Despite its benefits, robot-assisted radical cystectomy (RARC) remains a complex intervention with a substantial postoperative morbidity rate, reaching around 60%, even in the hands of experienced surgeons.^1,2 Complications, typically within 90 days after RARC, may not adequately convey the magnitude of the operation. Underreported long-term complications such as ureteroenteric stricture (UES), affect up to 25% of cases.^3,4 Because of the low success rate of endoscopic management, open ureteroenteric reimplantation, which has 80% to 90% long-term success rates, is being considered as the ultimate treatment option,^5-7 although its success rate could be decreased to 78% with longer follow-up period.⁸ However, a recent trend favors minimally invasive approaches, particularly robot-assisted procedures, and recent studies indicate lower morbidity in robot-assisted ureteroenteric reimplantation (RUER) by skilled surgeons (Table).^9-16 In this context, we present our experience of RUER.

Table. Summary of Different Series Reporting Open and Robotic Revisions of Ureteroenteric Stricture

Out of 808 RARC patients, 123 patients (15%) developed UES, after a median follow-up period of 30.4 (IQR 12.25,67.3 months). UES occurred in 13%, 17%, 17%, 18%, and 18% at 1, 2, 3, 4, and 5 years after RARC, respectively. The median time to develop UES after RARC was 4.4 months (IQR 3.0-7.0 months). Following unsuccessful endoscopic or percutaneous management, 52 (42%) patients underwent reimplantation. Of these, 45 (87%) underwent RUER, after a median time between the diagnosis of UES to RUER of 5.2 months (IQR 3.2-8.9 months). RUER was predominantly performed using Bricker’s technique (91%) and the majority (60%) were left-sided repair. The median age was 67 years (IQR 60-72) and the median estimated blood loss was 50 mL (IQR 25-120 mL). The estimated glomerular filtration rate at RUER was 43 mL/min, with an operative time of 174 minutes and a median length of stay of 3 days (IQR 2-4 days).

The study reported 56% 90-day complications and 22% major complications. Notably, the UTI rate was higher in our study as compared to other large series (18% vs 12%), but the rest of the complications, such as ileus (4% vs 8%), urine leak (4% vs 11%) and incisional hernia (0% vs 11%), were lower.⁹ After RUER, recurrent UES occurred in 13 patients (24%) after a median follow-up of 42.4 months (IQR 16.9-56.6 months). UES occurred in 8%, 29%, and 33% at 1, 3, and 5 years after RUER, respectively (Figure). Higher estimated blood loss, longer operative time, and longer hospital stay were correlated with recurrence after RUER on univariable analysis.

Our results suggest RUER as a viable alternative, emphasizing its feasibility and shorter hospital stay. Up to 24% of patients may develop recurrent UES and 22% may develop high-grade complications after RUER. Limitations include a small sample size and retrospective design, necessitating further research to optimize UES management. In conclusion, RUER is feasible with durable outcomes and has moved the field forward where minimally invasive approaches are utilized for complex redo constructive procedures.