EUROPEAN UROLOGY OPEN SCIENCE 35 (2022) 47–53 available at www.sciencedirect.com journal homepage: www.eu-openscience.europeanurology.com Reconstructive Urology Perioperative and Functional Outcomes of Robot-assisted Ureteroenteric Reimplantation: A Multicenter Study of Seven Referral Institutions Albert Carrion a, Ahmed Aly Hussein b, Daniel Eun c, Abolfazl Hosseini d,e, Josep Maria Gaya f, Ronney Abaza g, Xavier Bonet h, Umar Iqbal b, Randall A. Lee c, Ziho Lee i, Matthew Lee c, Carles Raventos a, Oriol Moreno a, Joan Palou f, Alberto Breda f, Fernando Lozano a, Francesc Vigués h, Enrique Trilla a,*, Khurshid A. Guru b a Department of Urology, Hospital of Vall Hebron, Autonomous University of Barcelona, Barcelona, Spain; b Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA; c Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA; d Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; e Department of Pelvic Surgery, Karolinska University Hospital, Stockholm, Sweden; f Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain; g Department of Urology, Ohio Health Dublin Methodist Hospital, Columbus, OH, USA; h Department of Urology, Hospital Bellvitge, University of Barcelona, Barcelona, Spain; i Department of Urology, University of Washington, Seattle, WA, USA Article info Abstract Article history: Background: Open revision of ureteroenteric strictures (UESs) is associated with Accepted November 5, 2021 considerable morbidity. There is a lack of data evaluating the feasibility of robotic revisions. Associate Editor: Objective: To analyze the perioperative and functional outcomes of robot-assisted Silvia Proietti ureteroenteric reimplantation (RUER) for the management of UESs after radical cystectomy (RC). Keywords: Design, setting, and participants: A retrospective multicenter study of 61 patients, Robot-assisted ureteroenteric who underwent 63 RUERs at seven high-volume institutions between 2009 and reimplantation Ureteroenteric stricture 2020 for benign UESs after RC, was conducted. Radical cystectomy Outcome measurements and statistical analysis: Data were reviewed for demo- Postoperative complications graphics, stricture characteristics, and perioperative outcomes. Variables associ- Bladder cancer ated with being stricture free after an RUER were evaluated using a multivariate Cox regression analysis. Results and limitations: Among 63 RUERs, 22 were right sided (35%), 34 left sided (54%), and seven bilateral (11%). Twenty-seven (44%) had prior abdominal/pelvic surgery and five (8%) radiotherapy (RT). Thirty-two patients had American Society of Anesthesiologists (ASA) scores I–II (52%) and 29 ASA III (48%). Forty- two (68%) RUERs were in ileal conduits, 18 (29%) in neobladders, and two (3%) in Indiana pouch. The median time to diagnosis of a UES from cystectomy was 5 y These authors are joint first authors. * Corresponding author. Department of Urology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Passeig de la Vall d’Hebron, 119-129, 08035 Barcelona, Spain. Tel. 0034 932746100. E-mail address: etrilla@vhebron.net (E. Trilla). https://doi.org/10.1016/j.euros.2021.11.005 2666-1683/Ó 2021 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). 48 EUROPEAN UROLOGY OPEN SCIENCE 35 (2022) 47–53 (3–11) mo. Of the UESs, 28 (44%) failed an endourological attempt (balloon dilata- tion/endoureterotomy). The median RUER operative time was 195 (175–269) min. No intraoperative complications or conversions to open approach were reported. Twenty-three (37%) patients had postoperative complications (20 [32%] were minor and three [5%] major). The median length of hospital stay was 3 (1–6) d and readmissions were 5%. After a median follow-up of 19 (8–43) mo, 84% of cases were stricture free. Lack of prior RT was the only variable associated with better stricture-free survival after RUER (hazard ratio 6.8, 95% confidence interval 1.10– 42.00, p = 0.037). The study limitations include its retrospective nature and the small number of patients. Conclusions: RUER is a feasible procedure for the management of UESs. Prospective and larger studies are warranted to prove the safety and efficacy of this technique. Patient summary: In this study, we investigate the feasibility of a novel minimally invasive technique for the management of ureteroenteric strictures. We conclude that robotic reimplantation is a feasible and effective procedure. Ó 2021 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons. org/licenses/by/4.0/). 1. Introduction to confirm the stricture in some cases or to exclude asymptomatic patients who had dilated pelvicalyceal systems with no deterioration of renal function or evidence of infection. Radical cystectomy (RC) with pelvic lymph node dissection and ileal urinary diversion is the standard of care for the management of muscle-invasive bladder cancer and refrac- 2.2. Surgical technique tory non–muscle-invasive bladder cancer [1]. Benign Supine or lithotomy in Trendelenburg position was utilized. Four 8-mm ureteroenteric strictures (UESs) occur in 3–19% of patients robotic ports were placed transperitoneally in triangulation around the according to large cystectomy series and represent the most internal end of the ileal conduit or in the same way as in robot- common cause for reoperations after RC [2–4]. Owing to the assisted radical cystectomy (RARC) in case of a neobladder (Fig. 1) [8]. low success rate of the endourological approach, open One assistant port of 12 mm and another of 5 mm could also be used. ureteroenteric reimplantation is the gold standard treat- Extensive adhesiolysis was often necessary to identify the key anatomi- ment for UESs [5]. However, open revisions are challenging cal components. Intraureteral or intradiversion administration of ICG as surgeries with a non-negligible risk of complications [6]. described by Lee et al. [9] could help identify anatomical landmarks and Recently, utilization of minimally invasive approaches for the site of stricture. Ureterolysis was performed circumferentially ureteral reconstructive procedures has increased. Although toward the urinary diversion. The dilated ureter proximal to the stricture only few single-center series of robot-assisted ureteroen- was dissected and transected. The distal extent of the UES was excised teric reimplantation (RUER) were reported previously, out- for pathology. The intravenous ICG injection could help in identifying comes are promising [7]. The potential benefits of this healthy distal ureteral tissue [10]. The healthy end of the ureter was procedure could be those related to the minimally- spatulated and reimplanted at a new site on the diversion using monofil- invasive approach as well as the three-dimensional vision, ament absorbable running or interrupted suture (4-0 or 5-0). For unilat- tremor filtering, ability to suture with precision, and use eral UESs, a Bricker anastomosis was recommended, and for bilateral of indocyanine green (ICG). UESs either a Wallace or a Bricker anastomosis could be used. After com- pleting the posterior half of the anastomosis, a ureteral stent was placed Herein, we aimed to report the perioperative and func- transabdominally across the anastomosis, with a guidewire inserted tional outcomes of RUER for the management of UESs after through the assistant port. The proximal end of the stent was advanced RC in a large series of patients from seven institutions. till the renal pelvis, and the distal end was inserted into the urinary diversion under direct visualization. In ileal conduit cases, the stent could be placed retrogradely through a sucker placed in the conduit. A nephroureteral stent was used for ileal conduits, while both nephrouret- 2. Patients and methods eral and double-J stents could be used for neobladders. 2.1. Study population 2.3. Study outcomes A retrospective multicenter study was conducted in 61 patients who underwent 63 RUERs between January 2009 and February 2020 for Data were reviewed for demographics and perioperative outcomes. Pre- benign UESs after RC. Patients who had other ureteroenteric complica- vious abdominal/pelvic surgery (apart from RC) or radiotherapy (RT) was tions (stone obstruction, ureteric tumor, stomal obstruction, or external reported. We also reviewed patients who failed endourological manage- compression) were excluded. Data were collected from seven institu- ment, defined as balloon dilatations or endoureterotomies. Perioperative tions, and institutional review board approval was obtained. Strictures parameters assessed were reimplantation side, stricture length (by ante- were diagnosed by a computed tomography (CT) scan during follow- grade pyelography), conversion to open approach, operative time (OT), up or as a consequence of worsening of renal function, pain, or urinary use of ICG (intraureteral, intraurinary diversion, or intravenous), intra- infection. Renal scintigraphy, pouchogram, and/or pyelography was used and postoperative complications, length of hospital stay (LOS), and hos- EUROPEAN UROLOGY OPEN SCIENCE 35 (2022) 47–53 49 A) B) Fig. 1 – Trocar mapping: (A) neobladder diversion: an 8-mm supraumbilical port for camera, 8-mm ports in the right and left paraumbilical regions for the second and third arms, and 8-mm port in the left hypochondriac quadrant for the fourth arm; a 12-mm port in the right hypochondriac quadrant for the assistant if required. (B) Ileal conduit diversion: an 8-mm supraumbilical port for camera, an 8-mm port in the right hypochondriac quadrant for the second arm, an 8-mm port in the left paraumbilical region for the third arm, and an 8-mm port in the left iliac quadrant for the fourth arm; a 12-mm port in the left lumbar region for the assistant if required. pital readmission within the 1st month after RUER. Treatment failure Table 1 – Clinicopathological characteristics of 61 patients treated (UES recurrence) was defined as radiological and/or clinical signs of with RUER recurrent obstruction requiring renal drainage, endourological or revi- Age (yr), median (IQR) 67 (60–72) sion of reimplantation, or nephrectomy. All procedures were performed Gender, n (%) using the da Vinci robot. Male 50 (82) Female 11 (18) BMI, median (IQR) 28.3 (25.7–33.6) 2.4. Statistical analysis ASA score, n (%) I 6 (9.8) Categorical variables were reported as frequencies and proportions, and II 26 (42.6) III 29 (47.5) continuous data as medians and interquartile range (IQR). Proportions, Creatinine (mg/dl), median (IQR) 1.32 (0.83–1.45) such as success rates and stricture characteristics, were compared by eGFR (ml/min), median (IQR) 72.2 (47.5–88.3) the Pearson chi-square test. Kaplan-Meier analysis and the log-rank test Prior abdominal/pelvic surgery other than RC, n (%) 27 (44.3) Prior abdominal/pelvic radiotherapy, n (%) 5 (8.2) were used to compare the likelihood of stricture-free survival after Neoadjuvant chemotherapy, n (%) 25 (41) RUER. Multivariate stepwise Cox regression analysis was fit to evaluate Cystectomy approach, n (%) predictors of being stricture free after RUER. Statistical significance Open 9 (14.8) was considered at p = 0.05. Statistical analysis was done using SPSS ver- Laparoscopic 2 (3.3) Robot assisted 50 (82) sion 20 (IBM Corp., Armonk, NY, USA). Type of urinary diversion, n (%) Ileal conduit 42 (68.8) Neobladder 17 (27.8) Indiana pouch 2 (3.2) 3. Results Urinary diversion approach a, n (%) Extracorporeal 10 (20) 3.1. Clinicodemographic characteristics Intracorporeal 40 (80) Type of neobladder, n (%) Studer 11 (64.7) A total of 63 RUERs were performed in 61 patients with a Padovana 3 (17.6) median age of 67 yr (IQR 60–72 yr); 22 strictures were right Hautmann 3 (17.6) sided (35%), 34 were left sided (54%), and seven were bilat- Overall death, n (%) 8 (13.1) Follow-up, median (IQR) 36 (21–66.5) eral (11%). Two patients underwent a separate revision for ASA = American Society of Anesthesiologists physical classification; BMI = each side. Twenty-seven patients (44%) had a prior abdom- body mass index; eGFR = estimated glomerular filtration rate; IQR = inal/pelvic surgery and five (8%) had prior abdominal/pelvic interquartile range; RC = radical cystectomy; RUER = robot-assisted RT. Of the patients, 26 (43%) had an American Society of ureteroenteric reimplantation. a Among robot-assisted cystectomy cases. Anesthesiologists (ASA) score of II and 29 (48%) had ASA III. The RC approach was open in nine (15%), laparoscopic in two (3%), and robot-assisted in 50 (82%) patients. Among 3.2. Perioperative characteristics and outcomes the RARC cases, ten (20%) underwent extracorporeal urinary diversion (ECUD) and 40 (80%) underwent intracorporeal The median time from cystectomy to stricture diagnosis urinary diversion (ICUD). Of the RUERs, 42 (68%) were in was 5 mo (IQR 3–11 mo). Twenty-eight cases (44%) failed ileal conduits, 18 (29%) in ileal neobladders, and two (3%) initial endoscopic and/or percutaneous management. The in Indiana pouch (Table 1). median time between the diagnosis and reimplantation 50 EUROPEAN UROLOGY OPEN SCIENCE 35 (2022) 47–53 was 4 mo (IQR 2–12 mo) and the median stricture length Table 2 – Perioperative characteristics and outcomes of 63 RUER procedures was 2 cm (IQR 1–3 cm). The pathological report of the resected ureter showed benign tissue in all cases. The med- Reimplantation side, n (%) ian OT was 195 min (IQR 175–269 min). No intraoperative Left 34 (54) complications, conversions to open approach, or intraoper- Right 22 (34.9) ative blood transfusions were reported. Two patients Bilateral 7 (11.1) Time to stricture formation a (mo), median (IQR) 5 (3–11) received a blood transfusion after the surgery as a Stricture length (cm), median (IQR) 2 (1–3) consequence of the intraoperative blood loss, but none of Renal scintigraphy, n (%) 37 (58.7) them had signs of postoperative active bleeding. Twenty- Anterograde pyelography, n (%) 57 (90.5) Preoperative urinary drainage, n (%) 62 (98.4) three patients (37%) had postoperative complications, of Nephrostomy tube 47 (75.8) which 20 (32%) were minor (Clavien I–II) and three (5%) Ureteral catheter 15 (24.2) were major (Clavien III). The minor complications com- Failed endoscopic procedure, n (%) 28 (44.4) Patients with ICG use, n (%) 16 (25.4) prised urinary tract infections, ileus (managed conserva- Intraureteral ICG 11 (17.4) tively), and urine leak (managed with prolonged stenting). Intraurinary diversion ICG 1 (1.58) The major complications included a femoral arteriovenous Intravenous ICG 6 (9.5) Operative time (min), median (IQR) 195 (175–269) fistula (secondary to an anesthesia line placement), bilateral Conversion to open approach, n (%) 0 (0) pulmonary embolisms requiring anticoagulation, and per- Intraoperative complications, n (%) 0 (0) cutaneous nephroureteral stent placement after nephrour- Intraoperative blood transfusion, n (%) 0 (0) Postoperative complications, n (%) 23 (36.5) eteral stent dislodgement. The median LOS was 3 d (IQR Type of postoperative complication b, n (%) 1–6 d), and hospital readmissions occurred in 5% (Table 2). Postoperative blood transfusion 2 (3.2) After a median follow-up of 19 mo (IQR 8–43 mo), ten Urinary tract infection 8 (12.7) Wound infection 1 (1.6) patients (16%) developed recurrent UESs with a median Septic shock 0 (0) time between reimplantation and recurrence of 13 mo Bleeding 0 (0) (IQR 6–35 mo). On Kaplan-Meier analysis, the estimated Incisional hernia 7 (11.1) Urine leak 7 (11.1) 3-yr stricture-free survival after RUER was 84% (Fig. 2). Bowel injury 0 (0) Ileus 5 (7.9) Pulmonary embolism 1 (1.6) 3.3. Predictors of success Femoral arteriovenous fistula 1 (1.6) Nephroureteral stent dislodgement 1 (1.6) Table 3 shows the univariate analysis of the potential pre- Length of ileus (d), median (IQR) 4 (2.5–9.5) Clavien-Dindo, n (%) dictors of success. Patients with prior abdominal/pelvic RT Minor (I–II) 20 (21.7) had a success rate of 60% compared with 86.2% in those Major (III) 3 (4.8) without RT (p = 0.12). A multivariate Cox regression analysis Length of hospital stay (d), median (IQR) 3 (1–6) Hospital readmission, n (%) 3 (4.8) for assessing potential variables associated with stricture- 30-d creatinine (mg/dl), median (IQR) 1.36 (1–1.87) free survival after RUER showed that the lack of prior 30-d eGFR (ml/min), median (IQR) 49.5 (36.9–61.7) abdominal/pelvic RT was the only significant variable (haz- Overall success, n (%) 53 (84.1) Time to failure (mo), median (IQR) 13 (6.25–35) ard ratio 6.80, 95% confidence interval 1.10–42.00, p = Follow-up (mo), median (IQR) 19 (8–43) 0.037; Table 4). eGFR = estimated glomerular filtration rate; ICG = indocyanine green; IQR = interquartile range; RUER = robot-assisted ureteroenteric reimplantation. a Time between the cystectomy and the first diagnosis of stricture. 4. Discussion b Data are presented for each individual complication. To our knowledge, this is the largest series of RUER for UESs after RC. A benign UES is a common complication that can lead to a variety of health conditions and impairment of et al. [12] found a higher rate of UESs after ICUD, especially quality of life. Management of this complication is challeng- during their early learning curve. ing, with several options described in the literature but It has been demonstrated that the endoscopic proce- without specific recommendations in clinical guidelines. dures have poor long-term efficacy for the management of UESs can occur in up to 19% of patients after RC. Previous UES [17]. Nevertheless, it is usually used as the initial man- studies reporting UESs varied in the surgical technique or agement in order to avoid the morbidity of an open surgery experience, and the frequency and duration of follow-up and the difficulty associated with operating in a previously [11,12]. Prior abdominal RT is a well-known risk factor for operated abdomen. Gin et al. [18] suggested that prior UESs [13]. Our series included both open RC (ORC) and endoscopic attempts could worsen the outcomes during RARC patients. Prospective randomized controlled trials subsequent ureteroenteric reimplantation and recom- have shown similar perioperative outcomes between ORC mended performing a primary open/robotic revision. and RARC, while a recent prospective study demonstrated Although prior failed endoscopic attempts were not a pre- no difference in stricture rate [14,15]. However, the associ- dictor of recurrence in our study, >50% of our patients ation between RARC (ICUD or ECUD) and UESs is still underwent a primary RUER. Our findings suggest that, cur- unclear. It was suggested that ECUD could increase the risk rently, the primary robotic revision of a UES could be of UESs as a consequence of the higher dissection of the increasing as a result of its low morbidity in the hands of ureters compared with ICUD [16]. In contrast, Ahmed experienced surgeons. EUROPEAN UROLOGY OPEN SCIENCE 35 (2022) 47–53 51 Fig. 2 – Kaplan-Meier analysis of ureteroenteric stricture-free survival after RUER of the overall cohort. RUER = robot-assisted ureteroenteric reimplantation. As a consequence of the low efficacy of conservative pro- procedures [18]. The other showed comparable periopera- cedures, open revision is considered the gold standard tive outcomes between six open and 16 robotic approaches treatment for UESs [17]. The success rate of open surgical [12]. A small number of robotic procedures were included in revision is up to 85% [5,18,19], although it could decrease both studies. In contrast, a recent series of eight patients to 78% at a longer-term follow-up [20]. The intra- treated with RUER reported five cases with postoperative abdominal adhesions with the risk of bowel injury and the complications. Despite the small sample, the authors surrounding major vessels around the stricture area could concluded that ureteroenteric reimplantation might be a deter surgeons from performing this procedure. With the morbid procedure regardless of the operative approach development of minimally invasive techniques, multiple [9]. In our series, postoperative complications occurred in small single-center series of RUER have shown a success 37% and only three (5%) were major. These results support rate of up to 80% [7,9,12,21]. A unique case of successful the belief that although RUER is a morbid surgery, the risk RUER performed by using a pure single-site approach of high-grade complications is lower than in the open (daVinci SP) and the initial experience of 11 laparoscopic approach. RUER has also been associated with a shorter ureteroenteric reimplantations have been also reported LOS than open reimplantation (3 vs 6–10 d) [5,16,18]. In [22,23]. However, the role of robotic surgery in the manage- the current study, the median LOS was 3 d with a readmis- ment of UESs is still undefined, and there is a lack of studies sion rate of 5%. However, the low number of patients, and comparing the outcomes between open and robotic revi- the variety in population and surgeons might decrease the sions. We found that 84% were stricture free 19 mo after generalizability and strength of our findings. RUER, demonstrating that this approach could be a reason- Identification of the ureters and urinary diversion in UES able alternative to open surgery. Our work is the first mul- patients could be challenging because of the intraperitoneal ticenter study in the literature that specifically investigates adhesions and periureteral fibrosis. The use of ICG (nontoxic the feasibility of this procedure in a relatively large series of tracer) could facilitate the identification of the ureter and patients. the site of the stricture. Two studies reported the outcomes Several studies have reported a high rate of postopera- of eight and ten patients, who underwent RUER with the tive complications following open management of UESs. A use of ICG injected in the ureter. They suggested that this summary of the most important series reporting on open approach provided a quick and precise identification of revisions of UESs is shown in Supplementary Table 1. Pack- the ureter and could reduce the risk of vascular and bowel iam et al. [6] found considerable perioperative morbidity in injuries [7,9]. Although ICG was injected into the ureter only a large series of open revision patients, reporting 48% of in 17% of our procedures, we did not report any case of con- postoperative complications, of which 12% were major [6]. version to open approach or intraoperative complication in Two studies compared postoperative complications the overall cohort. On the contrary, a UES is most commonly between open and robotic revisions. One reported 33% of attributed to compromised vascularity of the ureter. A postoperative complications among 45 patients who under- recent study reported a significant reduction in the UES rate went an open revision compared with zero in five robotic following the implementation of intravenous (IV) ICG dur- 52 EUROPEAN UROLOGY OPEN SCIENCE 35 (2022) 47–53 Table 3 – Univariate analysis for stricture-free rate in relation to tactile feedback. Dangle and Abaza [21] suggested that perioperative characteristics patients who had undergone previous RARC rather than % Stricture free (no. of p ORC may had reduced intraperitoneal adhesions, and this procedures/total no.) value in fact could facilitate ureteroenteric reimplantation. Our Gender 0.255 series included mainly patients having undergone mini- Male 86.5 (45/52) mally invasive RC, and the reported results are hardly com- Female 72.7 (8/11) BMI 0.92 parable with other results available in the literature. ≥30 83.8 (31/37) Nevertheless, although nine and ten patients of our series >30 84 (21/25) were previously treated with ORC and RARC with ECUD, Prior abdominal/pelvic 0.784 surgery respectively, none of them had to be converted to an open No 85.3 (29/34) approach or had intraoperative complications. We believe Yes 82.8 (24/29) that RUER is feasible with either approach to RC. Prior abdominal/pelvic 0.124 radiotherapy In accordance with previous studies of open revisions, No 86.2 (50/58) we found that the success rate of RUER did not differ by Yes 60 (3/5) reimplantation side, failed endoscopic attempt, type of uri- Neoadjuvant 0.541 chemotherapy nary diversion, and previous abdominal surgery [5]. One No 86.5 (32/37) study reported worse outcomes in open revisions among Yes 80.8 (21/26) patients who had a preoperative nephroureteral catheter Type of urinary diversion 0.268 Ileal conduit 79.1 (34/43) than in those with percutaneous nephrostomy, in contrast Neobladder 94.4 (17/18) to our findings [6]. We used both univariate analysis and Indiana pouch 100 (2/2) multivariate Cox regression analysis due to the low event Reimplantation side 0.506 Left 88.2 (30/34) rate. On multivariate analysis, lack of prior abdominal RT Right 81.8 (18/22) was the only variable significantly associated with being Bilateral 71.4 (5/7) stricture free after RUER. Given the difficulty of operating Preoperative urinary 0.735 drainage in a previously irradiated abdomen and the lower success Nephrostomy tube 83 (39/47) rate, patients should be counseled about the risk-benefits Ureteral catheter 86.7 (13/15) of undergoing RUER. It has been suggested that successful Failed endoscopic 0.28 procedure endourological treatment for stricture depends primarily No 88.6 (31/35) on stricture length [5]. This finding was not confirmed in Yes 78.6 (22/28) prior open or robotic series, and was not evaluated in the ICG use (any route of 0.913 administration) current study as it was missing for many patients. No 84.4 (38/45) To our knowledge, this is the largest report of RUER. Yes 83.3 (15/18) However, several limitations exist. The retrospective nature Intravenous ICG use 0.955 No 84.2 (48/57) has its known limitations. Another limitation is the varia- Yes 83.3 (5/6) tion among institutions in surgical volume, experience, sur- BMI = body mass index. gical technique, and follow-up protocols. However, all the procedures were performed at high-volume centers using high-volume robotic surgeons who followed similar stan- Table 4 – Multivariate Cox proportional regression analysis of dardized surgical techniques. Furthermore, our study is stricture-free rate in relation to preoperative characteristics strengthened by the fact that it is difficult to generate a large single-institutional series of RUER with optimal HR (CI 95%) p value follow-up. The relatively small number of patients and the Gender 2.5 (0.5–11.2) 0.214 variety in population can limit generalizability of the Prior abdominal/pelvic surgery 1.9 (0.4–7.6) 0.357 Prior abdominal/pelvic radiotherapy 6.8 (1.1–42) 0.037 * results. Reimplantation side 1.5 (0.4–4.9) 0.468 Failed endoscopic procedure 1.3 (0.3–5.1) 0.678 5. Conclusions CI = confidence interval; HR = hazard ratio. * p < 0.05. RUER is a feasible procedure for the management of UESs. Prospective and larger studies are warranted to prove the ing RARC [10]. Even though we agree that this maneuver is safety and efficacy of this technique. useful for the assessment of distal ureter vascularization, we did not find a higher success rate in patients who received intravenous ICG. However, our results have several Author contributions: Enrique Trilla had full access to all the data in the study and takes responsibility for the integrity of the data and the accu- limitations, including the low number of patients who racy of the data analysis. received IV ICG (10%) and that they were all from the same institution. ICG is helpful in assessing the vascularity only when injected IV rather than intraureteral. Prior intrau- Study concept and design: Carrion, Eun, Raventos, Guru. reteral ICG may preclude its benefit to assess vascularity. Acquisition of data: Carrion, Hussein, Hosseini, Gaya, Abaza, Bonet, Iqbal, Z. Limitations of robotic surgery remain the difficulty of Lee, M. Lee, Moreno. access in a previously operated abdomen and the lack of Analysis and interpretation of data: Carrion, Lozano. EUROPEAN UROLOGY OPEN SCIENCE 35 (2022) 47–53 53 Drafting of the manuscript: Carrion, Hussein, Eun, Lozano, Trilla. [8] Hosseini A, Ebbing J, Collins J. Clinical outcomes of robot-assisted Critical revision of the manuscript for important intellectual content: Carrion, radical cystectomy and continent urinary diversion. Scand J Urol 2019;53:81–8. Hussein, Hosseini, Abaza, Palou, Breda, Vigués, Guru. [9] Lee Z, Sterling ME, Keehn AY, Lee M, Metro MJ, Eun DD. The use of Statistical analysis: Carrion, Hussein, Raventos. indocyanine green during robotic ureteroenteric reimplantation for Obtaining funding: None. the management of benign anastomotic strictures. World J Urol Administrative, technical, or material support: Carrion, Iqbal, R.A. Lee. 2019;37:1211–6. Supervision: Carrion, Eun, Trilla, Guru. [10] Ahmadi N, Ashrafi AN, Hartman N, et al. Use of indocyanine green to minimise ureteroenteric strictures after robotic radical cystectomy. Other: None. BJU Int 2019;124:302–7. [11] Reesink DJ, Gerritsen SL, Kelder H, van Melick HH, Stijns PE. Evaluation of ureteroenteric anastomotic strictures after the Financial disclosures: Enrique Trilla certifies that all conflicts of interest, introduction of robot-assisted radical cystectomy with including specific financial interests and relationships and affiliations rel- intracorporeal urinary diversion-results from a large tertiary evant to the subject matter or materials discussed in the manuscript (eg, referral center. J Urol 2021;205:1119–25. employment/affiliation, grants or funding, consultancies, honoraria, stock [12] Ahmed YE, Hussein AA, May PR, et al. Natural history, predictors and management of ureteroenteric strictures after robot assisted ownership or options, expert testimony, royalties, or patents filed, radical cystectomy. J Urol 2017;198:567–74. received, or pending), are the following: None. [13] Large MC, Cohn JA, Kiriuk KJ, et al. The impact of running versus interrupted anastomosis on ureterointestinal stricture rate after radical cystectomy. J Urol 2013;190:923–7. Funding/Support and role of the sponsor: None. [14] Bochner BH, Dalbagni G, Marzouk KH, et al. Randomized trial comparing open radical cystectomy and 17 robot-assisted laparoscopic radical cystectomy: oncologic outcomes. Eur Urol Appendix A. Supplementary data 2018;74:465–71. [15] Anderson CB, Morgan TM, Kappa S, et al. Ureteroenteric anastomotic strictures after radical cystectomy—does operative Supplementary data to this article can be found online at approach matter? J Urol 2013;189:541–7. https://doi.org/10.1016/j.euros.2021.11.005. [16] Carrion A, Piñero A, Raventós C, Lozano F, Diaz F, Morote J. Comparison of perioperative outcomes and complications of robot References assisted radical cystectomy with extracorporeal vs intracorporeal urinary diversion. Actas Urol Esp 2019;43:277–83. [1] Witjes JA, Bruins HM, Cathomas R, et al. European Association of [17] Laven BA, O’Connor RC, Gerber GS, Steinberg GD. Long-term results Urology guidelines on muscle-invasive and metastatic bladder of endoureterotomy and open surgical revision for the management cancer: summary of the 2020 guidelines. Eur Urol 2021;79:82–104. of ureteroenteric strictures after urinary diversion. J Urol 2003;170 [2] Shah SH, Movassaghi K, Skinner D, et al. Ureteroenteric strictures (4 Pt 1):1226–30. after open radical cystectomy and urinary diversion: the University [18] Gin GE, Ruel NH, Parihar JS, et al. Ureteroenteric anastomotic of Southern California experience. Urology 2015;86:87–91. revision as initial management of stricture after urinary diversion. [3] Hautmann RE, Petriconi RC, Volkmer BG. 25 years of experience Int J Urol 2017;24:390–5. with 1,000 neobladders: long-term complications. J Urol [19] Msezane L, Reynolds WS, Mhapsekar R, Gerber GS, Steinbert GD. 2011;185:2207–12. Open surgical repair of ureteral strictures and fistulas following [4] Hussein AA, Hashmi Z, Dibag S, et al. Reoperations following robot- radical cystectomy and urinary diversion. J Urol 2008;179: assisted radical cystectomy: a decade of experience. J Urol 1428–31. 2016;195:1368–76. [20] Nassar OA, Alsafa ME. Experience with ureteroenteric strictures [5] Schöndorf D, Meierhans-Ruf S, Kiss B, et al. Ureteroileal strictures after radical cystectomy and diversion: open surgical revision. after urinary diversion with an ileal segment-is there a place for Urology 2011;78:459–65. endourological treatment at all? J Urol 2013;190:585–90. [21] Dangle PP, Abaza R. Robot-assisted repair of ureteroileal [6] Packiam VT, Agrawal VA, Cohen AJ, et al. Lessons from 151 ureteral anastomosis strictures: initial cases and literature review. J reimplantations for postcystectomy ureteroenteric strictures: a Endourol 2012;26:372–6. single-center experience over a decade. Urol Oncol 2017;35:112. [22] Kaouk J, Garist J, Eltemamy M, Bertolo R. Robot assisted surgery for e19–25. benign distal ureteral strictures: step by step technique using the [7] Tuderti G, Brassetti A, Minisola F, et al. Transnephrostomic SPÒ surgical system. BJU Int 2019;123:733–9. indocyanine green-guided robotic ureteral reimplantation for [23] Rosales A, Emiliani E, Salvador JT, et al. Laparoscopic management benign ureteroileal strictures after robotic cystectomy and of ureteroileal anastomosis strictures: initial experience. Eur Urol intracorporeal neobladder: step-by-step surgical technique, 2016;70:493–8. perioperative and functional outcomes. J Endourol 2019;33:823–8.