystectomy, a surgical procedure to treat invasive cancer of the bladder.

Seventy-five-year-old patient Julio Magalang and his family opted for the less invasive robotic radical cystectomy instead of the traditional open approach because of the advantages the former offers.

The team of Dr. Enrique Ian Lorenzo and Dr. Francis Raymond Arkoncel performed the procedure on Magalang from Mindoro Oriental diagnosed with high grade bladder cancer on August 18, 2014. Dr. Lorenzo is the head of Training and Research of the TMC robotics program. He and Dr. Arkoncel are part of an elite group of surgeons in the Philippines fully trained to perform robotic urologic surgery. Together with several other surgeons from TMC, they form the most experienced group of Filipino robotic surgeons to date.

The entire procedure lasted for six hours without needing any blood transfusion. The patient was able to stand and walk on his own the next day and resumed diet the following day. Mr. Magalang experienced minimal discomfort and needed minimal pain relievers. He was fit for discharge on the fourth day after surgery. He went home to his province three days later.

“We were surprised with my father’s recovery. The next day, he was able to walk to the comfort room unaided. He was not feeling any pain, only mild discomfort,” said Magalang’s daughter Rosalita.

Bladder cancer accounts for approximately 90% of cancers of the urinary tract (renal pelvis, ureters, bladder, urethra). The bladder is an organ located in the pelvic cavity that stores and discharges urine. Bladder cancer is not as common as prostate cancer. Dr. Lorenzo says that while it is not as common as Prostate cancer, it is more aggressive. Recurrence and progression rates are higher thus such a radical surgery may be necessary at times.

Bladder cancer can be low-grade or high-grade. Low-grade bladder cancer often recurs in the bladder after treatment but rarely invades the muscular wall of the bladder or spreads to other parts of the body. High-grade bladder cancer commonly recurs in the bladder and also has a strong tendency to be muscle-invasive or to invade the muscular wall of the bladder and spread to other parts of the body. For that reason, high-grade bladder cancer is treated more aggressively than low-grade bladder cancer.

Bladder cancer is also divided into muscle-invasive and nonmuscle-invasive disease. Muscle-invasive disease is much more likely to spread to other parts of the body and is generally treated by either removing the bladder or treating the bladder with radiation and chemotherapy.

Radical cystectomy is more commonly performed as an open surgical procedure due to its complexity. It may be considered as one of the most technically challenging urologic surgery. It is composed of three major parts- extensive removal of lymph nodes along major blood vessels, removing the entire prostate and urinary bladder, and creating a urinary diversion using a segment of the intestine to replace the bladder.

Dr. Arkoncel says robot-assisted or robotic radical cystectomy is relatively new and is a more effective minimally invasive surgical option for bladder cancer. It is indicated for high-grade and/or muscle invasive bladder cancer such as the case of patient Magalang.

“I presented three options to the patient’s family- open surgery, laparoscopic and robot-assisted cystectomy and they chose the latter because of its benefits to the patient - lower risk of major complications, less blood loss, less need for narcotic pain medicine, quicker return to a normal diet, shorter hospital stay and minimal scarring,” adds Dr. Lorenzo.

The actual procedure is performed using the Da Vinci Surgical System in which robotic arms are manipulated from a special viewing and control console. Only one to two centimeter openings in the body are needed.

The arms wield fine surgical instruments that can cut, dissect, and suture with full range of motion, and a camera that displays the operative site in three dimensions, magnified up to 10 times. This allows the surgeon to make smaller incisions and spare vital and delicate- nervous, vascular and muscle tissues.

For both men and women, reconstruction may include a continent reservoir which holds urine in the abdominal cavity until the patient has been fitted with a catheter to empty urine or a bladder replacement and an external bag for urine collection. The system being used by the TMC Robotics team provides the surgeon with superior visualization of the surgical planes and improved surgical dexterity during bladder removal and reconstructive procedures. Surgeons are also able to dissect and reconstruct the bladder with relative ease.

The removal of the prostate was also beneficial to patient Magalang who incidentally had a concomitant prostate cancer. Dr. Lorenzo says prostate cancer may be found in up to one third of the patients who underwent a bladder removal procedure.

Just like the recent robot-assisted radical cystectomy, the first robotic radical prostatectomy in the Philippines was performed in June 2010 also by TMC Urologists using the 4-arm Da Vinci surgical robot. A radical prostatectomy is an operation done to remove the entire prostate due to cancer. The first robot-assisted partial nephrectomy was likewise performed in the same institution. It is a surgical procedure to remove renal tumors without having to remove the entire kidney.

"It is quite a joy to be able to perform complex procedures in a minimally invasive fashion. At the end of the day, seeing the smiles of happy patients makes our day. We must remember that we are dealing with cancer here. These conditions can be very unpredictable. The surgical robot assists us to face these extra challenges, giving us the opportunity to provide patients the best results.” says Dr. Lorenzo.

The Magalang family however adds that while they are amazed at how good robotic surgery is, the robot is still just a machine. “In the end, it is the excellent and experienced team behind it that matters,” says Rosalita.