Robotic vs. open surgical management of ureteroenteric anastomotic strictures: technical modifications to enhance success

A multicenter study of perioperative and functional outcomes of open vs. robot assisted uretero-enteric reimplantation after radical cystectomy

INTRODUCTION

Open ureteroenteric reimplantation (OUER) of ureteroenteric strictures (UESs) is related to important morbidity. Robot-assisted ureteroenteric reimplantation (RUER) has been proposed to provide similar outcomes with lower morbidity. We aimed to compare perioperative and functional outcomes between RUER and OUER.

METHODS

A retrospective multicenter study of 80 patients, who underwent 82 ureteroenteric reimplantations (17 OUER vs 65 RUER) at 8 institutions between 2009-2021 for benign UESs after radical cystectomy. All the open procedures were performed by the same center in order to compare the robotic approach with a standardized technique. Data were reviewed for demographics, stricture characteristics, and perioperative outcomes. Complication and stricture recurrence rates were compared between both groups.

RESULTS

Among 82 reimplantations, 44 were left sided (54%) and 12 bilateral (14%). Median time from cystectomy to diagnosis of stricture was 6 months (range 3-18). Baseline characteristics (gender, age, BMI, side, type of urinary diversion and previous abdominal radiotherapy) were comparable between RUER and OUER groups, except for ASA score and rates of prior robotic cystectomy. The 30-day overall postoperative complication rate was 37% in RUER compared to 70.6% in OUER (p = 0.026). Patients who underwent a RUER had statistically significant lower rate of intraoperative blood transfusion (0% vs 12%, p = 0.041), urinary tract infection (12% vs 53%, p < 0.001), bowel injury (0% vs 12%, p = 0.041) and high-grade complications (Clavien III-IV) (4.6% vs 23.5%, p = 0.031). RUER patients had shorter median length of hospital stay (3 days IQR[1-6] vs 6 IQR[3-9], p = 0.018) and lower readmission rate (4.6% vs 29.4%, p = 0.008). After a median follow-up of 23.5 months (8.7-43), 80% of RUER cases were stricture free compared to 90% of OUER (p = 0.42).

CONCLUSIONS

RUER achieved a success rate comparable to that of open revisions and may provide some advantages in terms of perioperative outcomes. Prospective and larger studies are warranted to prove its superiority compared to the standard open technique.

Single-Port Robotic Ureteroenteric Stricture Repair: A Retrospective Cohort Review

Introduction The objective of this study is to present a series of 16 cases utilizing single-port robot-assisted repair for ureteroenteric anastomosis stricture (UES). To our knowledge, this is the first case series recorded detailing successful single-port UES revision.  Methods A retrospective review of all patients under a single surgeon undergoing single-port robotic revision of ureteroenteric stricture following radical cystectomy with urinary diversion at our institutions from September 2020 through July 2024 was performed. Patient demographics and perioperative outcomes were assessed. Results The study consisted of 3 bilateral ureteroenteric strictures and 13 unilateral strictures, more commonly on the left. Stricture length averaged 2.2 cm on the left and 2.1 cm on the right. Surgeries were performed by a single surgeon using the da Vinci SP surgical system (Intuitive Surgical, Sunnyvale, California, US). The type of stricture repair included excision and primary anastomosis (EPA) with Bricker or Wallace reconstruction or Heineke-Mikulicz (HM) repair, although one case involved the necessity of revision ileocalycostomy. Two of the 16 cases were converted from robotic to open due to extensive adhesions. The average procedure length was 265 minutes (148-440). Length of stay (LOS) ranged from 0-46 days, averaging 4.9 days. There were five postoperative complications encountered including two seromas, two incisional hernias, and an episode of urosepsis. Pre- and postoperative changes in creatinine level ranged from -0.26 to 0.3 mg/dL. No renal units were lost. No patients were readmitted following initial surgical discharge. All patients returned for follow-up; none required repeat intervention. Conclusion SP robotic repair of ureteroenteric anastomoses is safe and feasible. The risk of complications is low with a high chance of success and possibly a lower length of stay; more research is warranted.

Open and Robotic Uretero-enteric Stricture Repair: Early Outcomes and Complications

Objective: To characterize our single institutional experience with robotic and open uretero-enteric stricture (UES) repair. Materials and Methods: We queried our ureteral reconstructive database for UES repair between 01/2017 and 10/2023. Patients with <3 months follow-up were excluded. Prior to surgery, patients underwent ureteral rest (4 weeks) with conversion to nephrostomy tube. Clinical characteristics, complications, reconstructive success (uretero-enteric patency), need for repeat intervention, and renal function were assessed in patients undergoing open and robotic UES reconstruction. Results: Of 50 patients undergoing UES repair during the study period, 45 were included for analysis due to complete follow-up (34 [76%] robotic and 11 [24%] open repair). UES repair was performed in 50 renal units a median of 13 months (interquartile range 7-30) from index surgery, and most often involved the left renal unit (34/50; 68%). Compared with robotic, open cases were significantly more likely to have undergone open cystectomy (100% vs 68%, p = 0.04), have longer strictures (median 4 vs 1 cm, p < 0.001), require tissue substitution (27% vs 3%, p = 0.04), and have lengthier postoperative hospitalization (5 vs 2 days, p < 0.001). There was no significant difference in total operative time (410 vs 322 minutes) or 30d major complications (18% vs 21%). At a follow-up of 13 months, per patient reconstructive success was 100% (11/11) for open and 97% (33/34) for robotic, respectively. Conclusion: In select patients with short UES unlikely to require advanced reconstructive techniques, a robotic-assisted approach can be considered. Careful patient selection is associated with limited morbidity and high reconstructive success.

Robotic Ureter Reimplantation After Urinary Diversion

INTRODUCTION

Benign ureterointestinal anastomotic stricture (UIAS) is a recognized long-term complication following radical cystectomy with urinary diversion (UD). The incidence of UIAS following robotic-assisted radical cystectomy varies, with reported rates ranging from 6.5%-25.3%.1 Although endourologic treatments have been employed, their overall success rate is relatively low, ranging from 26%-50%. In contrast, open surgical revision has demonstrated higher success rates, between 80% and 91%.2,3 Given the morbidity associated with open surgery, there has been a shift toward minimally invasive approaches. The robotic approach offers a minimally invasive alternative to open surgery that is not inferior, with similar outcomes for UIAS reconstruction.4 In this video, we demonstrate a robotic technique for the revision of UIAS, which aims to combine the effectiveness of open surgery with the reduced morbidity of a minimally invasive approach.

MATERIALS AND METHODS

From May 2020-March 2023, 6 patients underwent surgery. The mean age was 62 years (range 49-68 years). Among these, 2 patients received conduits in open technique and 4 were provided with robotic neobladders. The strictures were located as follows: 2 on the left side, 2 on the right, and 2 on both sides. The average time to stricture formation in the series was 4.5 months. The case presented involves a 49-year-old man who developed a left ureteroileal anastomotic stricture (UIAS) 6 months following robot-assisted radical cystectomy and neobladder creation. The obstruction was managed initially with nephrostomy tube drainage. The surgical technique employed is demonstrated in a step-by-step manner. Standard Da Vinci surgical instruments were used. The patient was positioned in a 30° Trendelenburg position, with port placement similar to that in robotic prostatectomy. The pneumoperitoneum was established through a supraumbilical mini-laparotomy using the Hasson technique. Adhesions around the neobladder were carefully freed. Subsequently, the affected ureter and the stricture were identified and localized. This was achieved by intraluminal application of 10 mL of indocyanine green solution (2.5 mg/mL concentration) through the nephrostomy catheter. The ureter was mobilized as needed. The ureteral stricture was identified and then fully excised. To exclude any malignancy at the ureteral margin, a frozen section analysis was conducted. The ureter was then spatulated. Reanastomosis between the ureter and neobladder was performed using a continuous 4-0 Stratafix suture. A double-J ureteral catheter was inserted to secure the anastomosis, and the anastomosis was completed over this catheter.

RESULTS

The mean operative time at the robotic console was 122 minutes, ranging from 80-160 minutes, and the mean blood loss was 42 mL, within a range of 50-100 mL. Intraoperative frozen sections revealed no evidence of malignancy in all cases. No postoperative complications exceeding Clavien-Dindo grade 3 were observed. Two patients were treated for symptomatic urinary tract infections. The median length of stay in the hospital was 4 days, with a range of 2-7 days. Median times for cystography with transurethral catheter removal and double-J catheter removal were 15 postoperative days (range: 12-27) and 23 postoperative days (range: 17-37), respectively. No recurrence of the condition was observed during a mean follow-up period of 23 months (range 6-40 months).

CONCLUSION

The robotic approach represents a viable, minimally invasive alternative to conventional open surgery for the reconstruction of UIAS following urinary diversion. The surgical outcomes are comparable to those of open surgery, with the added benefits of a minimally invasive approach, including reduced blood loss and shorter hospital stays.

Robot-Assisted Repair of Ureteroenteric Strictures After Cystectomy with Urinary Diversion: Technique Description and Outcomes from the European Robotic Urology Section Scientific Working Group

Background: Robot-assisted repair of benign ureteroenteric anastomotic strictures (UAS) provides an alternative to the open approach. We aimed to report short-, medium-, and long-term outcomes for robotic repair of benign UAS, and to provide a detailed video demonstration of critical operative techniques in performing this procedure robotically. Materials and Methods: Between January 2013 and September 2022, 31 patients from seven institutions who previously underwent radical cystectomy and subsequently developed UAS underwent robotic repair of UAS. Perioperative variables were prospectively collected, and postoperative outcomes were assessed. The surgery starts with a lysis of adhesions after previous surgery. Ureters are dissected, and the level of the stricture is identified. The ureter is then divided, and the stricture is resected. Finally, the ureter is spatulated and reimplanted with Nesbit technique after stenting with Double-J stents. In cases where both ureters show strictures, Wallace technique for reimplantation can be applied. Results: After robotic or open cystectomy, 31 patients had a total of 43 UAS at a median (interquartile range) follow-up of 21 (9-43) months. Median stricture length was 2.0 (1.0-3.25) cm, operative duration was 141 (121-232) minutes, estimated blood loss was 100 (50-150) mL, and length of hospital stay was 5 (3-9) days. One (3.2%) case was converted to open and one (3.2%) intraoperative complication occurred. Seven (22.6%) patients experienced postoperative complications, including four (12.9%) Clavien-Dindo grade 3 complications. No Clavien-Dindo grade 4 or 5 complications occurred. Stricture recurrence occurred in 2 (6.5%) patients. Conclusions: These results demonstrate that robotic repair of UAS is feasible and effective approach with outcomes in line with prior open series. Patient Consent Statement: Authors have received and archived patient consent for video recording and publication in advance of video recording of procedure.

Successful Multidisciplinary Repair of Severe Bilateral Uretero-Enteric Stricture with Inflammatory Reaction Extending to the Left Iliac Artery, after Robotic Radical Cystectomy and Intracorporeal Ileal Neobladder

Uretero-enteric anastomotic strictures (UES) after robot-assisted radical cystectomy (RARC) represent the main cause of post-operative renal dysfunction. The gold standard for treatment of UES is open uretero-ileal reimplantation (UIR), which is often a challenging and complex procedure associated with significant morbidity. We report a challenging case of long severe bilateral UES (5 cm on the left side, 3 cm on the right side) after RARC in a 55 years old male patient who was previously treated in another institution and who came to our attention with kidney dysfunction and bilateral ureteral stents from the previous two years. Difficult multiple ureteral stent placement and substitutions had been previously performed in another hospital, with resulting urinary leakage. An open surgical procedure via an anterior transperitoneal approach was performed at our hospital, which took 10 h to complete, given the massive intestinal and periureteral adhesions, which required very meticulous dissection. A vascular surgeon was called to repair an accidental rupture that had occurred during the dissection of the external left iliac artery, involved in the extensive periureteral inflammatory process. Excision of a segment of the external iliac artery was accomplished, and an interposition graft using a reversed saphenous vein was performed. Bilateral ureteroneocystostomy followed, which required, on the left side, the interposition of a Casati-Boari flap harvested from the neobladder, and on the right side a neobladder-psoas-hitching procedure with intramucosal direct ureteral reimplantation. The patient recovered well and is currently in good health, as determined at his recent 24-month follow-up visit. No signs of relapse of the strictures or other complications were detected. Bilateral ureteral reimplantation after robotic radical cystectomy is a complex procedure that should be restricted to high-volume centers, where multidisciplinary teams are available, including urologists, endourologists, and general and vascular surgeons.

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.

Contemporary management of benign uretero-enteric strictures after cystectomy: a systematic review

INTRODUCTION

Uretero-enteric stricture (UES) is a common post-operative complication after radical cystectomy with urinary diversion. The aim of this systematic review is to discuss the contemporary management of benign UES after cystectomy and to compare the different surgical approaches.

EVIDENCE ACQUISITION

A systematic review was performed from January 2000 through January 2021. Search engines used included PubMed, Embase and Medline databases. Search query was: ((ureteroileal OR uretero-ileal OR ureteroenteric OR ureteroenteric) AND (stricture OR stenosis)) AND (management OR treatment). Study selection followed the PRISMA statement. Studies tackling management of UES, either through open, endoscopic, laparoscopic or robot-assisted approaches, were included in our systematic review.

EVIDENCE SYNTHESIS

Forty-one studies were finally included in this systematic review. No prospective studies were found; all included studies were retrospective. Open surgical repair had a 78-100% success rate, a significant rate of complications, and a low recurrence rate (6-8%). Endourological management decreased complication rate, length-of-stay, and blood loss, with however lower success (15-50%) and higher recurrence rates (62%-91%) compared to open surgery. Robotic assisted surgery showed comparable success rates to open surgery (80-100%), while limiting the number of major complications and hospital length-of-stay.

CONCLUSIONS

Surgical management of UES remains challenging. Open surgery maintains a role given its high success rate, at the cost however of a significant morbidity. On the other hand, endourological procedures offer a favorable and low complication risk, but a low long-term success rate. Robotic-assisted surgery is emerging with a valid resolution of UES as it offers comparable success rates to an open approach, while reducing surgical morbidity. Head-to-head comparisons are awaited to confirm these findings.