Pfannenstiel vs. midline incision for urinary diversion, following minimally invasive radical cystectomy: single center experience

Abstract

Introduction and Objectives: Minimal access radical cystectomy is now com-monly performed for localised carcinoma bladder but 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 physi-ological principles. In comparison with other treatment options, radical cystec-tomy offers better local disease control and 5-year survival. Approaches for radical cystectomy are open, laparoscopic or robotic; and 'open' approach was gold standard of surgical treatment. Even in this era of minimal invasive surgery, there are some institutions/centre, which practice the 'open' approach. Open approach has its own disadvantages like intra-opera-tive 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 surgical management of organ confined carcinoma bladder with advantages of less blood loss, high lymph node yield, less pain, early recovery, less compli-cations and mortality, short hospital stay. Only disadvantages of minimal access surgical approach are costs of implementation and lack of hap-tic feedback. AIM: To assess the morbidity on comparing Pfan-nenstiel versus Midline incision following minimally invasive radical cystectomy. Method(s): A retrospective comparative study, Study period February 2004-February 2017, Number of patients studied (n = 116). Patients were divided into Group 'A', (Pfannenstiel incision) and Group 'B' (Midline incision). Parameters analysed were age, sex, co-morbidity, tobacco exposure, occupation, presentation, CT findings, hydronephrosis, TURBT Report, duration of surgery (in minutes), hemoglobin drop (in gram per deciliter), need for blood transfusion (number of units), hospital stay (in days), epidural analgesia, analgesic requirement, pain score on first 3 post-operative days (on Visual analogue scale), complications, lymph node yield (numbers). Standard steps included Cystectomy with bilateral pelvic lymph-adenectomy done either through the laparoscopic or robotic approach and specimen retrieval along with diversion through either Pfannenstiel or Midline incision. Result(s): Primary end points, Post-operative pain score (p = 0.0001), analgesic requirement (p = 0.0003), Post-operative wound complication (p = 0.002), length of hospital stay (p = 0.0003) all were less (statistically significant p < 0.05) for Group A as compared to Group B and Secondary end points, duration of surgery (p = 0.0002), Post-operative paralytic ileus duration (p = 0.0006) were less (statistically significant P < 0.05) for Group A as compared to Group B. Other secondary end points, post-operative hemoglobin drop (p = 0.08), the number of units of blood transfused (p = 0.189) and lymph node yield (p = 0.533) were comparable in either group (statistically insignificant p >= 0.05). Conclusion(s): Minimally invasive (laparo-scopic or robotic) radical cystectomy with extra-corporeal diversion through Pfan-nenstiel incision offers an advantage of less morbidity than midline incision.