Bladder Cancer

Bladder cancer occurs when abnormal cells develop in the bladder lining, often due to risk factors such as smoking, exposure to industrial chemicals, chronic bladder inflammation, and a history of radiation or chemotherapy.

The most common type is urothelial carcinoma, which can range from superficial, non-invasive tumors to aggressive, muscle-invasive disease. Early-stage bladder cancer is often treated with endoscopic resection (TURBT) and intravesical therapy, while muscle-invasive bladder cancer (MIBC) or high-risk recurrent disease may require radical cystectomy—the surgical removal of the bladder. Radical cystectomy is indicated for muscle-invasive cancer, high-grade recurrent non-invasive cancer, and certain aggressive or therapy-resistant cases.

As a fellowship-trained urological cancer surgeon, Dr Dewar receives many referrals from his urology colleagues, locally, nationally, and from elsewhere in Africa for this complex surgical case. This has made him perhaps the highest-volume cystectomy surgeon in the country. During 2024, he performed 23 radical cystectomies – 13 robotic and 10 open.

For both open and minimally invasive cystectomy, there is ample evidence that complication rates and cancer-related outcomes are significantly better when these procedures are performed by high-volume surgeons, fellowship-trained surgeons, and in high-volume centres.

Robotic-Assisted Radical Cystectomy

Robotic radical cystectomy (RARC) is a minimally invasive approach that uses the Da Vinci surgical robot to enhance precision and reduce surgical trauma. The surgeon controls robotic instruments from a console, performing the procedure with a high-definition, 3D magnified view. Compared to open surgery, robotic cystectomy results in smaller incisions, reduced blood loss, fewer complications, and faster recovery. Additionally, intracorporeal urinary diversion, where the new urinary system is reconstructed inside the body, is possible with robotic surgery, leading to improved recovery and reduced risks of complications associated with open reconstruction. This approach is ideal for patients who can benefit from a faster return to normal activities.

Dr Dewar underwent a hands-on practical robotic cystectomy course at the prestigious ORSI Academy in Belgium, where he was the only participant, and instructed personally by Dr Alex Mottrie and Dr Henk van der Poel on robotic cystectomy, intracorporeal ileal conduit diversion, and orthotopic neobladder formation. He is the only South African surgeon to have completed this course. He was then proctored through four cases locally by Dr Frederiek D’Hondt from Aalst in Belgium.

Post-Operative Care & Considerations

 Open Radical Cystectomy

Open radical cystectomy (ORC) is the traditional approach, involving a larger incision in the lower abdomen. It remains an excellent option for complex cases requiring extensive reconstruction or in patients where robotic surgery is not feasible. In experienced hands, ORC offers excellent oncological outcomes, and urinary diversion—whether through an ileal conduit (urostomy) or neobladder—can be performed safely. The choice between robotic and open cystectomy depends on individual patient factors and surgeon expertise.

Post-Operative Care & Considerations

 Orthotopic neobladder

Most patients who undergo a radical cystectomy have their urine stream diverted to an ostomy bag on the skin that collects the urine continuously. An orthotopic neobladder is a more advanced type of urinary diversion that can be used after radical cystectomy, where a longer segment of small intestine is used to create a new bladder. This allows patients to urinate normally without an external bag. During the procedure, a segment of the small intestine is reshaped into a new bladder (neobladder) and connected to the urethra, enabling urine storage and passage through the natural urinary pathway. Over time, patients regain bladder control, though initial urinary leakage, especially at night, is common. With pelvic floor exercises, most achieve good continence. While neobladders can offer a better quality of life compared to urostomies, they require motivation, bladder training, and regular follow-up for monitoring. Dr Dewar has both the training and experience to perform this procedure.

Post-Operative Care & Considerations

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