Incidence, Etiology, Prevention and Management of Ureteroenteric Strictures after Robot-Assisted Radical Cystectomy: A Review of Published Evidence and Personal Experience

Benign ureteroenteric anastomosis strictures (UESs) are one of many critical complications that may cause irreversible disability following robot-assisted radical cystectomy (RARC). Previous studies have shown that the incidence rates of UES after RARC can reach 25.3%, with RARC having higher UES incidence rates compared to open radical cystectomy. Various known and unknown factors are involved in the occurrence of UES. To minimize the incidence of UES after RARC, our group has standardized the procedure and technique for intracorporeal urinary diversion by applying the following five strategies: (1) wide delicate dissection of the ureter and preservation of the periureteral tissues; (2) gentle handling of the ureter and security of periureteral tissues at the anastomotic site; (3) use of indocyanine green to confirm good blood supply; (4) standardization of the ample ureteral spatulation length for Wallace ureteroenteric anastomosis through objective measurements; and (5) development of an institutional standardized procedure manual. This review focused on the incidence, etiology, prevention, and management of UES after RARC to bring attention to the incidence of this complication while also proposing standardized surgical procedures to minimize its incidence after RARC.

The perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion compared with laparoscopic radical cystectomy with extracorporeal urinary diversion at a single institution.

Background The number of facilities adapting intracorporeal urinary diversion (ICUD) using robots instead of extracorporeal urinary diversion (ECUD) is increasing, but the clinical evidence is limited. Methods We retrospectively analyzed 26 consecutive patients who underwent ICUD with an ileal conduit following robot-assisted radical cystectomy (RARC) between 2018 and 2020 (RARC + ICUD group), and compared them with 26 consecutive patients who underwent ECUD with an ileal conduit following laparoscopic radical cystectomy (LRC) between 2012 and 2019 (LRC + ECUD group) at Yokohama City University. Results In both groups, the patient background was similar except for age and neoadjuvant chemotherapy. In the RARC + ICUD group vs. the LRC + ECUD group, the median total operation time was 516 min vs. 532.5 min (p = 0.217), the time to cystectomy was 163 min vs. 194.5 min (p = 0.007), and the time of urinary diversion with an ileal conduit was 161 min vs. 201.5 min (p < 0.001). The postoperative maximum value of C-reactive protein was 6.98 mg/L vs. 12.46 mg/L (p = 0.001). The median number of days to oral intake was 3 days vs. 5 days (p = 0.003). The median length of hospital stay was 17 days vs. 32 days (p < 0.001). The postoperative complication rate (within 90 days) was 23.1% vs. 42.3% (p = 0.237). Clavien-Dindo classification ≥ 3 was noted in 1 vs. 4 patients (p = 0.350). The median number of dissected lymph nodes was 20 vs. 15 (p = 0.008). Conclusions RARC + ICUD was superior to LRC + ECUD in terms of time to cystectomy and ileal conduit urinary diversion, invasiveness, and lymph node dissection. We consider ICUD with an ileal conduit following RARC to be the more advantageous procedure.