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    Radical cystectomy for bladder cancer: Tools vs. technique

    Basic principles of cystectomy remain the same regardless of surgical approach used

     

    Surgical tips and tricks

    Based on the author’s own experience performing radical cystectomy, here are some additional tips and tricks:

    Having adequate exposure and traction of tissues is critical to the successful completion of the steps of the operation. Spending extra time adjusting the retractor or retracting arm in robotic cases will keep the surgeon on track and minimize the risk of injury to adjacent organs.

    Whenever possible, use natural planes of dissection. For most of the operation, dissection should be carried through loose areolar tissue unless cancer is locally advanced or tissues are fibrotic from prior treatment or surgery. This will shorten operative time, lessen blood loss, and minimize inadvertent organ injury.

    It is important to minimize blood loss during the operation. Keeping tissue planes free of blood will improve visualization and avoid errors during surgery. Before moving on to the next step, spending extra time achieving hemostasis is always a good idea. Furthermore, minimizing postoperative anemia may potentially avoid the use of blood transfusions and aid in convalescence.

    General considerations

    It is important to emphasize that the basic principles of a cystectomy remain the same regardless of the surgical approach used. In the case of major abdominal surgery with a reportedly high perioperative complication rate, proper intra-operative technique and postoperative management far outweigh the effect of incision size. It is therefore not surprising that a randomized study comparing open to robotic cystectomy failed to demonstrate a significant difference in morbidity (Eur Urol 2015; 67:1042-50). Wide surgical resection of malignant tissue, respecting given tissue planes, and proper tissue handing are important no matter what tool is used to accomplish the operation.

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