Oncological interventions

Urology

• Robot-assisted radical prostatectomy (RARP) is currently the most modern procedure for minimally invasive removal of the prostate. The optical magnification of up to 12x and the three-dimensional imaging in the da Vinci give us an optimal view of the surgical site. The robot's instruments are extremely mobile and flexible, allowing us as surgeons to perform extremely fine and precise procedures.
  
• The advantages clearly lie in the lower complication rate, less blood loss (blood transfusion rate < 2%), faster convalescence/recovery and significantly less pain due to the smaller surgical access.
  
• Progression: During the operation, the patient is positioned with the upper body lowered. Access is made via six small abdominal incisions. After the abdominal cavity is filled with carbon dioxide gas and the camera trocar (arm of the da Vinci with camera) is inserted, the other trocars are placed in the accesses under control. First, the prostate is carefully exposed. The urethra is then separated above the prostate in the area of the bladder neck. After exposing the seminal vesicles and cutting the vas deferens, the pelvic floor and rectum are separated. During the exposure of the prostate, if feasible from an oncological point of view, a nerve-sparing operation can be attempted. The prostate can then be completely separated from the urethra. Finally, the urinary tract or urethra and bladder neck are connected by a continuous suture. The connection is splinted with a permanent catheter. A wound drain is usually inserted. Finally, after removal of the prostate, the small abdominal incisions are closed through a slightly widened incision.

• Organ-preserving kidney surgery (partial kidney resection) is considered the gold standard for kidney tumors that do not involve the renal pelvic caliceal system and the renal hilum. At our clinic, most kidney tumors are treated using the so-called robot-assisted, minimally invasive surgical technique (daVinci procedure).
  
• This technique has already become established for smaller tumors. The further development of the robot-assisted technique now also enables the safe removal of complex tumors without prolonged clamping time.
  • Good visualization of the tumor: Intraoperative ultrasound makes it easier to find a tumor.
  • Visibility of tumor-supplying blood vessels: The da Vinci allows up to 12-fold magnification - allowing surgeons to see even small blood vessels clearly. The fluorescent dye technique with indocyanine green (ICG) using the so-called firefly technique makes the procedure gentler on the kidney, as it makes arteries that directly supply a tumor visible.
    
• The minimally invasive procedure allows for a shorter hospital stay. The decision on the time of discharge is made on an individual basis. As a rule, the hospital stay is four to five days.

• A nephroureterectomy is performed for a malignant tumor of the upper urinary tract (ureter and renal pelvis). This involves removing the kidney and the entire ureter, including its entrance into the bladder (bladder cuff). At our clinic, we can perform this procedure robot-assisted, minimally invasive and therefore particularly gentle.

• RLA is the surgical removal of the lymph nodes in the posterior abdominal cavity (retroperitoneum), the first stage in the metastasis of testicular carcinoma via the lymphatic channels. This operation is rarely indicated nowadays. In addition to the open approach, it can also be performed minimally invasively using so-called keyhole surgery (laparoscopic or robot-assisted).
  
• In cases where chemotherapy or a surveillance strategy is not possible, surgical removal of the lymph nodes in the area described above is an alternative option. Care must be taken to ensure that the operation is as nerve-sparing as possible in order to avoid ejaculation backwards into the bladder (retrograde ejaculation).
  
• The advantages of robot-assisted over laparoscopic RLA:
  • 3-D view and 360° angled instruments
  • of the entire retroperitoneal space from the renal vessels to the external inguinal ring can be achieved almost as with open surgery without redocking the robot.
    
• Patients with small residual tumors without prolonged vascular contact are suitable candidates for robot-assisted residual tumor resection (RTR).

• Tumors in the adrenal gland (incidentalomas) are usually discovered by chance. These tumors are rarely hormone-active (produce hormones). Malignant tumors in the adrenal gland are even rarer. Sometimes removal of the adrenal gland (adrenalectomy) is recommended for larger benign tumors.
  
• The minimally invasive surgical technique with the da Vinci can also be used here. The 360° angled instruments of the da Vinci system allow the adrenal gland to be reached very easily. The 3D view allows the vascular supply to be precisely recorded.

A radical cystectomy involves the removal of the urinary bladder including the removal of the lymph nodes in the pelvis. While the prostate is also removed in men to be on the safe side, part of the front wall of the vagina, uterus, ovaries and fallopian tubes are removed in women. The reason for a radical cystectomy is usually the occurrence of bladder cancer.

When is a radical cystectomy performed?

With radical cystectomy, the right time for this operation is crucial. On the one hand, all other options for treating bladder cancer should have been exhausted. On the other hand, the operation should take place before metastasis occurs. For this reason, the surrounding organs and nearby lymph nodes are also removed in this case.

Around 70% of those affected are initially diagnosed at an early stage of the tumor. If the urinary bladder muscles are not yet affected at this stage, patients receive radiotherapy and/or chemotherapy as an alternative to a simple or radical cystectomy.

The following clinical pictures speak in favor of radical bladder removal:

• Muscle-invasive carcinoma of the bladder: the tumor has already penetrated the muscle layer of the bladder wall and possibly surrounding tissue, but not yet more distant tissue.

• Superficial bladder carcinoma with an aggressive growth tendency: A non-muscle-invasive bladder cancer that nevertheless exhibits rapid and uncontrollable growth.

• Minimally invasive, difficult-to-access, superficial bladder carcinomas: These superficial bladder carcinomas are carcinomas that cannot be controlled even with a transurethral resection (endoscopic resection via the urethra, also known as TURB).

• As a palliative measure: If an inoperable bladder carcinoma leads to increased pain, bleeding and other symptoms that restrict the quality of life, a radical cystectomy is also advisable.

• Non-existent bladder capacity: Bladder shrinkage can severely restrict bladder capacity. This results in constant urge incontinence, which greatly reduces the quality of life of those affected.

Procedure of a radical cystectomy with the daVinci

As an alternative to the conventional surgical method, a minimally invasive surgical technique using the daVinci may also be an option. In this laparoscopic method (using a laparoscopy), surgical devices including a video camera are inserted through the abdominal wall using tiny incisions in the skin.

This robot-guided, minimally invasive bladder removal is considered a major challenge with a high degree of difficulty. Nevertheless, the advantages of this method outweigh those of open abdominal surgery:

• Blood loss is significantly less,
• the healing of the surgical wounds is much faster and there are fewer complications.
• complications occur less frequently.
• In addition, the aesthetic advantages of this method are literally obvious, as it only results in minimal scarring.

Artificial urinary diversion

Depending on the findings and the course of the operation, another form of artificial urinary diversion may be considered after a radical cystectomy. Of course, the patient's wishes or dislikes with regard to certain forms of ur inary diversion are also taken into account.

There are 3 options for the artificial drainage of urine:

1. Wet or incontinent urinary diversion: with this method, the urine flows from the abdominal cavity directly into a bag, which cannot be seen by those around you. This form of urinary diversion is particularly advisable if the disease has already severely impaired the patient's general condition.
   
2. Dry urinary diversion: If the ureters are intact, the patient's general condition is good and the bowel is healthy, the surgeon removes part of the small intestine, sometimes also a piece of the large intestine, and constructs a replacement bladder, the "neobladder".
   
   - Preoperative patient training.
   
3. Dry urinary diversion via the skin: In cutaneous urinary diversion (via the skin), the surgeon also constructs a urine reservoir in the abdomen from parts of the intestine. This urinary reservoir, known as a pouch, extends to the area around the navel, where there is a kind of valve for draining the urine. If the pouch fills up and presses on your artificial outlet, you can empty the pouch with a disposable catheter. This type of "abdominal urinary bladder" is called a continent or dry urostomy, as you can control the emptying yourself.