Page 99 - Read Online

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

Conclusion: Minimally invasive (laparoscopic or robotic) radical cystectomy with an extra-corporeal diversion through
Pfannenstiel incision offers an advantage of less morbidity than midline incision.

Keywords: Pfannenstiel, midline, incision, minimally invasive radical cystectomy, conduit, neobladder, morbidity

INTRODUCTION
Minimal access radical cystectomy is now commonly performed for localized carcinoma bladder but the
reconstructive part of surgery is challenging. Open reconstruction can offer the advantage of minimal
access surgery (MAS). Morbidity of open surgery can be reduced and the advantage of MAS can be gained
with Pfannenstiel incision, transverse incisions in abdominal surgery are based on better anatomical and
physiological principles . In comparison with other treatment options, radical cystectomy offers better local
[1]
disease control and 5-year survival.

Usually, radical cystectomy has become the part of multimodality of treatment of bladder cancer in select
cases (in which neo-adjuvant chemotherapy is followed by radical cystectomy). Approaches for radical
cystectomy are open, laparoscopic or robotic; and "open" approach is the gold standard of surgical treatment.
Even in this era of minimally invasive surgery, there are some institutions/centers, which practice the "open"
approach. Open approach has its own disadvantages like intra-operative blood loss, prolonged hospital
stay, delay in recovery, significant morbidity and even mortality. But now, in the era of minimal access
surgery, laparoscopy and robotic approaches can become standard of care for the surgical management of
organ-confined carcinoma bladder with advantages of less blood loss, high lymph node yield, less pain, early
recovery, fewer complications and mortality and short hospital stay. The major disadvantages of minimal
access surgical approach are costs of implementation and lack of haptic feedback.

This study aims to assess the morbidity on comparing Pfannenstiel vs. midline incision for urinary diversion,
following minimally invasive radical cystectomy.

METHODS
This is a retrospective comparative study from February 2004 to February 2017 and the number of patients
studied was 116. Patients were divided into group A (Pfannenstiel incision) and group B (midline incision).
All operations were performed by the single surgeon with experience of doing about 20 radical cystectomies
per year. The incision was not allocated by any random chart or table as it is a retrospective study. The
allocation was based on surgeon's preference.

We used minimal access approach for radical cystectomy. Standard steps included transperitoneal approach.
5 ports for laparoscopy and 6 ports for robotic surgery were employed. Steps were bilateral ureter dissection,
posterior peritoneotomy, bilateral seminal vesicles and vas dissection, dissection of the prostate, while
cystoprostatectomy specimen was freed all around, specimen bagged, followed by bilateral standard lymph
node dissection and initiation of the reconstructive part. We have not used staplers for any reconstruction
due to financial constraints. The procedure was completed in two stages for ileal conduit: first, pelvic
lymphadenectomy with cystoprostatectomy; second, extracorporeal formation of the ileal conduit. The
procedure was completed in three stages for ileal neobladder: initially, pelvic lymphadenectomy with
cystoprostatectomy, secondly, extracorporeal formation of neobladder and thirdly, re-docking the robot,
intra-corporeal urethro-neo-vesical anastomosis.

For reconstructive part of the procedure (either an ileal conduit or ileal neobladder), we used lower midline
vertical incision (group B) or Pfannenstiel incision (group A); we divided the patients into two groups.
One was with lower midline vertical incision and the other with Pfannenstiel incision. We compared