Introduction

Bladder cancer is the fourth leading cause of cancer death in men over the age of 80 and is diagnosed at a rate of 80,500 new cases per year in the US.¹ Currently, the gold standard management strategy for patients with muscle-invasive disease is radical cystectomy with urinary diversion. Most patients present with advanced age and multiple comorbidities which contributes to higher morbidity compared to most major urologic oncology procedures.² A significant portion of the morbidity (infection, electrolyte disturbances, ileus, small bowel leak/fistulas, wound complications) and increased length of stay can be attributed to the bowel harvesting and reconstruction required for urinary diversion. While early return after surgery protocols have been developed to help mitigate postoperative complications and improve patient recovery, patients often remain hospitalized for up to 5-7 d, even with the most optimized protocols.³

Potential Advantages

Robotic cystectomy with cutaneous ureterostomy (CU) may be an appealing primary urinary diversion option in patients who desire incontinent diversion. Robotic cystectomy combined with a CU diversion offers optimal outcomes for the extirpative portion of the procedure (lower blood loss, improved visualization of posterior rectal plane),² obviates the complications associated with intestinal segment harvesting and bowel anastomosis, and, if combined in a total intracorporeal robotic approach, offers improved postoperative recovery with smaller incisions. When compared to a robotic prostatectomy, there is not much difference in the number/length of incisions of either procedure. Furthermore, the surgical “work” required is not dissimilar, as both require node dissection, extirpation (prostate vs bladder/prostate removal), and reconstruction (vesicourethral anastomosis over foley catheter vs ureterostomy creation over stent; Figure 1). Therefore, it may not be unreasonable to think that patients could similarly be discharged on postoperative day (POD) 1 after robotic cystectomy with CU urinary diversion. At our institution, patients are discharged most frequently on POD 2 due to the time required to teach patients how to manage their stomal appliances.

Robotic radical cystectomy with CU may also expand the population of patients eligible for cystectomy by allowing for the inclusion of patients who were medically unfit for an open surgery and/or unable to tolerate the morbidity associated with bowel urinary diversion.⁴ Lastly, the smaller and more discreet stoma of a CU compared to a classic ileal conduit may also have some appeal to patients (Figure 2).

Historical Dogma

While offering favorable early postoperative outcomes, one primary reason for a lack of adoption of the CU is due to high rates of stomal stenosis and/or kinking of the ureter as it crosses the fascia/subcutaneous tissue. Approximately 50%-70% of patients will experience some degree of CU stomal stenosis which necessitates stent changes every 3-6 months.⁵ While several techniques have been proposed to mitigate this complication, results have demonstrated varying success. A Toyoda technique is one where the dermis is exposed and the distal ureter is cut to splay the ureter prior to suturing the ends into the dermis, with a reported patency rate of up to 94% over a median 18 month follow-up.⁵ The Wallace technique has similarly been utilized at skin level with the thought that a wider ostium may reduce stomal stenosis. Y-V or V-V ureteroplasty at the skin level is another technique which is often performed.⁶

Of note, when selecting patients for CU diversion, several technical and physical variables must be considered preoperatively. Body habitus must be considered for CU placement as the ureters may not reach the skin in patients with excessive subcutaneous fat and elevated BMIs >40 kg/m². Similarly, technical considerations such as available ureter length, the quality/health of the ureters overall, history of radiation, and location of CU stoma need to be examined.

Lastly, managing patient expectations, particularly on the need for chronic stenting of the ureterostomy, is essential. Patients with poor dexterity and mental capacity may not be able to maintain position or place the stents through stomal appliances, which results in poor overall patient satisfaction.

While stomal stenosis may be high, 30%-50% of patients may not develop any stenosis. In those who do develop stenosis, we have found that clinic-based, bedside ureteral stent placement and/or exchange is a reasonable and well-tolerated management strategy to maintain ureterostomy patency. Stents can be exchanged in-clinic and can either be kept indwelling for up to 6 months at a time or exchanged more frequently depending on how quickly stents develop encrustation. Many patients will require serial visits for surveillance imaging and labs per national follow-up guidelines, which allows an opportunity for stent change without excessive additional visits.

At our institution we created a single, right-sided cutaneous ureterostomy with a proximal left-to-right uretero-ureterostomy. With only a single ureterostomy, only 1 stent exchange is required to maintain ureterostomy patency. In contrast, distal ureteral Wallace-type anastomosis requires 2 stents per exchange, adding to expense and time for each exchange.

Conclusions

Robotic cystectomy with cutaneous ureterostomy has numerous perioperative benefits without having increased risk of wound, infectious, electrolyte, or bowel diversion–related complications. Such a procedure may allow medically unfit patients to undergo cystectomy when they would have otherwise been excluded. It is not unreasonable to think that robotic cystectomy with cutaneous ureterostomy could have a similar recovery to robotic radical prostatectomy, with potential to achieve discharge on POD 1 or 2. These benefits must be carefully balanced with the risk of ureterostomy stomal stenosis and patient acceptance of potentially lifelong stent changes.