First robot assisted cystectomy in TN - 18 Jan 2012

Wishing one & all a very Happy New Year!

New Year = new tidings. I am hoping this will be the year that will serve to influence my continued stay in India!!

Another memorable day in my life: 18th January 2012.

The day I performed robotic radical cystectomy in Apollo Hospital, Chennai. This is a first for Apollo Hospital, Chennai, as well as for Tamilnadu.

KS at console of Da Vinci Si - Apollo Hospital

Radical cystectomy - this term refers to complete removal of the urinary bladder for invasive cancer of the bladder. The patient was in her early 40s and an inveterate smoker. It was quite unfortunate that she presented with severe urinary symptoms as well as significant loss of weight over the preceding several months. Initial resection of the tumour (TURBT - transurethral resection of bladder tumour) had revealed a high grade cancer invading the muscle coat of the bladder. Clinically, it was also stuck to the adjacent structure. Staging investigations had shown some enlarged lymph nodes in the pelvis, but no evidence of spread to other organs.

Under these circumstances, suitable patients are usually advised radical cystectomy and given a few options about how the urine is diverted - either into a loop of bowel that is brought out through the abdominal wall (ileal conduit), creation of a new bladder (neo-bladder) using small bowel, which is then connected to the native water passage (urethra) or into the terminal part of the large bowel (where it admixes with stools). These options vary between individuals depending on their age, performance status, co-existing illnesses / health problems, nature / extent of the cancer, etc. This patient was advised an ileal conduit.

Ports placed prior to docking of the robot

Radical cystectomy can be done in one of three ways - open, laparoscopic or robot assisted laparoscopic cystectomy. I have described the difference between laparoscopic and robotic surgery in an earlier post about robotic prostatectomy (http://krish-sairam.blogspot.com/2011/11/my-first-robotic-radical-prostatectomy.html). Having done all three forms of radical cystectomy, it is my personal opinion that robotic cystectomy offers advantages for the patient as well as the surgeon.

Robot docked to the patient

Advantages for the patientThe entire procedure including the construction of the ileal conduit can be done through keyholes (although in this particular patient we did the reconstruction through a mere 5 cm cut in the tummy). Since there is no large cut in the patient's abdomen, recovery is faster. Also, with the precision and  magnified 3-D vision available with the Da Vinci Si system, dissection is precise that results in very little blood loss if any. With appropriate placement of the ports, removal of lymph nodes from the pelvis (which is an integral part of this procedure) as well is done with ease.

Also, since the bowel is not handled much (as in open surgery), it resumes activity over a shorter period of time.

Advantages for the surgeon

Surgeon fatigue is reduced, which translates to better technical execution. The patient is likely to benefit from this. The views of the pelvis obtained in robotic surgery is unmatched - this is my personal experience. Since there is no chopstick effect (as in laparoscopic surgery), dissection proceeds with precision, due mainly to motion scaling and tremor elimination - this, in my opinion, translates to enhanced patient safety and reduced liability for the surgeon.

Note the steep head down position of the patient

Estimated blood loss during the procedure was less than 100 ml. Patient was ambulant in 36 hours and had return of bowel activity in just over 48 hours. She was discharged on the 5th post-op day (which would be an unusual occurrence with open cystectomy).

With TG

As procedures go in urology, radical cystectomy is one of the most morbid and complex ones, and doing it especially with robotic assistance requires patience, dedication, and an excellent team of table side surgeons, anaesthetists and nurses. I am very lucky to have Dr Thirumalai Ganesan as my urology partner. As ever, thanks TG for everything! At the north end of the table, I am most grateful to the couple  - Dr Sumathi and Dr Aravind. And my thanks to the nursing and support staff in Apollo Hospital, Chennai for making this possible. I am certain that we are in for some exciting times ahead!

May I take this opportunity to mention that my personal website is now online although the patient info page is still not complete. Hope you will visit the site (http://www.krishsairam.com)

and send me your comments!

And folks, remember - SMOKING KILLS. So please give up the vile habit.