Numbers may not lie, but they don’t tell the whole story, either. Certainly not when it comes to Dr. Janet Kukreja’s work.
Kukreja, a University of Colorado School of Medicine urologic surgeon, is North America’s most prolific robotic cystectomist. That is, she performs radical cystectomies – the removal of a cancerous bladder and neighboring tissues followed by the sewing together of alternatives, all via a surgical robot. She did 115 of them in 2022. Having completed her 100th of 2023 by October, she’s on track for a similar tally this year.
More numbers: Her patients are routinely referred from 10 surrounding states, and Intuitive Surgical, maker of the Da Vinci Surgical System, has chosen UCHealth University of Colorado Hospital on the Anschutz Medical Campus to be among just three visit sites for surgeons learning the procedure. They’ll watch and listen as Kukreja works.
She credits her expertise in part to her youth. She learned robotic surgery in parallel with open surgery during a residency at the University of Rochester that she wrapped up in 2016. By then, it was clear that robotic bladder surgery was just as effective in removing cancerous tissue and had the advantages of smaller incisions, less blood loss, and faster recovery.
More senior surgeons, Kukreja said, “had to make this transition where they went from open to robotics, and I was just kind of born a robotic surgeon. It’s like when you learn two languages, English and Spanish, from birth versus learning Spanish as a second language. So I’ve always been bilingual in that sense.”
The number Kukreja pays the most attention to is “one.” That’s the patient in front of her, one who is psychologically battered from a bladder cancer diagnosis and who must make a decision regarding which of two paths Kukreja can take during a potentially life-changing procedure. Ryan Kenney, 50, of Eagle, was among those “ones.”
When a cancerous bladder tumor requires surgery
Kenney, Vail’s chief of police, is an avid mountain biker. In the summer of 2021, he noticed pain when urinating. A local doctor suggested switching out his mountain bike saddle. It didn’t help. A cystoscopy determined why: Kenney had a bladder tumor, and it looked cancerous. The urologist recommended he see Kukreja.
Kenney asked, “Am I going to survive this?”
The urologist said she couldn’t really answer that yet.
The uncertainty hung over Kenney, wife Vicki and daughters Summer, Rayna, and Reef for a month until his October 2021 appointment with Kukreja at UCHealth Tony Grampsas Urologic Cancer Care Clinic – Anschutz Medical Campus. Kukreja introduced herself and got right to the point.
“What do you need to know right now?” she asked.
Kenney asked what he had asked the Eagle County urologist a month back.
“Of course, you’re going to survive this,” Kukreja said. “In a couple of months, you’ll be back to 100%, and you won’t even remember my name.”
Kukreja would be half right.
A biopsy showed the tumor to be an aggressive cancer. The options included chemotherapy with uncertain chances of success and bladder removal. Kenney underwent his robotic cystectomy on Dec. 29, 2021. Less than four months later, he was mountain biking in Fruita.
Of course, it wasn’t that simple. First of all, radical cystectomies consistently involve the removal of the bladder, nearby lymph nodes, and, sometimes, neighboring organs. But then they can go in one of two very different directions, both having to do with the plumbing after bladder removal surgery.
The first involves an ileal conduit (a.k.a. urostomy), in which a surgeon takes a section of the small intestine called the ileum and uses it as the end of a pipeline that exits the body near the belly button. Urine collects in a bag outside the body.
The second has Kukreja stitching together a replacement bladder, called a neobladder, typically out of a longer section ileum. Kukreja is among the few robotic surgery experts who routinely construct neobladders via the quarter-inch-thick stainless-steel arms of a robot halfway across the operating room.
And while living with an external bag versus a replacement bladder seems a simple choice (in fact, 90% of bladder cancer patients who undergo bladder removal go with the ileal conduit rather than the neobladder), Kukreja devotes a lot of effort and attention to making sure patients understand the pros and cons of both. Her academic research centers on it, in fact.
Putting the patient’s needs first when discussing bladder removal surgery
Kukreja is leading a pilot project that’s developed a web-based app to help patients answer urinary diversion questions based on their personal circumstances and preferences. It explains both procedures and their risks and benefits. There are vignettes of patient stories and sliders to establish their values to help them make a decision.
The goal, she says, is to put the ultimate direction of bladder removal surgery in the hands of the patient. Too often, she says, “they’re very heavily swayed by the paternalism of the doctor. They’re like, ‘Well, Doc, what do you think I should do?’ And a lot of doctors say, ‘Well, I think you should do an ileal conduit because it’s the easiest.’ But it’s not necessarily the easiest. It’s kind of what fits your life best.”
With the ileal conduit, you have to deal with the bag. But you sleep through the night, for example, something bladder cancer patients often haven’t done for a very long time. A neobladder leaks for a couple of months, particularly at night, before the body gets used to a new sensation of having to go (rather than familiar bladder pressure, it feels like gas pressure). Even then, patients end up having to get up at least once a night.
Kukreja explained this and much more to Kenney.
“She’s so good at laying out your options and explaining the positives and negatives. She just made it such an informed choice,” he said.
He went with the neobladder.
For two months, tubes and healing connections prevented strenuous physical activity as Vicki and their daughters cared for him. Kenney regained much of his cardiovascular fitness by the time he was biking Fruita. Having lost some 50 pounds, most of it muscle, during his time on the shelf, his gym-related strength took longer. But as Kukreja had promised him in that first meeting, he was back to himself within months.
She was wrong, though, about him forgetting her name.
“Dr. Kukreja saved my life,” Kenney said. “And she’s amazing.”