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Complex urologic disorders,
like kidney cancer and bladder cancer, can now often
be treated with new minimally invasive techniques. Endoscopic
procedures, guided by robotic systems, can result in
smaller incisions and faster recoveries.
Laron Richardson knows
what it’s like to experience a miracle. In July
2003, he was the victim of a violent assault and was
taken to the Trauma Center at University Hospital. Bullet
fragments had torn through his left kidney, and the
irreparable organ was removed by the trauma team. People
can lead healthy lives with only one kidney, but here’s
the twist: Mr. Richardson’s right kidney had a
tumor, the result of renal cell cancer.
That left Mr. Richardson’s
doctors with a highly unusual situation. Their first
priority was the 27-year-old’s recovery from the
gunshot wound: His spleen also had to be removed, and
he lost about 70 percent of his blood from internal
injuries.
After a hospital stay
of 28 days and an overall recovery period of about two
months, Mr. Richardson returned to the hospital for
a second operation. Dr.
Mark Jordan, professor and chief, division of urology
at New Jersey Medical School and head of the urology
department at University Hospital, performed a renal
autotransplant: Mr. Richardson’s right kidney
was taken out of his body; the tumor was removed; and
the kidney was transplanted back. Dr. Jordan has been
told by his colleagues in the community that they believe
it was the first time a renal autotransplant on a solitary
kidney was performed in New Jersey.
The surgery was a success:
amazingly, Mr. Richardson’s repaired kidney started
working immediately, and he completely avoided the risk
and stress of dialysis. Today, Mr. Richardson’s
right kidney is still functioning well.
“Every time the
doctors see me, they look at me as though they can’t
believe I’m still alive,” says Mr. Richardson.
“It is amazing, and I’m glad to be living
right now. I don’t worry about small things anymore.
I’m just happy to have a second chance.”
A
Remarkable Design
The urinary system, with
its primary purpose of removing waste from the body,
is exquisitely designed. As foods break down during
digestion, the body absorbs nutrients, and the bloodstream
carries the remaining waste products to the kidneys.
The kidneys act as filters, removing urea (a product
made from protein breakdown) from the blood. Urine,
produced in the kidneys, is a combination of urea, water,
and other waste. It is carried by two long, thin tubes,
the ureters, from the kidneys to the bladder. The bladder
expands like a balloon to hold urine; sphincter muscles
keep the bladder closed until nerve signals indicate
that the bladder is full and needs to be emptied. The
brain then allows the bladder to contract and the sphincter
muscles to relax, and urine travels out of the body
via the urethra.
Like anything else, when the urinary
system is working well, most people take it for granted.
However, there are a whole host of conditions that can
impair the process, such as incontinence, urinary tract
infections, and bladder emptying problems, as well as
some that can prove fatal, namely, cancer and kidney
failure.
At University Hospital,
Dr. Jordan leads a dedicated team of highly trained
specialists in such areas as urologic oncology, reconstructive
surgery, and laparoscopic surgery. Supported by new,
state-of-the-art equipment, the division provides all
of the imaging and diagnostic tests that are needed
by the hospital’s urology patients.
“The hospital is
located in an area where there’s a tremendous
need for quality, comprehensive urologic care. African
American men are at high risk for prostate cancer, and
yet, so many are undiagnosed until the cancer is in
an advanced stage,” says Dr. Jordan. “With
our new equipment and enhanced services, we are better
able to meet the needs of our community.”
One new development in
urology is the use of minimally invasive surgery for
a variety of procedures, such as the removal of kidney
stones. A kidney stone is a build-up of crystals within
the kidney. Some are small enough to pass through the
body unaided. Others become large, block the flow of
urine, and cause severe pain. Urologists have several
choices for treating kidney stones, including breaking
up the stone non-invasively with shock waves, but surgery
sometimes is necessary.
Before minimally invasive
techniques were developed, the “open” surgery
to remove kidney stones required a five- to seven-day
hospital stay and a four- to six-week recovery period.
Now, an endoscope—a thin, flexible tube with a
tiny camera attached—can be inserted through a
small incision into the patient’s body. The surgeon
sees magnified images on a monitor in the operating
room, and using specially designed instruments, extracts
the stone. In many cases, the patient can go home the
same day and quickly resume regular activities.
Minimally invasive surgery
also has a role in urologic oncology. Kidney cancer,
which affects about 1 of 800 people, often requires
surgery to remove part or all of the diseased kidney.
The traditional procedure—an open radical nephrectomy—can
be difficult on patients, with a 10- to 12-inch incision
and sometimes the removal of a rib to gain access to
the kidney.
When a kidney is removed
with minimally invasive techniques, there are several
¼- to ½-inch incisions, resulting in less
blood loss, less post-operative pain, and a faster recovery
period (about 2 weeks as compared with 4-6 weeks). Cure
rates are nearly the same between the two procedures;
a 2001 study by the Washington University School of
Medicine reported a 5-year survival rate of 92 percent
with the minimally invasive procedure, compared with
91 percent after the traditional surgery.
Minimally invasive techniques
also can be used for a partial nephrectomy, as well.
“We are able to remove the tumor and save the
kidney,” says Dr. Jordan. “In cases where
previously the entire kidney would need to be removed,
we can preserve kidney function.”
Technology is taking
minimally invasive surgery to an even higher level.
Robots in the operating room no longer are the product
of a science fiction writer’s imagination. They
have been used quite successfully in cardiac surgery;
the da Vinci Surgical System is used at University Hospital
to harvest a mammary artery for cardiac bypass and for
epicardial lead placement. Beginning in August, the
da Vinci system will be used for certain urological
surgeries at University Hospital, such as removing prostate
glands.
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The da Vinci Console. |
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The robotic arm mimics
a surgeon's hands but with greater precision. |
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The da Vinci system has
two main parts: a surgical arm and a viewing and control
console with 3-D imaging capabilities. The surgeon is
in control at the console, directing the movements of
the arm in “real time.”
“Robotic urology
uses endoscopic techniques, so the patient will benefit
from smaller incisions and a faster recovery time,”
says Dr. Jordan. “The robotic arm also offers
precise control of the surgical instruments. Robotic
prostatectomy adds to University Hospital’s options
for prostate cancer patients, which include prostatectomy
using nerve-sparing techniques and the University Brachytherapy
Center.” Dr. Jordan has recruited a urologist
with expertise in robotic surgery—specifically,
robotic prostatectomy. Dr.
Rahul Bhalla will join the division of urology this
August.
Bladder Cancer:
A Common Problem
Although it may not receive much attention
in the mainstream media, bladder cancer is more common
than many people realize. It is the fourth most frequent
cancer in men and the 10th most frequent in women, according
to the American Cancer Society, which estimates that
about 60,000 Americans will be diagnosed with bladder
cancer this year. Smokers have twice the risk of developing
bladder cancer than non-smokers do.
The primary symptom of bladder cancer
is blood in the urine; however, hematuria, as it is
known, also can be a symptom of other conditions, such
as urinary tract infections, an enlarged prostate, or
kidney stones. People with bladder cancer might also
need to urinate frequently and have pain while doing
so. Anytime there are unusual changes in urinary habits,
it’s wise to consult a urologist, who might conduct
certain tests: an intravenous pyelogram, which uses
X-ray and contrast solutions to view the bladder; cytoscopy,
in which a lighted instrument passed into the bladder
enables the urologist to examine the lining and take
a tissue sample; and a urine test.
When detected early,
most bladder tumors are confined to the bladder lining
and have not penetrated deeper into the bladder wall,
says Dr.
Georgi Guruli, assistant professor of surgery at
New Jersey Medical School and a urologic surgeon at
University Hospital. A common treatment for superficial
bladder cancer is transurethral resection, by which
the tumor is removed with instruments passed through
the urethra. Immunotherapy or chemotherapy—administered
directly into the bladder—might be recommended
either before or after surgery.
“However, invasive bladder cancer—when
the tumor invades the bladder wall—almost always
requires that the bladder be surgically removed,”
says Dr. Guruli. This procedure is called a cystectomy.
Because the kidneys still produce urine, which must
exit the body, doctors have developed methods known
as urinary diversion to compensate for the lack of a
natural bladder. These “alternate routes”
fall into two categories, non-continent (urine stored
outside of the body) and continent (urine storage inside
the body).
The most common type
of non-continent urinary diversion is ileal conduit.
The patient’s ureters—the thin, long tubes
through which urine previously traveled from the kidneys
to the bladder—are connected to part of the intestine,
which is brought up to the abdomen and connected to
an external ostomy bag. The urine then continually drains
into the bag, which is worn under clothes. The bag needs
to be emptied about 4 to 6 times a day. Patients or
their caregivers need to be taught how to properly care
for an ostomy and keep themselves healthy following
an ileal conduit. Urine leakage, skin irritations, and
urine reflux (backing up into the intestines) are some
of the potential drawbacks of an ileal conduit, but
with support and proper training, many patients learn
to adapt to wearing an ostomy bag.
Still, for a patient
who would rather not have an ostomy bag, continent urinary
diversion may be a possibility. The surgeon can create
a pouch from the person’s own intestine to store
urine. There are two main types of continent urinary
diversion.
A continent urinary reservoir
is an internal pouch that is brought up to the patient’s
skin; the patient empties the pouch by way of a catheter
several times a day. With an orthotopic neobladder,
the pouch is connected to the patient’s urethra,
and urine exits the body as before. Not every patient
can have continent urinary diversion; for example, someone
whose sphincter muscles were removed along with their
bladder would not be able to have a neobladder, which
requires that muscular capability.
There are benefits and
disadvantages to both types of continent urinary diversion.
“The patient with a continent urinary reservoir
has no external bag, but still has to empty the pouch
with a catheter several times a day,” says Dr.
Guruli. “While a neobladder is like a bladder
in some ways, the patient loses the natural sensation
to urinate and must re-learn how to empty the bladder
regularly. Exercises that strengthen the pelvic floor
can help reduce leakage; yet, a few patients don’t
regain full continence, especially at night.”
Dr. Guruli helps his
cystectomy patients make the best choice for them and
learn to live with whichever system they have. “I
have seen patients very happy with a neobladder, but
I also believe that people can lead a quality life with
an ostomy bag,” he says.
To
learn more about robotic prostate surgery, visit our
website at www.theuniversityhospital.com/prostate.
For more
information about urologic minimally invasive surgery
or treatment of complex urological problems, call the
Division of Urology at (973) 972–4488.
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