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Tak et al. Mini-invasive Surg 2018;2:15 I http://dx.doi.org/10.20517/2574-1225.2018.05 Page 7 of 8

of 6 h. The average operating time in that series was 5 h for making an open neo-bladder without the use of
surgical staplers. The shorter operating time is an important step forward in minimally invasive surgery and
it would reduce the anesthesia time and the need for elective ventilation in the postoperative period.

Castillo et al. published the complications of laparoscopic RC. Complications (morbidity and mortality) in
[5]
this study, were comparable with our study, especially that of group A (Pfannenstiel incision group).

Laparoscopic RC and robotic RC provide advantages of minimally invasive surgery with better or at least
equivalent outcomes in terms of cancer control. During an initial phase of learning, the operative time will
be longer, but over time, there will be an apparent improvement in operational performance, thus reducing
the duration of surgery .
[2]
Grantcharov and Rosenberg observed that transverse incision offers as good an access to most intra-
[1]
abdominal structures as a vertical incision. The transverse incision resulted in significantly less postoperative
pain and fewer pulmonary complications. Vertical laparotomy, however, is associated with shorter operating
time and better possibilities for extension of the incision. The pooled odds ratio for burst abdomen in the
vertical incision group was 2.86 (95% confidence interval 1.72-4.73, P = 0.0001), in our study it was significant
too (P = 0.008). Grantcharov and Rosenberg concluded that transverse incisions in abdominal surgery
[1]
were based on accurate anatomical and physiological principles. They should be recommended, as the
early postoperative period is associated with fewer complications (pain, burst abdomen, and pulmonary
morbidity). Their observations were similar to what we find in our study.

Lunacek et al. had very positive experience with the Pfannenstiel incision approach for radical retro pubic
[6]
prostatectomy. They concluded, this approach provides good exposure of surgical field wound heals well
with a cosmetically acceptable scar and facilitates hernia repair through the same approach; if needed, which
mimic the results of our study but their study was for an open procedure and the radical prostatectomy,
rather than for cystectomy.

Smith et al. conducted multi-institutional prospective randomized trial (RAZOR) comparing open vs.
[7]
robotic radical cystectomy and found that estimated blood loss was significantly lower in the robotic arm,
translating into significantly lower blood transfusion rates. Major complications (grade III and above) were
similar in both groups. The number of lymph nodes removed was comparable. There was a trend to a shorter
length of stay for robotic RC. The results were similar to the group A of our study in terms of complications,
estimated blood loss, lymph node yield, and length of hospital stay.

This is a retrospective study, hence the inherent biases of the study design should be considered while
interpreting the results. Our data shows we had a bias to perform neobladder with a midline incision in
our initial learning curve. This fact might have skewed the data towards significantly high blood loss and
duration of surgery in group B (midline incision group). This bias associated with the learning curve (rate of
surgeon's progress in gaining experience) should be considered while interpreting the data.

We feel that more advanced disease may make the operation more challenging and potentially longer or
with more complications. Higher stage of disease may make the procedure more challenging, but this needs
further evaluation and confirmation with future studies. This study was not based on enhanced recovery
after surgery (ERAS) protocol.

In conclusion, Pfannenstiel incision enhances postoperative recovery with minimal complications. It has an
advantage over midline incision without compromising oncological outcomes. Pfannenstiel can be incision
of choice for extra-corporeal diversion.