Better Treatment for Kidney and Bladder Cancer

written by Dr Chua Chong Beng on 22 June 2011


Better Treatment For 
Kidney And Bladder Cancer
Consultant urologist Dr C.B.Chua talks about the new advancements in treating bladder and kidney cancer.
Bladder Cancer – Neobladder
Bladder cancer are malignant growths that occur at the bladder. The most common type is called transitional cell carcinoma. “Bladder cancer is closely related to smoking. It is a common disease in Malaysia due to the high number of smokers. I have seen men in their 30’s or 40’s having bladder cancer,” says consultant urologist of Prince Court Medical Centre, Dr C.B.Chua.
In the past, when the bladder was removed due to cancer, the surgeon would perform an ileal conduit, a surgical procedure to divert the urine to an external collection device (often referred to as the ‘bag’). During the operation, the urethra, which carries the urine from the kidneys are attached to one end of a segment of intestine (patient’s own) while the other end is brought up to the skin surface and attached to the bag.
“Wearing a bag is inconvenient, especially for people in their 30’s or 40’s. One of the biggest fears of patients in making the decision to have their bladder removed is because they don’t want to wear a bag,” Dr Chua notes.
“The good news is, today, we can reconstruct the bladder for replacement so that the patient doesn’t have to wear a bag and can pass urine the ‘normal’ way.” This ‘new’ bladder, constructed from the patient’s own bowel, is called the neobladder.
According to Dr Chua, a piece of intestine measuring 45cm to 60cm is obtained from the patient’s own body. With the blood supply still intact, the intestine is cut open and stitched into a spherical shape which resembles the original bladder. The neobladder will then be joined to the urethra. There are a few types of neobladder but the most common ones are the Struder and W pouch.
“As a substitute, the neobladder will not be able to function exactly like the original bladder, as bladder muscles are designed to contract and expel urine. Nevertheless, many patients can succeed in emptying the neobladder completely by pressing on their lower abdomen (where the neobladder is) and pushing with their abdominal muscles while relaxing their sphincter muscles. Patients who are unable to pass urine will need to insert a catheter into their urethra to empty the neobladder once or twice a day.
“Secondly, while the lining of the bladder is almost waterproof, the bowel’s natural ability is to absorb. Therefore, a neobladder might cause some of the solutes inside the urine to be absorbed back into the body. In the long run of about 10-15 years, some patients might encounter problems in regard to metabolic acidosis (excess acidity in the blood). Nonetheless, measures can be taken to prevent it, such as alkanising the urine.”
Dr Chua says that while the W pouch is more complicated to design, its shape is more spherical and it behaves more like a bladder. He also noticed that patients given a bladder replacement with the W pouch have fewer problems excreting their urine completely.
“Generally, most people prefer having the neobladder than a complicated bag system. It’s also cheaper in the long run. With the option of the neobladder, nowadays people are more willing to have their cancerous bladder removed – a life-saving operation which enables them to continue living for a long time,” Dr Chua remarks.
Kidney Cancer – Robotic Partial Nephrectomy
According to Dr Chua, with kidney cancer, the only chance of cure is through surgery. “In the past, operations were rather aggressive and the whole kidney was usually removed even for a small tumour. But we know that today, due to the prevalence of diabetes, high blood pressure and metabolic syndromes (which are main causes of kidney failure in this country), it is not good to be left with only one kidney. Kidney cancer patients with only one functioning kidney stands a higher risk of having to go for long-term dialysis,” he explains.
To preserve kidney function, surgeons realised that they cannot be overly aggressive. Therefore, nephron-sparing surgery or partial nephrectomy, where only the tumour and kidney tissues affected are removed, is more commonly done than complete kidney removal.
“Moreover, doctors are also seeing more early stage kidney cancers due to the increasing usage of intra abdominal imaging. A rising number of kidney cancers are detected merely through ultrasound or urine testing. For instance, a patient with abdominal pain goes to see a doctor and an ultrasound scan is performed, revealing the fact he has kidney cancer. Small tumour as such would never have been picked up if the patient does not go for an incidental screening.”
Dr Chua says that since early 2000, laparoscopic (or keyhole) surgery instead of open surgery is more commonly performed for kidney removal, as it provides quicker recovery, less pain and better cosmetic result.
“In cases where only a part of kidney is required to be removed, there exist competing and conflicting interest as to whether the laparoscopic surgery (in which the patient loses the whole kidney) or partial nephrectomy (in which an open surgery is required) should be done.
“It is very difficult to perform partial nephrectomy via keyhole surgery because the ischemic time for the kidney is usually 20-30 minutes when blood supply is temporarily halted. The surgeon has to complete the operation within that period of time before kidney tissues are damaged. Only a few very accomplished, highly-skilled surgeons in the world are able to perform such an operation,” he says.
The good news is, with the introduction of the robotic partial nephrectomy, nowadays partial nephrectomy can be performed via keyhole incisions. “The robot allows open surgical techniques to be replicated inside the body through keyhole incisions. This means that surgeons can now look into the patient’s body (which will be shown on the computer screen) and perform the surgery without having to open up the patient. A surgeon skilled at controlling the robot can complete the whole procedure within 20 minutes.”
In the field of urology, there are numerous established operations performed with the robot in regards to prostate , kidney and bladder cancer. Although robotic partial nephrectomy has only been around in Malaysia for a few years, Dr Chua believes that it will be the preferred choice of the future due to various benefits, including improved visualisation of surgical field, better posture and comfort for the surgeon, and minimal trauma which translates into earlier recovery for the patient.
Specialties of the Urologist
The urologist specialises in treating diseases of the urinary tract of both gender and the genital tract of men. He is both a physician and surgeon. Diseases the urologist treats include :
· Stones in the kidney, urethra and bladder
· Kidney, bladder and prostate cancer
· Functional disorders of the bladder
· Impotence, infertility, male menopause (andropause) and other male sexual and reproductive disorders