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    Do you ERAS? The future of post-cystectomy care

    Henry Rosevear, MDDr. Rosevear, MDRecently my partner and I were performing a cystectomy, and as is common during most long cases, our discussion became a bit philosophical. Both of us were trained in the era of open cystectomy, but as this case was being done robotically, the conversation turned toward the future of surgical treatment of muscle-invasive bladder cancer.

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    Surgical treatment of bladder cancer has a long and storied history dating back to 1852. Detubularization to create a low-pressure reservoir was a milestone by Kock in the mid-1960s, and Mitrofanoff described the trans-appendicular continent cystostomy in 1980. In 1992, the first pure laparoscopic simple cystectomy was reported, and by 2003, case series of robot-assisted cystectomy and diversion were reported. (For a more detailed account, see “Bladder cancer and diversion: A historical perspective”)

    Now, completely intracorporeal robotic procedures have been reported and are common.

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    So where do we go from here? Unless someone is able to grow a new bladder using the patient’s own tissue, the surgical technique we have maintains good oncologic principles while providing an outcome that mimics the patient’s original bladder and can be done in a minimally invasive manner. Are we done advancing the field? Absolutely not. While the technique works, radical cystectomy still carries an unacceptably high complication rate likely secondary to a combination of patient-specific issues (patients tend to be older and sicker) and disease- and procedure- specific issues (the operation still exposes patients to major abdominal surgery combined with the metabolic changes that go along with exposing urine to the bowel).

    Next: "What is the future? The future is Enhanced Recovery After Surgery, or ERAS."

    Henry Rosevear, MD
    Dr. Rosevear, a member of the Urology Times Clinical Practice Board, is in private practice at Pikes Peak Urology, Colorado Springs, CO.

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