June 30, 2015 | by Laurel DiGangi
“With bladder cancer, the majority of patients that I see can be cured,” said urologist Kevin Chan, M.D., head of reconstructive urology at City of Hope. “The challenge is to get patients the same quality of life that they had before surgery.”
To meet this challenge, Chan and the urologic team at City of Hope ensure that bladder cancer patients who need a cystectomy, or bladder removal, are fully aware of their options. According to Chan, the majority of urologic surgeons will recommend only an “incontinent diversion,” in which the urine drains into an external bag.
But at City of Hope, 60 percent of patients receive “continent diversions” — either a neobladder or Indiana pouch—in which a section of intestine is used to create an internal reservoir. The neobladder allows patients to urinate out of their urethra, whereas the Indiana pouch results in a stoma on the abdomen that patients catheterize to empty.
“We spend an hour with each patient, explaining all three reconstructive procedures,” said Chan. “We go through the pros and cons of each one in that patient’s particular situation. And as long as it’s reasonable and makes sense from a cancer perspective, we will do everything we can to give them the reconstruction they want.”
City of Hope leads the way in reconstructive urology that improves the patient’s quality of life. “We also have the world’s largest experience in robotic radical cystectomy continent urinary diversion,” Chan said.
Chan feels particular joy when his patients who have undergone bladder removal return to their former active lifestyles. “One 42-year-old woman is a boot camp instructor and teaches 14 classes a week with the Indiana pouch,” Chan said. “Another patient, one with an external bag, shot a hole-in-one golfing nine months after surgery.”
Meeting challenges with a patient-centered approach
Bladder reconstructive surgery presents special challenges. The complication rate — from infection and dehydration — is high, about 60 to 70 percent. “There are all sorts of speed bumps along the way,” Chan said. In addition, the postsurgical self-care may be complex and overwhelming to some patients.
“That’s why I feel very fortunate to work at City of Hope, where there is such commitment to the patient experience,” Chan said. “So many people are dedicated to helping patients transition back to a normal life.”
Playing a key role in this patient-centered approach is urologist Laura Crocitto, M.D., M.H.A., an associate clinical professor and City of Hope physician advisor. She and her colleagues developed a unique “care pathway” that addresses the special needs of bladder cancer patients.
“The patient is part of a team,” Crocitto said. “And each day the patient meets with a core group that consists of the urologist, supportive care medicine physician, social worker, case manager, urology fellow, nurse coordinator, mid-level provider — either a nurse practitioner or a physician’s assistant — and bedside nurse.” Since this approach has been implemented, the average length of hospital stay postsurgery has been shortened, and readmission rates have also fallen.
“The care pathway program is a testament to the physicians who supported this concept,” Crocitto said. “That’s why it’s so successful.”
Research and the future
Not only is City of Hope on the forefront of bladder cancer surgery, its experts are conducting significant research. “There’s a gene expression modeling that can evaluate the genes in a tumor specimen and potentially predict its response to chemotherapy,” Chan said. “This will help identify those patients who will benefit from chemotherapy before surgery and those who will not, and would benefit from surgery upfront.”
Chan is excited about the future of bladder cancer surgery. “We’re continuing to work on optimizing outcomes, minimizing complications and decreasing the length of hospital stays,” he said. “Every patient’s journey is different. But we really have a lot of great outcomes and that’s the reward, that we see them through this hard time and then see them back to being normal again, completely.”
Learn more about bladder cancer treatment and research at City of Hope.
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