Bladder Patient Chooses Minimally Invasive Surgery

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By Mary Brolley, MD Anderson Staff Writer

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Born in tiny Lennon, Mich. -- "just a spot on the road, population 400" -- Adeline "Gail" Smith always wanted to travel the world.

So, straight out of high school, she joined the Women's Army Corps (WAC) and served five years, including a stint in Germany. Then she married, had two sons and worked in administrative office jobs before retiring to Naples, Fla., several years ago.

Having shown such spunk all her life, it was no surprise that when faced with a rare form of bladder cancer in 2008, Smith wasn't willing to take the first medical advice she got without question.

And, ultimately, the minimally invasive surgery she chose allowed her to return to her active life quickly and painlessly.

Second opinion reflects multidisciplinary approach
Diagnosed in October 2008 with a stage III urothelial carcinoma, her primary care physician advised immediate surgery to remove one of her kidneys and the affected ureter, the tube that connects the kidney to the urethra.

Smith decided to take some time to explore her options. And her sons, one of whom lives in Texas, wanted her to get a second opinion at MD Anderson. There, her medical team agreed that surgery was necessary -- but not yet.

Led by Arlene Siefker-Radtke, M.D., the MD Anderson team advised Smith to begin with chemotherapy to shrink the tumor and reduce the chances of its spreading. They suggested she consider enrolling in a clinical trial.

"They explained it to me honestly," Smith says. "Their opinion was that it would help me."
The chemotherapy regimen, which lasted eight weeks, was arduous but effective. The tumor shrank considerably.

"I was floored," Smith says. "They showed me exactly how it had shrunk. They were all pleased, but not as pleased as I was."

How best to treat this rare cancer?
Urothelial carcinoma, also known as transitional cell carcinoma, is the most common type of cancer in the bladder. But in about 4% of cases, including Smith's, it occurs in the ureter or renal pelvis (the inner part of the kidney where urine collects).

This called for a specialized approach, says Smith's surgeon, Surena Matin, M.D., associate professor in the Department of Urology and medical director of the MINTOS (Minimally Invasive and New Technology in Oncologic Surgery) Collaborative Group at MD Anderson.

 "The surgery not only requires removal of the kidney, but also the entire ureter down to the bladder including a little portion of bladder that surrounds the ureter," he says. "The old-fashioned approach to this (open surgery) required one very long incision or two separate incisions."

But with the minimally invasive technique suggested by Matin, Smith would likely have less pain, blood loss and scarring. She'd need less postoperative pain medication. 
Best of all, she'd go home sooner.

In the last decade, MD Anderson has increasingly embraced minimally invasive surgical techniques -- endoscopy, image-guided surgeries, robotic surgeries and those using real-time MRIs -- because of such benefits to patients. (For more information, see link to Q&A at the end of this story, in which Matin answers questions about this type of surgery.)

"What's more important though," Matin says, "is the rational integration of these techniques into the spectrum of cancer care. In this case we not only did the standard surgery after chemotherapy, but also did a fairly extensive lymph node dissection. Most gratifying was the fact that she had a complete response, something that was rarely ever seen before the multidisciplinary approach."

"Our minimally invasive cases have quadrupled since 2001," Matin says. The majority of radical prostatectomies at MD Anderson are done with minimally invasive techniques. Other procedures that lend themselves to these techniques are radical and partial nephrectomies (complete or partial surgical removal of a kidney) and robotic cystectomies (surgical removal of the bladder).

Matin, who got his start at the Cleveland Clinic in the 1990s when these techniques were being explored and developed, believes that the use of minimally invasive techniques will only grow. 

"Of course, there will always be a role for open surgery, because many patients come to us with more advanced disease or need complex reconstruction," he says.

Treatment over, back to 'gallivanting'
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Over the six months of her treatment, Smith developed a strong admiration for her medical team. "They treat you like a person -- a human being. They respect you," she says.

She recalls Matin's willingness to collaborate to determine the best treatment for her. "Because my cancer was rare, especially in women, he discussed my case with experts to see what was the best thing to do," she says.

Within a day or so of surgery, Smith was up and walking, and her recovery went smoothly. Nearly 18 months later, she's back to her favorite pastimes: walking, reading, shopping and "gallivanting around" with her sister.

She marvels at the small incision that's the only souvenir of her lifesaving surgery. "It amazes me how he got that kidney out. It blows your mind," she laughs.

Related story:

Q&A: Minimally Invasive Surgery
Surena Matin, M.D., associate professor in the Department of Urology and medical director of the MINTOS (Minimally Invasive and New Technology in Oncologic Surgery) Collaborative Group at MD Anderson, answers questions about minimally invasive surgery. Read More

MD Anderson resources:

MD Anderson Bladder Cancer Support Message Board

Minimally Invasive Surgery

Bladder cancer treatment (audio podcast)

MD Anderson Genitourinary Center

Additional resources:
American Cancer Society overview on bladder cancer

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