Reesink DJ, Gerritsen SL, Kelder H et al: Evaluation of ureteroenteric anastomotic strictures after the introduction of robot-assisted radical cystectomy with intracorporeal urinary diversion-results from a large tertiary referral center. J Urol 2020; 101097JU0000000000001518.

In our retrospective study “Evaluation of Uretero-Enteric Anastomotic Strictures after the Introduction of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion – Results from a Large Tertiary Referral Center,”¹ we studied the effect of introducing robot-assisted radical cystectomy (RARC) with an intracorporeal urinary diversion (ICUD) approach on the incidence of ureteroenteric strictures (UES). We compared results to open radical cystectomy (ORC).

With a median followup of 50 months, our study shows a relatively high overall UES incidence of 17%, with a median time to development of 3 months. We found that the incidence was significantly higher after RARC, with 25% of patients developing a UES compared to 13% after ORC. Especially in the first year RARC was introduced in our institution, there was a peak incidence of UES of 47% (figure). The incidence diminished to 14% in the last study year. Ureteroenteric strictures have a high impact on the quality of life of the already vulnerable patient. Often, surgical re-interventions are required. Our study shows endoscopic interventions are often unsuccessful, and open ureteral reimplantation is required.

Figure. Uretero-enteric stricture (UES) incidence in robot-assisted radical cystectomy patients, stratified for each study year.

In previous literature, multiple factors have been associated with increased risk of UES development. Baseline factors such as age, gender at birth, body mass index and Charlson Comorbidity Index score were not associated with UES development in our study. Patients who developed UES had, compared to non-UES patients, more often urinary leakage after RC <30 days (11% vs 4%) and urinary tract infections <90 days (30% vs 12%). However, on Cox regression analyses, only surgical technique (RARC) was associated with higher rates of UES.

Multiple retrospective studies showed a higher incidence of UES after RARC compared to ORC.^2,3 Also, a study comparing RARC with an extracorporeal urinary diversion (ECUD) vs ICUD approach found an UES-incidence of 6% vs 16%, respectively.⁴ It is believed that during RARC, there is less haptic feedback and magnified visualization, resulting in the ureters being prone to excessive handling, especially with an ICUD approach. This results in a higher incidence of UES.³

Introduction of new techniques will unequivocally result in initial higher incidence of complications, including UES. The findings of our study suggest a significant initial learning curve, which shows the importance of surgeon experience. Future studies with honest reporting of complications are required to show whether the robot-assisted technique will advance and the incidence of UES will become equal to ORC.