Minimally Invasive Surgery for Bladder Cancer: Recent Advancements

Introduction:

The urinary bladder is a pear-shaped muscular organ of the urinary tract. It is situated in front of the pelvic cavity. The usual volume of the urinary bladder is 400 to 600 milliliters. It acts as a storage site for urine. Also, the voluntary excretion of urine is regulated by the urinary bladder. Cancerous changes in the basement membrane of the urinary bladder are known as bladder cancer. Different treatment modalities have been employed to treat such conditions.

What Is Bladder Cancer?

Neoplastic changes in the urinary bladder cells are known as bladder cancer. Bladder cancer is the most common type of urological carcinoma. This type of cancer is mostly seen in men. This type of carcinoma is mostly seen in the European population. Usually, older individuals are affected by this cancer. The average age group affected by bladder cancer is 73. Bladder cancer is the tenth most prevalent cancer worldwide. It is the sixth most common cancer seen in men and the seventeenth most common cancer in females.

Family factors and genetic factors are the predominant cause of bladder cancer. Genetic mutation of genes like HRAS, RB1, NAT2, and GSTM1 is associated with an increased risk of bladder cancer. Smoking and alcoholism increase the incidence of bladder cancer. Occupational exposure to the chemicals, carcinogenic chemicals, and schistosomiasis infection (infection caused by parasitic worms) are responsible for the increased incidence of bladder cancer. Chemicals like arsenic, Cyclophosphamide (a medicine used for the treatment of neoplasms), arylamine dye, and aniline dye are some of the causes. Exposure to substances like petroleum products, rubber, and paint is associated with such types of cancer.

Based on severity, bladder cancer can be low-grade (stage 1 and stage 2 cancer) cancer and high-grade cancer (stage 3 cancer). Based on the invasion of the local structures, it can be non-invasive, non-muscle invasive, and muscle-invasive. The most common histological type of bladder cancer is urethral carcinoma or transitional cell carcinoma. Other types of bladder cancers are squamous cell carcinoma, adenocarcinoma, and small cell carcinoma.

The symptoms of bladder cancer are:

1. Pain in the lower back region and abdomen.

2. Pain and burning sensation during urination.

3. Increased frequency of urination and urination at night.

4. The urge to urinate without the urinary bladder is full.

5. Presence of blood in the urine. Sometimes blood clots are present.

What Are the Treatment Options?

The treatment options for bladder cancer are based on the extent of the lesions and their involvement with the surrounding structure. The treatment options are:

1. Surgical Resection: Transurethral resection of bladder tumor (TURBT) is done for prognostic and therapeutic purposes. An endoscope-type device is used for removing cancer tissues. Along with this, burning the surrounding tissues helps to kill cancer cells. The low-grade bladder can be treated by partial cystectomy (removal of part of the bladder). Treatment for bladder cancer which has extensive tissue involvement along with lymph node involvement is radical cystectomy with urinary diversion (removal of the bladder along with lymph node).

2. Radiation Therapy: External beam therapy is useful in curing bladder cancer cases. Radiation therapy helps to kill cancer cells and reduce the size of the cancer.

3. Chemotherapy: Chemotherapy is used to restrict the growth of the cancer cells. It is used mostly before the surgical treatment options. The systemic chemotherapeutic agents are injected via a vein. Another method of chemotherapeutic treatment is intravesical chemotherapy. In this option, drugs are inserted into the urethra via a tube.

4. Immunotherapy: Immunotherapeutic drugs boost immunity and help to kill cancer cells. These drugs are used for the second line of therapy and adjuvant cases. These drugs are also used as the first line of drugs in low-grade bladder cancer cases.

What Is Minimally Invasive Surgical Procedure?

Minimally invasive surgery procedures are those procedures that include minimal tissue trauma, small incisions, less blood loss, and fewer postoperative complications. Minimally invasive procedures are getting popular due to their advantages and high success rates with fewer complications. Minimally invasive procedures used in urology are; laparoscopic radical cystectomy, transurethral resection of bladder tumor (TURBT), and robot-assisted surgical procedure.

1. Transurethral Resection of Bladder Tumor (TURBT): In this procedure, a type of endoscopic device known as a resectoscope is used. This is used mainly in cases of early stages of bladder cancer. The patient is placed under general anesthesia and in the dorsal lithotomy position (the patient is lying on the dorsum with hips and knees flexed at ninety degrees). After examining the urethra, a rigid resectoscope is inserted. A cystoscope is used to view the inside of the urinary bladder, and a cancerous mass is removed. It is done to remove stage 0 or noninvasive papillary carcinoma and carcinoma in situ. This procedure can be used for diagnostic purposes also. The cystoscopy is equipped with narrow-band imaging, which helps identify cancerous tissue changes. En-bloc resection of the tissue is helpful for biopsy procedures.

2. Minimally Invasive Cystectomy: A minimally invasive procedure for bladder removal can be either partial or radical. This procedure is also done under general anesthesia by placing the patient in a dorsal lithotomy position. A 5-millimeter port is inserted in the patient’s left side. The diameter of this tractor is 12 millimeters. A second tractor with a 10-millimeter diameter is placed 1 centimeter above the umbilicus. At the true McBurney point, a 10-millimeter trocar is placed to accept a 10-millimeter instrument. On the midline, a 5-millimeter trocar is placed, one span below the umbilical trocar. A fifth 5-millimeter trocar is placed at the horizontal level of the navel on the vertical line of the right lateral trocar. These instruments are used to remove the cancerous portion of the bladder and to create a new pathway for urinary excretion.

3. Robot-Assisted Procedure: In a single incision procedure, a relatively large skin is made, and several instruments are inserted. One of the main problems associated with the single-site approach was the clashing of instruments. The external clashing of arms can be avoided by the adoption of the chopstick technique. In this technique, arms are placed on both sides of the body and maintain a safe distance. On the other hand, in single-port surgery, a small incision is made on the fascia, and a single port is used for inserting instruments. Different robotic systems like da Vinci, Revo-I, and Avatera can be used for this purpose.

The contraindications for minimally advanced procedures are:

1. Severe cardiac problem.

2. Advanced cases of carcinoma with metastasis to other tissues.

3. Severe comorbidity.

Conclusion:

Bladder cancer is one of the most common cancers of the urinary tract. Surgical resection, radiotherapy, and chemotherapy are the traditional treatment options. The application of minimally invasive procedures like endoscopic and laparoscopic techniques can be beneficial in reducing surgical complications. Advanced procedures like robot-assisted techniques are also beneficial for treating bladder cancer.