Robot-assisted uretero-enteric reimplantation for uretero-enteric anastomotic strictures following robot-assisted radical cystectomy: Surgical approach and outcomes over two decades

doi:10.1016/j.ajur.2023.10.002

Asian Journal of Urology, 2024, 11 (3): 384-390 doi: 10.1016/j.ajur.2023.10.002

Surgery Alive

Robot-assisted uretero-enteric reimplantation for uretero-enteric anastomotic strictures following robot-assisted radical cystectomy: Surgical approach and outcomes over two decades

Abdul Wasay Mahmood,Grace Harrington,Zhe Jing,Qiang Li,Ahmed A. Hussein,Khurshid A. Guru^*(

)

Department of Urology, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, New York, NY, USA

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Abstract

Objective: We described the technique and outcomes of robot-assisted repair of uretero-enteric strictures (UES) following robot-assisted radical cystectomy (RARC) and urinary diversion.

Methods: Retrospective review of our RARC database from November 2005 to August 2023 at Roswell Park Comprehensive Cancer center was performed. Patients who developed UES and ultimately underwent robot-assisted uretero-enteric reimplantation (RUER) were identified. Kaplan-Meier method was used to compute the cumulative incidence recurrence rate of UES after RUER. A multivariable regression model was used to identify variables associated with UES recurrence.

Results: A total of 123 (15%) out of 808 RARC patients developed UES, of whom 52 underwent reimplantation (45 patients underwent RUER [n=55 cases] and seven patients underwent open uretero-enteric reimplantation). The median time from RARC to UES was 4.4 (interquartile range 3.0-7.0) months, and the median time between UES and RUER was 5.2 (interquartile range 3.2-8.9) months. The 3-year recurrence rate after RUER is about 29%. On multivariable analysis, longer hospital stay (hazard ratio 1.37, 95% confidence interval 1.16-1.61, p<0.01) was associated with recurrent UES after RUER.

Conclusion: RUER for UES after RARC is feasible with durable outcomes although a notable subset of patients experienced postoperative complications and UES recurrence.

Key words： Stricture Cystectomy Reimplantation Robot-assisted

Received: 16 June 2023 Available online: 20 July 2024

Corresponding Authors: *E-mail address: Khurshid.guru@roswellpark.org (K.A. Guru).

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Abdul Wasay Mahmood,Grace Harrington,Zhe Jing, et al. Robot-assisted uretero-enteric reimplantation for uretero-enteric anastomotic strictures following robot-assisted radical cystectomy: Surgical approach and outcomes over two decades[J]. Asian Journal of Urology, 2024, 11(3): 384-390.

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http://www.ajurology.com/EN/10.1016/j.ajur.2023.10.002 OR http://www.ajurology.com/EN/Y2024/V11/I3/384

Robot-assisted ureteroenteric reimplantation—port placement. C, camera port; RA, right arm (8 mm, robotic); LA, left arm (8 mm, robotic); A1, assistant port (12 mm, laparoscopic); A2, assistant port (5 mm, laparoscopic) A3, assistant port (8 mm, robotic).

Variable	No UES after RUER (n=42)	UES after RUER (n=13)	Total (n=55)	p-Value
Parameters at the time of RARC
Gender (male)	38 (90)	11 (85)	49 (89)	0.62
African American	0 (0)	0 (0)	0 (0)	-
Charlson Comorbidity Index	5 (4-6)	4 (3-5)	4 (4-6)	0.4
Neoadjuvant chemotherapy before cystectomy	19 (45)	7 (54)	26 (47)	0.75
History of abdominal surgery before cystectomy	20 (48)	10 (77)	30 (55)	0.11
History of radiation before cystectomy	2 (5)	1 (8)	3 (5)	0.56
Intracorporeal approach urinary diversion at cystectomy	41 (98)	12 (92)	53 (96)	0.42
Neobladder urinary diversion	7 (17)	0 (0)	7 (13)	0.18
Ileal conduit urinary diversion	35 (83)	13 (100)	48 (87)	-
Type of ureteral anastomosis^a
Bricker	36 (88)	13 (100)	49 (91)	0.32
Wallace	5 (12)	0 (0)	5 (9)	-
Stent placement at cystectomy	37 (88)	12 (92)	49 (89)	1
Parameters at the time of RUER
Age at RUER, year	69 (61-73)	65 (61-69)	66 (61-73)	0.51
BMI at RUER, kg/m²	29 (27-34)	27 (23-32)	29 (25-33)	0.21
Months from RARC to UES	4.5 (3.3-7.5)	3.9 (1.9-5.5)	4.4 (3.0-7.0)	0.18
Months from UES to RUER	4.8 (2.5-8.9)	5.3 (4.1-9.4)	5.2 (3.2-8.9)	0.33
Estimated blood loss, mL	50 (20-88)	150 (100-150)	50 (25-120)	0.001
Type of ureteral anastomosis
Bricker	40 (95)	10 (77)	50 (91)	0.08
Wallace	2 (5)	2 (15)	4 (7)	-
Left to right	0 (0)	1 (8)	1 (2)	-
Stent placement at RUER	19 (45)	7 (54)	26 (47)	0.75
Operative time, min	163 (129-186)	179 (170-279)	174 (135-189)	0.03
Transfusion	0 (0)	0 (0)	0 (0)	-
Conversion to open	0 (0)	0 (0)	0 (0)	-
Laterality of RUER
Left side	31 (74)	6 (46)	37 (67)	0.09
Right side	11 (26)	7 (54)	18 (33)	-
LOS, day	3 (2-4)	6 (2-7)	3 (2-4)	0.03
ICU admission	6 (14)	1 (8)	7 (13)	1
ICG intraoperative use	10 (24)	1 (8)	11 (20)	0.27
GFR, mL/min
Before RUER	44 (37-67)	41 (34-56)	43 (36-66)	0.59
Day 90 after RUER	46 (34-58)	41 (35-48)	43 (34-56)	0.59
Number of conservative managements before RUER	2 (2-3)	2 (1-3)	2 (2-3)	0.67

Demographics and perioperative outcomes of 45 patients who developed UES and underwent RUER after RARC.

Complications after RUER in 90 days.

Overall stricture recurrence rates after robot-assisted uretero-enteric reimplantation.

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