Surgeons at the University of Nebraska Medical Center/Nebraska Health
System successfully performed the world’s first ileal conduit urinary diversion
using a combination of the da Vinci Surgical System (computer assisted
laparoscopic arms) and traditional laparoscopic techniques. The combined
technique now offers significant quality of life enhancement — with greatly
reduced pain and recovery time — for thousands of patients needing urinary
diversions for various diseases affecting the urinary bladder.
On Sept. 4, a team of five surgeons, led by K.C. Balaji, M.D., UNMC
associate professor, section of urologic surgery, performed the complex
ileal conduit urinary diversion on Frank Holmead, an 83-year retired architect
from Sidney, Neb. The team included George Hemstreet, M.D., Ph.D., UNMC
chairman of urologic surgery; Paulos Yohannes, M.D., Creighton University
assistant professor in the division of urologic surgery; and Dmitry Oleynikov,
M.D., and Corrigan McBride, M.D., UNMC assistant professors in general
surgery and co-directors of the Minimally Invasive Surgery and Robotic
Initiative.
The ileal conduit urinary diversion procedure consists of using a 6-inch
section of bowel to connect the two ureters (the tubes that drain urine
made by the kidneys) on one end, and turned into a stoma for external drainage
through a stoma bag on the other end. Although urologists all over the
world perform this procedure, almost all urologists are only trained in
the open method — making large incisions to allow the surgeons hands inside
the body to do the intricate maneuvers.
The primary reason most patients suffer permanent loss of bladder function
is due to bladder cancer, Dr. Balaji said. There are 50,000 cases of
bladder cancer diagnosed in America each year now and at least 5,000 or
more of these cases result in the complete removal of the bladder.
Holmead’s bladder was severely scarred during radiation treatments for
prostate cancer 20 years ago. He suffered from side effects for 15 years
that included progressive incontinence due to irreversible damage to the
bladder and external sphincter from the radiation, recurring bladder infections
and constant wetness due to urinary incontinence necessitating two or three
layers of adult diapers every day.
In the last six months, Holmead was hospitalized for multiple urinary
infections, spasms and bleeding. Holmead and his wife, Phyllis, sought
a second opinion from Dr. Balaji with regard to further treatment options.
Dr. Balaji felt that instead of removing the entire bladder, an ileal conduit
urinary diversion would produce
the same symptomatic relief without the added risks of bladder removal
in an elderly patient.
Dr. Balaji made it clear from the beginning that this would be a new
surgical method, said Phyllis Holmead, Frank’s wife for 33 years.
His communication with Frank and I was outstanding. He never dodged or
evaded a single question. He never talked down to us. He described in detail
how he planned and rehearsed the surgery. And what really meant a lot to
our family was that Dr. Balaji — during the 10 hours of surgery — repeatedly
called me in the waiting area and updated us on what was being done and
how everything was progressing.
Only a handful of medical centers even do traditional laparoscopic urinary
diversions. The UNMC/NHS commitment to use the da Vinci Surgical
System in diverse surgical procedures puts the medical center on a competitive
footing to become the regional center — if not national destination point
— for the world=s least invasive urinary diversion procedure, Dr. Balaji
said.
Without the da Vinci, this would have been a lot harder to do — especially
the intricate suturing that has to be done inside the closed body, Dr.
Balaji said. The team effort was incredible. Dr. Hemstreet was very supportive
of the procedure, involved in the planning process from the beginning and
attended the surgery. Dr. Yohannes, the outstanding laparoscopic urologist,
brought great expertise from Creighton throughout the entire procedure.
Drs. Oleynikov and McBride also assisted in the planning processes, did
a lot of the clinical laboratory work in advance of the surgery, and Dr.
McBride did excellent work on the bowel resection for the conduit.
This is the kind of collaboration that allows all of us to pursue new
procedures and continue to build up Nebraska as a national competitor —
if not leader in increasing areas of medicine.
Holmead didn’t even have a recovery period in intensive care, a routine
expectation for such an invasive surgery after traditional methods. He
went to a regular room and left the hospital in three days. He was taken
off intravenously administered pain medication within 24 hours of surgery.
Instead of a several inches long abdominal incision required under the
traditional method, Holmead had four small incisions — each less than
a half-inch long — where the da Vinci robotic arms were inserted. Phyllis
said Frank had no bruising whatsoever at the insertion points and now it
just looks like he has a couple of extra navels. In less than a week,
Holmead was changing his own stoma bag and showing outstanding post-operative
recovery.
I feel fine, Frank said. At my age and condition, this wasnt about
making some kind of radical change in my life. But it really means a lot
to just be finally free from pain and recurring infections. And I no longer
have to wear diapers for the first time in years.