Center for urological surgery and robotic surgery

Epidemiology

Robotic bladder surgery is primarily used to treat what it known as “infiltrative” bladder tumors, meaning those that have invaded the musculature of the organ. More than 10,000 cases of bladder cancer are diagnosed each year, and 30% of these are infiltrative. The average age at diagnosis is 70. Tobacco use is the main risk factor, but exposure to chemical products like aromatic amines and some parasite infections such as urinary bilharzia may also case infiltrative tumors. The main histological form is urothelial carcinoma, which is associated with tobacco use, but there are other much rare forms like adenocarcinoma or epidermal carcinoma that receive the same surgical treatment.

Pre-surgical exams

Before deciding on treatment, additional tests need to be performed to determine whether the disease is restricted to the bladder and has not extended outside of the organ or metastasized. Abdominal and pelvic CT scans must be performed, as well as bone scintigraphy and sometimes an 18 FDG-PET scan. Other tests known as “feasibility tests” are needed in the event of cystectomy. Before preforming this serious intervention, it is important to confirm that the lungs, heart and arteries are in good condition. Due to significant tobacco use, patients with this disease often have other conditions which may increase the risk of post-operative complications.

Treatment protocol

These days, cystectomy is performed for patients with local bladder tumors, meaning that there are no metastases. Standard treatment involves neoadjuvant chemotherapy before surgery. The protocol includes three courses of combined treatment with gemcitabine and cisplatin before the cystectomy is performed. This protocol (first chemotherapy then surgery) has been shown to be more effective than surgery alone in terms of survival.

Surgical treatment

Surgical treatment involves two steps:

• first, bladder ablation
• second, reconstruction

The reconstruction step can involve replacing the bladder by reconstructing a bladder pouch using part of the digestive tube or, if the patient is elderly (over 75 years old) or frail, redirecting the urine through a segment of the digestive tube separated from the rest of the normal tract to a hole in the skin called a stoma. In both cases, the ureters are reimplanted into the intestine, either the tube leading to the stoma or the replacement pouch.

The role of robotic surgery in cystectomy

This surgery should only be performed in expert centers by surgeons who are familiar with this technique. Even today, cystectomy via laparotomy remains the standard treatment because few centers have access to a robot to perform this operation. The advantage of robotic surgery in this case is less bleeding compared to open surgery. It also enables neurovascular slings to be retained more effectively than classic surgery does, which means that patients are able to engage in normal sexual activity postoperatively if they had been able to do so pre-surgery. Ablation of the pelvic lymph nodes, which must be performed along with bladder ablation, can be achieved very precisely and completely with the robot. Organ ablation can be accomplished without opening the abdominal wall in women by removing the organ through the vagina; in men, a small, lateral incision measuring a few centimeters must be made just over the pubic bone. The reconstruction is the most delicate part of the operation and must be performed by a surgeon who has experience with this technique. Whether the bladder is replaced or a urinary stoma is created, having a “closed” surgery is undeniably better for the patient. The post-operative recovery is simplified by a lower level of post-operative pain (as the muscle wall is not opened), earlier recovery of intestinal transit, reduced post-operative fatigue, a decreased risk of requiring blood transfusion and a better functional result (continence and erection) than that achieved by classic surgery. Thus, the hospitalization time is decreased and the patient can return home earlier.

Anesthesia consultation

An anesthesia consultation must take place at least one week before the procedure.

Post-operative recovery

Visiting the resuscitation department after surgery is not always necessary. It depends on how long the surgery takes, the patient’s medical history and any difficulties encountered during the operation. In all cases, the patient will have drains that need to be removed in the days following the surgery. The kidney drainage stents, also known as the urethral stents, will be left in place for 10 to 12 days, and the bladder drain for 12 to 15 days. Normal eating can be resumed 3 to 5 days after the surgery.

Discharge

Discharge from the hospital will occur within 10 to 15 days.

Recovery and medical follow-up

Rest and recovery will take one month. During this time, is a stoma was created, a specialist nurse will provide patient education. For patients who underwent bladder replacement, sphincter retraining may bee needed. This will be determined after the 1-month follow-up consultation.

Epidemiology

Kidney cancer represents 3% of all adult cancers, with a male/female ratio of approximately 2/1. Its frequency increases with age until 65: one out of two cancers is diagnosed before the age of 65. In 2012, 11,500 new cases were reported, and 13,000 in 2015. Due to ultrasound and CT scan assessment, this cancer is discovered earlier, which means it is often treatable by partial surgery, meaning only the tumor is removed.

Risk factors

Tobacco use, significant obesity, high blood pressure and renal insufficiency in patients on dialysis. There are family forms represented by rare genetic diseases. Some professional exposures: petrol products and heavy metals.

Treatment

Surgical. The details of the procedure are discussed in Multidisciplinary Team Meeting (MTM) attended by the entire urological team from the Ambroise Paré Clinic (seven urologists), radiologist, oncologists and anatamopathologists.

Surgeries

Partial nephrectomy

Only the tumor is removed; the rest of the healthy kidney is left intact to preserve as much of your renal function as possible.

Using the Da Vinci surgical system: this is the technique that we have used in the majority of cases at the Ambroise Paré Clinic for more than 10 years.

We have a latest generation Da Vinci robotic surgery system. This is a particularly powerful tool that enables us to perform surgeries that are as precise and conservative as possible. The three-dimensionality, high-resolution visibility, instrument manipulability and related technologies (intraoperative ultrasound, Firefly technique, etc.) allow conservative interventions to be performed in a very large number of cases, including lesions up to 7 cm.

Néphrectomie

Partial nephrectomy: DA VINCI ROBOT

Digitally enhanced precision

-amplifies gestures

-eliminates fatigue tremors

The surgical procedure consists of removing the tumor while preserving the healthy kidney. In most cases, the blood supply to the kidney must be temporarily interrupted using clamps (temporary blockage of the blood vessels that supply the kidney) for the time it takes to remove the tumor, after which the kidney is sutured. All of these steps can be performed more precisely and more quickly due to robotic technology, which limits the duration of kidney ischemia and limits blood loss. The tissue removed during the procedure is then subjected to microscopic analysis as part of the anatamopathological exam.

As the scars (generally 5 or 6) are small (1 cm), post-operative recovery is faster, particularly as the trauma to the muscle wall is substantially reduced compared to conventional open surgery.*

Total nephrectomy

The entirety of the diseased kidney is removed. This intervention is most often performed by robot-assisted laparoscopy, and in rare cases as an open procedure. Once the date of the surgery has been determined by your surgeon, he or she will provide you with a file containing information about your stay, how the procedure will be performed, the different tests that will need to be performed, contact information for making an appointment with the anesthetist and the details of the admission procedure.

*open surgery: this means making a traditional opening called a lumbotomy incision.

Preparing for the procedure

An anesthesia consultation must take place at least one week before the intervention.

Inpatient stay

You will generally be required to stay at the hospital for 5 days, in a shared or private room depending on your preference. You will be welcomed to the urology service on the 6^th floor the day before your procedure by our administrative assistant ELSIE (Tel: 01 46 41 87 75) and by the floor’s medical and paramedical team. This team will collect your medical file, and particularly your radiological file. The day of the procedure you will be taken down to the operating room and then put to sleep, as the intervention is performed under general anesthesia. The length of the procedure varies, depending on your case. Once the procedure has been completed, you will be transferred to the recovery room where a specialized team will take care of you before authorizing your return to your room. You will not be able to have your first meal until the following day.

Care at the Ambroise Paré Clinic

Care will be provided by a nursing team and nursing assistants who specialize in urology, as well as by physical therapists. The anesthetist and the surgeon will see you every day until you are discharged.

Discharge

Elsie will give you your prescriptions when you leave (at-home nursing care, any medications needed, biological exams to be performed) and will let you know when your next appointment is.

Recovery

You will be allowed to resume as normal a life as possible (walking, using stairs, although you should avoid lifting heavy objects for a month) in the place of your choosing. While it is recommended that you not drive for the first 10 days following discharge, you can be a passenger. You can resume your normal eating habits.

Medical follow-up

The first post-operative appointment will take place one month after you leave the clinic, after which your surgeon will determine the frequency of subsequent follow-up visits.

Radical prostectomy

Anatomy

The prostate gland is part of the male reproductive system. Its role is to generate and store seminal fluid, an essential component of sperm. The prostate is the size of a chestnut and weighs approximately 20 to 25 grams. It is located under the bladder and surrounds the urethra, the vessel that carries urine from the bladder to outside the body. Due to this location, the prostate can cause urinary problems, particularly if it becomes enlarged or cancerous.

Prostate

Rectum

Penis

Scrotum

Location of the prostate

Indications for prostatectomy

Biopsies have indicated the presence of a malignant tumor. The intervention that is advised in this case is total prostatectomy, also known as radical prostatectomy. This intervention removes the entire prostate, as well as the seminal vesicles. In some cases, the nearby lymph nodes may also be removed. Other options for treating prostate cancer are available, such as radiotherapy, curietherapy, localized treatments or watchful waiting. The advantages and disadvantages of each of these treatments will always be explained and discussed with you during an appointment with your urologist. The decision to perform a total or radical prostatectomy depends on the patient’s age and general health status and the features of the tumor. If the tumor is left untreated, it may develop further locally or at a distance in the form of metastases.

How the prostatectomy is performed

Total or radical prostatectomy is carried out under general anesthesia. Different surgical techniques are possible; the choice depends on your surgeon’s preferences:

• Open prostatectomy with an incision made under the navel
• Laparoscopic prostatectomy achieved by guiding the instruments through small holes in the abdomen
• Robot-assisted prostatectomy

This is the technique that we have used in the majority of cases at the Ambroise Paré Clinic for more than 10 years.

We have the latest generation Da Vinci robot. This is a particularly powerful tool that enables us to perform surgeries that are as precise and conservative as possible. The urological surgeon will remove the entire prostate, including the tumor and the seminal vesicles. If necessary, the surgeon will also remove the lymph nodes during the same procedure. In all cases, a urinary stent will be put into place, and a drain will be installed at the end of the procedure. The prostate and all of the associated tissue that were removed will be sent to the laboratory or the anatamopathology service to be analyzed. These analyses allow detailed observation of the removed tissues and the extent of the cancerous cells. The results will be sent to your surgeon after several days.

Timeline

An anesthesia consultation must take place at least one week before the intervention.

Preparing for the intervention

If you wish, psychological support (Psychologist: Mrs. Bethemont Donatienne - Tel: 01 46 39 89 89) can be provided.

Hospitalization

Your inpatient stay will generally last 5 days. You will be welcomed to the urology service on the 6th floor the day before the intervention by our administrative assistant Mrs. Elsie Crespy (01 46 41 87 75) and our nursing team. The team will collect your medical file, and particularly your radiology file. The day of the intervention you will be taken down to the surgical department, settled in an operating room and put to sleep, as the intervention is carried out under general anesthesia. The length of the surgery varies, depending on your case. Once the procedure has been completed, you will be transferred to the recovery room, which are specialized team will oversee your care before authorizing your return to your room. You will not be able to have your first meal until the following day. Care at the clinic: delivered by a team of nurses and nursing assistants specializing in urology, as well as physical therapists.

Operating rooms

In the majority of cases, the total or radical prostatectomy that you undergo will be carried out with no complications. The length of your inpatient stay can vary from 3 to 5 days. Treatment for pain may be prescribed if needed, and anti-coagulation treatment is administered to prevent the risk of phlebitis. The urological surgeon will decide when to remove the urinary drain and stent. The day after the procedure, the patient is allowed to get up from bed under the supervision of medical personnel. The urological surgeon and the patient will decide together how and when the patient can resume his or her normal activities. Like all surgical interventions, prostatectomy can involve certain risks and complications associated with the anesthesia or with the procedure itself. Your surgeon will discuss these different aspects with you and give you a written information sheet to obtain your informed consent prior to the operation. In practice: Once the date has been decided on by your surgeon, he or she will give you a file regarding your stay, the specifics of your intervention, the different exams that will be performed, contact information for making an appointment for your anesthesia consultation and the details of the admission procedure. The anesthetist and the surgeon will see you every day until discharge.

Discharge: Elsie will give you your prescriptions when you leave (at-home nursing care, any medication needed, biological exams to be performed) and will let you know the date of your next appointment.

Recovery: You will be allowed to resume your normal life as much as possible (walking, using stairs, although you should avoid lifting heavy objects for a month) in the place of your choosing. It is recommended that you not drive for 10 days after leaving the hospital, but you can be as passenger. You can resume your normal eating habits.

Medical follow-up: The first follow-up appointment will take place one month after you leave the clinic, after which your surgeon will decide on the frequency of subsequent follow-up visits.

The kidney is an organ that filters the blood. It is an internal organ located in the abdomen under the diaphragm and touching the spinal column. Urine produced by the kidney drains toward the bladder through a system of ducts: the calyx and renal pelvis in the kidney, then the ureter until the bladder. The transition between the renal pelvis and the ureter is called the ureteropelvic junction. When the urine cannot flow freely, it accumulates in the kidney, which constitutes ureteropelvic junction obstruction. This can have very significant effects on the kidney and cause it to lose function.

What causes ureteropelvic junction obstruction?

• It can occur due to an artery that passes too close to and compresses the channel and/or an abnormality in the size of the channel itself, secondary to a flaw in its muscular wall.
• Sometimes the narrowing is secondary to a disease leading to inflammation in this part of the body.

The accumulation of urine in the kidney causes high pressure that progressively destroys the kidney tissue. The symptoms that are most commonly seen include:

• Side pain or an infection
• Stones, whose formation is promoted by urine retention
• This condition may also be discovered fortuitously during a radiological exam. Sometimes in these circumstances the discovery may be made too late, if the kidney has already lost functionality.

Diagnosis is based on imaging:

• Ultrasound showing dilation of the kidney cavities
• Urogram or intravenous urogram showing asymmetrical function between the two kidneys

Use of the surgical robot (Da Vinci)

This anomaly is repaired surgically: the procedure consists of removing the part of the channel that no longer functions, as well as the excess part of the renal pelvis. The urine will then be able to flow freely. Most commonly, an internal stent (double-J stent) is placed to protect the stitches. This stent is typically left in place for 4 to 6 weeks after the intervention. This procedure was traditionally performed as an open surgery, and then later by laparoscopy. Today, it is performed using a surgical robot (Da Vinci). The benefit of using the robot is that it combines the advantages of laparoscopy (open surgery not required) and the precision of the surgical gestures of the robotic instruments guided by the surgeon. One of the most important aspects of this intervention is the quality of the reparative stitches made between the ureter and the renal pelvis, after having removing the diseased tissue. We have more than 10 years’ experience with the Da Vinci robot, and currently use the latest model. This system provides 360° rotation (more than the human hand) and very fine instruments (2 mm). Very precise stitches can be made using thread that is less than a tenth of a millimeter in diameter.

An anesthesia consultation must take place at least one week before the intervention.

Preparing for the intervention

It is essential to confirm that the urine is not infected by performing a urinalysis. It may be helpful to consume a diet low in vegetable fiber for 4-5 days prior to the intervention to make the intestine as flat as possible, which can facilitate the surgical approach. Our assistant is located in the urology service on the 6^th floor of the Ambroise Paré Clinic (Mrs. Elsie Crespy – 01 46 41 87 75) and can help you prepare for admission.

Your inpatient stay

You will be admitted the day before or the morning of the intervention. An anesthesia consultation must take place prior to admission. We also ask that you inform us of any anticoagulant medication you may be taking before the intervention. When you arrive, the nurses and our administrative assistant will check your medical file. It is important to provide in in its entirety, including any radiology images that were taken. The length of stay is determined by the complexity of the repair, and typically ranges from 3 to 5 days.

Care at the Ambroise Paré Clinic

It may be helpful to retain a bladder stent (for 3 to 5 days) to ensure that the bladder remains empty to avoid urine backing up in the internal (double J) stent. It is important to protect the stitches in the kidney as long as possible.

Recovery

One of the advantages of robotic surgery is the absence of incisions, which means that you will be able to return to your normal activities more quickly. When you return home, we recommend resting for at least 10 days. You may leave the house, but significant physical or athletic activity should be avoid for 1 month. You should drink plenty of water, around 1.5 to 2 L per day. You may occasionally notice blood in your urine. This is not cause for concern, unless it is accompanied by pain or you notice large clots. The internal stent may sometimes cause a sensation of discomfort in the bladder or kidneys.

Medical follow-up

This stent is typically removed under a local anesthetic, between 4 and 6 weeks after the intervention, and the entire procedure takes less than 5 minutes. Post-operative monitoring also includes urinalysis and imaging to check the quality of the repair.

Genital prolapse is commonly referred to as “organ descent” because it indicates the descent of one or more female pelvic organs. The bladder in the front, the uterus in the middle and the rectum in the back can, separately or together, over time (menopause) and/or after multiple deliveries, no longer be properly supported and begin to descend into the vagina. The patient senses and/or sees a “bump in the vagina”. This can bulge into the vagina, reaching or passing the level of the vulva.

If the bladder bulges into the vagina, this is referred to as a cystocele; this is due to a lack of support between the bladder and the anterior (front) part of the vagina. If the rectum bulges into the vagina, this is referred to as a rectocele; this is due to a lack of support between the bladder and the posterior (back) part of the vagina.

If the uterus falls, it falls into the middle of the vagina due to a lack of support from the ligaments that typically hold it in place, and this is referred to a hysteroptosis. Cystoceles, rectoceles and hysteroptoses can be associated with each other to different degrees. The intervention suggested by your urologist will enable complete and appropriate correction of the elements contributing to your prolapse. The general idea is to replace the defective supportive tissues with a synthetic prosthetic material attached to a very solid ligament that passes in front of the vertebral column at the level of the sacrum. In this way, each pelvic organ will be returned to its normal place.

Anesthesia consultation

Required at least one week prior to the intervention

Preparing for the procedure

An anesthesia consultation must take place several days prior to the surgery. The anesthetist will decide whether or not you should continue taking your usual medications, particularly anticoagulants. You should bring a complete list of all medications you are taking to the consultation. Your urologist will ask you to arrive the day before or the morning of the procedure. You may be prescribed an enema prior to the intervention. Bring all of your radiological exams with you.

Your inpatient stay

Administrative admission takes place on the ground floor of the clinic. The Ambroise Paré Clinic urology service is located on the 6^th floor. Our administrative assistant Elsie and the nursing team will be there to greet you.

The intervention

The nursing team will explain and then perform the skin preparation procedure (cleaning/shaving). The surgical suite is in the basement of the clinic. When it is time for your operation, you will be taken there by a porter. Once you have arrived in the operating room, the surgical nursing staff will take over. You urology surgeon will be there, as well as your anesthetist, who will put you to sleep. The procedure is carried out under general anesthesia. A urinary stent is put in place.

Da Vinci robot-assisted laparoscopic surgery avoids the need for creating a large opening in the abdominal wall. The surgical instruments and the synthetic slings are inserted through small openings (typically 5) about 1 to 1.5 cm in length across the lower abdomen. At the end of the procedure, these openings are closed with resorbable stitches, which means that they will disappear by themselves without having to “have your stitches taken out”. The stitches will disappear in approximately 3 weeks.

Da Vinci robot-assisted laparoscopic surgery enables the surgeon to have a magnified view in three dimensions and enhances the precision of his or her movements, so that the dissection and placement of the sling can be achieved better and more safely. After the intervention, whose duration can vary depending on the case, you will be transferred to the recovery room where you will be cared for by another specialized team that will monitor your emergence from anesthesia. The anesthetist will decide when you can return to your room.

After the procedure

Your urologist and anesthetist will visit you every day. Care will be provided by a nursing team that specializes in urology and by nursing assistants. Physical therapists support the nursing team. In general, you should not experience much pain after the procedure, but pain medication can be prescribed if needed. The urologist will decide when you can drink and eat, based on you health status. In general, you should be able to drink something the evening after the intervention if it took place in the morning, or if not then the next day, and you should be able to eat the next day if your intestinal transit has been restored. Laxatives may be prescribed. The urinary stent is typically removed two days after the surgery. If a vaginal mesh was installed, it will be removed the day after the intervention. You may take a shower the day after the intervention if the incisions are not giving you any discomfort. You will generally stay at the clinics for two to three nights after the intervention.

Discharge

Discharge prescriptions (in-home nursing care, any medications needed (particularly for constipation), biological tests to be performed) will be given to you by our administrative assistant Elsie. She will tell you when your post-operative appointment is.

Recovery

Even though recovery after Da Vinci robot-assisted laparoscopic surgery is short, enabling you to quickly resume your professional activities, you should not lift any heavy objects or engage in athletic activity for several weeks. Your surgeon will decide when you can resume these activities during your follow-up consultation. The incisions should not be “immersed” for a month, so only showers are permitted during this time, and “tanning” is not allowed for a year (otherwise there is a risk that they will become permanently tattooed on your skin).