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Surgeon’s console and patient side cart	High-performance InSite® Vision System	Proprietary EndoWrist® Instruments

• Ergonomically designed surgeon’s console
  While sitting comfortably at the console, the surgeon operates while viewing a 3-D color image of the surgical field.
• Patient-side cart with four interactive robotic arms
  (three instrument arms and one endoscope arm) that execute the surgeon's commands through the key-hole incisions in the patient's abdomen. Surgical team members assist the surgeon by properly installing the Endowrist instruments.
• High-performance InSite® Vision System
  with high-resolution 3-D endoscope provides real-time 3-D images of the operative field, with magnification of 12-15 times. This advanced technology spares nerves and delicate tissues during the operation, which plays an important role in patients’ fast recovery.
• Proprietary EndoWrist® Instruments
  the instruments are designed with seven degrees of motion that mimic the movements of the human hand and wrist. All movements of the surgeon hands are translated into precise movements with micro-instruments.

Treating Bladder Cancer
Invasive cancer can be highly dangerous and needs to be treated aggressively. A new diagnosis of invasive bladder cancer requires a metastatic survey with a CT scan, bone scan, and chest x-ray or chest CT scan. Some blood work may also be performed. If the bladder cancer appears to be confined to the bladder then the standard treatment for invasive bladder cancer is a radical cystectomy. Radical cystectomy is a major operation with significant risk of blood loss and blood transfusion as well as significant risk of heart attack, stroke, and pulmonary embolism. Radical cystectomy also requires a reconstruction of the remaining urinary tract (the upper tracts) so that the urine can drain out of the body in the absence of the bladder. This urinary reconstruction usually involves creating an ileal loop urinary diversion which is using a piece of small bowel to create a loop that drains urine to a bag on the abdomen. Small bowel could, alternatively, be used to reconstruct a new bladder for certain patients. If you're a candidate for this “neobladder" using bowel and you are interested in such a diversion and you require radical cystectomy you should be prepared to catheterize your neobladder through the urethra. Radical cystectomy involves complete removal of the bladder and prostate in the male and in the female radical cystectomy involves complete removal of the bladder, the female pelvic organs, and part of the vagina. There is usually a seven to ten day stay in the hospital if there are no major untoward events during the postoperative recovery. Most patients experience some small or even major setback during the recovery period of a radical cystectomy. Such a setback might include any of the serious consequences mentioned above or a delay in the healing process to slow the recovery of bowel function or a wound infection or a ureteral stricture (a narrowing of the ureter where it connects to the ileal diversion) or pneumonia or some other type of difficulty that delays the recovery process. Dr. Schanne is one of about a dozen urologists in the United States completing this complex procedure using the robotic technique.

If invasive bladder cancer has spread beyond the bladder chemotherapy and possibly radiotherapy may be used as additional therapy. In some cases radiotherapy and chemotherapy and TURBT can be used (without radical cystectomy) to manage invasive bladder cancer. This management option is called bladder salvage therapy and is usually consider suboptimal therapy in comparison to radical cystectomy. Bladder salvage therapy is often considered for patients who have invasive bladder cancer but are also high risk surgical patients. We generally advise our bladder cancer patients going to radical cystectomy to plan on receiving four cycles of pre-op, or neo-adjuvant, chemotherapy with cisplatin and gencitabinc to improve their chances of cancer cure.

Some cancers invade the lamina propria but do not clearly invade the deeper muscle and connective tissue. These lesions are called T1. T1 lesions are controversial in their management. Most T1 lesions are managed by BCG intravesical therapy as described above but some patients might opt to treat a T1 lesion with radical cystectomy. The rationale for such aggressive treatment of a T1 lesion is based on the possibility that a T1 lesion might actually be an invasive cancer. Studies of patients who have had a T1 lesion who went on to have radical cystectomy showed that their surgical pathology showed invasive cancer 20-25% of the time. So patients with a T1 lesion are at risk for having an invasive cancer or developing an invasive cancer and so they could consider radical cystectomy for treatment. Choosing radical cystectomy for T1 bladder cancer is a very difficult decision for patients.

Radical Cystectomy and Ileal Conduit Diversion can be performed by laparoscopic technique with robotic assistance. Dr. Schanne is the only urologist in Delaware and one of the few urologists in the United States offering this treatment option for bladder cancer. Performing the bladder removal laparoscopically greatly reduces blood loss and speeds recovery. Even though robotic assisted laparoscopic approach decreases risk and speeds recovery, radical cystectomy is still a major operation with significant risk.

Urinary Diversion
Urinary diversion is a surgical reconstruction to drain the urine from the kidneys and ureters when the bladder will no longer be used. This urinary diversion is often done as part of a radical cystectomy for bladder cancer, but might also be used to manage a dysfunctional bladder. Some typical bladder dysfunctions where urinary diversion might be considered, includes neurogenic bladder due to multiple sclerosis, spinal cord injury, or other neurologic dysfunction, severe refractory urinary incontinence, or severe refractory urinary tract infections.

The most commonly used form of urinary diversion is an ileal loop urostomy using about eighteen centimeters of ileum (small bowel). The eighteen centimeter segment of ileum is separated from the remaining ileum and the remaining ileum is put back together to keep the bowel functioning in continuity. The eighteen centimeter segment of ileum is then used to connect then ureters at one end and to bring the other end of the ileum out on the abdomen, usually the right lower quadrant (to the right of and below the belly button). Where the ileal loop exits the abdominal wall is called a stoma. The stoma is a pink fleshy exit orifice that has a diameter that can usually accommodate an index or “pinky” finger. The urine drains from this stoma continuously into a plastic urostomy appliance.

Finding the right urostomy appliance to fit your stoma and learning how to manage your appliance so that there is no urine leakage is a major part of the post-operative recovery. Nurses in the hospital and visiting nurses that come to your home, your family members, vendors who supply appliances, our office staff, and prior patients can all help you learn to manage the appliance.

One of the critical surgical features of any urinary diversion is the suturing of ureter to ileum (the ureteral anastamosis). Because this is a man made anastamosis, it will heal with scar tissue. If this scar narrows down too much it is called a ureteral or anastamotic stricture. Robotic technology reduces, but does not eliminate, the risk of stricture. If a stricture does occur, it could need dilation or surgical revision in the future. To protect the ureteral anastamosis, plastic stents are left in both ureters for six weeks after surgical urinary diversion. These stents may be visible at the stoma intermittently.

Because the ileum is a piece of bowel, it will always shed its inner cell lining, or mucosa, daily. This results in significant mucus production from the stoma. This is normal. The amount of mucus may decrease over time, but it will never entirely stop.

Another form of urinary diversion is an ileal neobladder where a new bladder is created using sixty centimeters of ileum. The ileum is opened and reconfigured into a sphere and the ureters are sutured into the neobladder sphere. The neobladder is then sutured to the urethra over a foley catheter. The foley catheter and ureteral stents and several other surgical drains remain in place for several weeks.

Again, the ileum sheds its mucosal lining, creating substantial mucus. With an ileal loop, the mucus simply exits out the stoma. With a neobladder, the mucus becomes trapped inside the neobladder. This mucus must be irrigated out of the neobladder, and this need for irrigation continues for life. A patient who elects neobladder reconstruction must be able to catheterize his or her new bladder through the urethra for life. This catheterization process is necessary for irrigating out mucus and maintaining the neobladder. Catheterization may also be needed because 20% or more of neobladder patients cannot empty their new bladder by urination but must catheterize daily or several times a day to drain their new bladder. Neobladder reconstruction also significantly lengthens surgical time and so it increases risks of surgery.

• Robotic Cystectomy