By Todd Neff and Katie Kerwin McCrimmon
When it comes to life-saving bladder cancer surgeries, Dr. Janet Kukreja is the top surgeon in the U.S.
Kukreja is North America’s most prolific “cystectomist.” This means that 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.
Kukreja does about 150 of these robotic surgeries each year at UCHealth University of Colorado Hospital on the Anschutz Medical Campus. Kukreja is also an associate professor of urology surgery at the University of Colorado School of Medicine.
As the leading surgeon in her field, Kukreja cares for patients from multiple states in the Rocky Mountain region and across the U.S. She’s also a mentor and teacher for newer doctors who are learning how to save the lives of bladder cancer patients.
Intuitive Surgical, maker of the Da Vinci Surgical System, which Kukreja uses for her robotic surgeries, sends doctors from around the country to Colorado to learn how to do cystectomies. Newer surgeons watch and listen as Kukreja works.
She credits her expertise in part to her youth and her willingness to embrace new technology.
Kukreja knew she wanted to be a surgeon.
“When I was a medical student, I decided to explore urology because my grandfather had prostate cancer. I knew I wanted to do cancer care, but I wasn’t sure exactly what I wanted to do,” she said.
After attending medical school at the University of Missouri, Kansas City, Kukreja took the advice of a research mentor who encouraged her to become the world’s expert in robotic bladder cancer surgery.
“You should make this your life’s work,” Kukreja’s mentor told her.
And so she did.
Kukreja learned robotic surgery in parallel with open surgery during her residency at the University of Rochester, which she wrapped up in 2016. In 2018, she completed a fellowship at the University of Texas at Houston/MD Anderon Cancer Center Program. 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.”
When a cancerous bladder tumor requires surgery
For patients, receiving a bladder cancer diagnosis can be utterly devastating. That’s when Kukreja steps in to offer guidance and options.
Ryan Kenney, 52, of Eagle, received life-saving care from Kukreja.
Kenney, who joined the Vail Police Department in 2017 and became chief of police in 2023, is also 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.
Bladder cancer can be very dangerous if it’s not treated early, Kukreja said.
“It can be lethal,” she said. “If it’s not managed appropriately, people die from it.”
If left untreated, the cancer can spread quickly and kill people within a year or two.
“Once it metastasizes, the survival rates are grim,” Kukreja said. “It’s only 10% at five years. That’s on par with pancreatic cancer. It’s very bad.”
Bladder cancer is the tenth leading cause of cancer death in the U.S., according to the American Cancer Society.
The causes of bladder cancer are also unclear.
“About 50% of cases are associated with smoking, but we don’t know what causes the other 50%,” Kukreja said.
Like many patients, Kenney never smoked, so he’ll never know what caused his cancer.
But many other people find themselves in Kenney’s shoes.
Bladder cancer is the fourth most common cancer in men, behind prostate, lung and colon cancer, according to the National Cancer Institute.
Among women, bladder cancer is less common, but it can still be dangerous. Bladder cancer is among the 11th most common type of cancer that women get. The most common types of cancer in women are breast, lung, colon, uterine, melanoma, lymphoma, pancreatic, thyroid, kidney, leukemia and bladder cancer.
Bladder cancer: ‘Am I going to survive this?’
Uncertainty hung over Kenney, his wife Vicki, and their daughters, Summer, Rayna, and Reef, for a month until his October 2021 appointment with Kukreja at the UCHealth Tony Grampsas Urologic Cancer Care Clinic on the 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 earlier.
“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, 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 of the 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 has led a project to develop 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 patients decide how to proceed.
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 feeling like himself within months.
She was wrong, though, about him forgetting her name.
“Dr. Kukreja saved my life,” Kenney said. “And she’s amazing.”