Stapled vs Manually Sutured Bowel Anastomosis in Robot-Assisted Radical Cystectomy: a single-center retrospective analysis

Stapled vs Manually Sutured Bowel Anastomosis in Robot-Assisted Radical Cystectomy: a single-center retrospective analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Stapled vs Manually Sutured Bowel Anastomosis in Robot-Assisted Radical Cystectomy: a single-center retrospective analysis Thomas Hermans, Giel Schevenels, Steve Motmans, Yannic Raskin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4621377/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Apr, 2025 Read the published version in BMC Urology → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Radical cystectomy is the primary treatment for muscle-invasive bladder cancer and certain cases of high-risk non-muscle-invasive disease. Robot-assisted cystectomy techniques (RARC) have emerged as a minimally invasive alternative to traditional open surgery, offering enhanced precision. The creation of an effective bowel anastomosis is critical in these procedures, with manually sutured anastomosis being a good and significantly cheaper alternative to the standard stapled anastomosis. Methods: We conducted a retrospective study of 92 patients who underwent RARC between March 2021 and November 2023. Bowel anastomosis was performed using either stapled or manually sutured techniques. Outcome parameters included bowel-related complications, operation duration, length of hospital stay, intensive care unit (ICU) stay, readmissions, and postoperative recovery metrics. Results: Of the patients, 59 received manually sutured bowel anastomosis, while 33 received stapled anastomosis. Demographic analysis showed no significant differences between the groups. Gastrointestinal (GI) complications occurred in 25% of patients, predominantly paralytic ileus. There were no statistically significant differences in complication rates between the two techniques. Readmissions were higher in the sutured group, mainly due to non-GI complications. Operation duration and length of stay were similar in both groups. Conclusion: This study found comparable outcomes between stapled and manually sutured bowel anastomosis in RARC, with no significant increase in GI complications or in operation duration in manually sutured anastomosis. Considering the substantial financial advantage in favor of manual suturing, this technique could become the new standard. Bowel anastomosis robot-assisted radical cystectomy stapled sutured muscle-invasive bladder cancer cost Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction/Background Radical cystectomy stands as the gold standard treatment for patients afflicted with muscle-invasive bladder cancer and select cases of high-risk non-muscle-invasive disease that are unresponsive to more conservative therapies. ( 1 , 2 ) The primary indications for radical cystectomy are multifaceted, encompassing muscle-invasive bladder cancer that extends beyond the mucosa, carcinoma in situ refractory to intravesical therapy, and recurrent high-grade non-muscle-invasive tumors that do not respond to conservative measures. It is also performed for a wide range of functional complaints such as therapy refractory bladder pain syndrome and radiocystitis. In cases where patients are deemed unfit for radical surgery or have personal preferences that align with bladder preservation, alternative therapies such as trimodal therapy may be considered. However, radical cystectomy remains the cornerstone for achieving optimal oncologic outcomes and long-term disease control. This surgical intervention involves the removal of the urinary bladder, surrounding lymph nodes (when performed for malignancies), and adjacent structures such as the distal ureters and sometimes the urethra, aiming to achieve both oncological efficacy and functional preservation. While traditional open surgery has been the historical approach, the advent of robotic-assisted cystectomy techniques (RARC) has revolutionized the landscape of radical cystectomies, offering enhanced precision and a minimally invasive alternative. ( 3 ) Over the years, several surgical techniques and urinary diversions have been developed. The most frequently used diversion is currently the ileal conduit, but there are several alternatives such as orthotopic neobladder construction, catheterisable pouches and ureterocutaneostomies. ( 4 ) For the creation of most of these diversions, a part of the distal ileum is used. The creation of an effective bowel anastomosis is therefore a critical aspect of the surgical procedure, influencing both short-term recovery and long-term quality of life. Traditionally, the anastomosis between the ileum and the urinary conduit or neobladder has been executed using manual suturing, an intricate and time-consuming process. Since the 1960’s medical devices for the stapling of bowel tissue have been introduced as an alternative technique, offering potential advantages in terms of reduced operative times, decreased complications, and enhanced standardization ( 5 ). These staplers have slowly become the standard of care for bowel anastomosis. Despite the potential advantages associated with stapled bowel anastomosis in RARC, it is crucial to acknowledge and critically evaluate the inherent drawbacks of these devices. With the dawn of minimally invasive cystectomies, in many centres the creation of the urinary diversion as well as the bowel anastomosis is now also performed intracorporeally. Laparoscopic, as well as robot-assisted staplers, are usually quite bulky and more difficult to manoeuvre and articulate than their counterparts in open surgery. This is mostly due to lack of space when working intra-abdominally. ( 6 ) Furthermore, the mechanical nature of stapling introduces a risk of compromised blood supply and tissue ischemia at the anastomotic site.( 7 ) This could contribute to an increased risk of anastomotic leaks or necrosis, a complication with severe consequences in the postoperative period. Using the da Vinci Fluorescence Imaging Vision System (Firefly) to identify blood supply in the bowel mesenterium with Indocyanin Green (ICG), could help to selectively avoid cutting through these vessels. ( 8 ) Another noteworthy concern pertains to the limited adaptability of staplers in managing variations in tissue thickness and quality. Unlike the tactile feedback available during manual suturing, stapling devices do not provide the same level of sensitivity to tissue characteristics. This limitation can be particularly relevant in cases where the bowel tissue is friable, fibrotic, or otherwise challenging to manipulate. The most notable disadvantage however, lies in the cost and resource implications associated with the utilization of surgical staplers. Stapling devices, though efficient, are expensive and contribute to increased overall procedural costs. This economic consideration becomes particularly pertinent in healthcare settings with constrained resources, raising questions about the cost-effectiveness of stapled bowel anastomosis compared to traditional manual suturing. Having experience with manually sutured bowel anastomoses in open surgery, the primary bladder surgeon in our centre uses both robotical stapling as well as manual suturing in RARC. Initially, the majority of patients underwent stapled anastomosis. However, over time, there was a gradual transition towards manual suturing, with the surgeon increasingly favoring this technique. Eventually, robotic stapling was reserved for specific indications (e.g. for very short ureters or a unique kidney, where a separate uretero-enteral anastomosis is easier), reflecting the surgeon's growing confidence and proficiency in manual suturing during RARC procedures. We conducted an extensive literature search and concluded that there is almost no recent evidence on this topic. Most studies comparing both techniques are more than 20 years old and only very few are from the era of minimally invasive surgery. ( 11 – 15 ) Comparisons between robot-assisted staplers and robot-assisted manually suturing have been made, but there are almost no studies from the field of urology. ( 16 , 17 ) We only found two studies comparing robot-assisted stapling with manual anastomosis in RARC: one retrospective study and one prospective feasibility study, showing no significant short-term disadvantages of using the manually suturing technique. ( 10 , 18 ) We therefore decided to retrospectively compare our manually sutured with our stapled approaches, seeking to elucidate differences in terms of safety, efficacy, and postoperative outcomes. With this article, we aimed to get a better understanding of the benefits of both techniques. 2. Material and methods 2.1 Patients We carried out an extensive analysis of all patients that underwent RARC in our centre between March 2021 (start of RARC program) and November 2023. Patients that underwent an open (n=9) or partial cystectomy (n=17) were excluded, as well as patients that had to be converted to open during the procedure (n=1). Other exclusion criteria were if no bowel anastomosis was performed (eg. ureterocutaneostomy, n=0), if bowel anastomosis was performed extracorporeally (n=0) and emergency cystectomies (n=4). We finally also decided to exclude one patient in which the anastomosis was performed using a laparoscopic stapler (handled by a bedside assistant). We thus identified a total of 124 RARC patients, of whom 32 were excluded. 2.2. Outcome parameters Primary outcome parameter was bowel-related complications (in-hospital and after discharge). Secondary outcome parameters were operation duration, length of hospital stay, intensive care unit (ICU) stay, readmissions, complications (all-type), time to intake, time to flatus, time to defecation and time to extraction of the drain. We predefined a limited follow-up of three months after discharge, not expecting relevant bowel-related complications after that period of time. All kinds of food ingestion, fluid or solid, exceeding mere water were accepted as ‘intake’. Flatulence was defined as audible bowel movements in combination with experienced expulsion of gas. Under defecation, all kinds of stool production were accepted. We defined (paralytic) ileus as abdominal distension with the presence of nausea or vomiting, requiring at least the cessation of oral intake. Mechanical ileus was a radiological diagnosis. 2.3 Surgical technique All RARC procedures were carried out by the same high-volume surgeon (>500 robotic cases) using a four-arm Da Vinci Xi surgical robot setup (Intuitive Surgery) and a 30° camera. Instruments used for dissection were a Maryland bipolar forceps, a ProGrasp forceps and curved scissors, for suturing and handling of bowel tissue a needle driver and either a normal fenestrated bipolar forceps or the Cadiere forceps as well as the ProGrasp were used. All procedures were performed completely intracorporeally and in a standardized manner, using a 15-20° Trendelenburg position and an abdominal insufflation pressure of 9-12 mmHg. Standard protocol included a single shot of Cefazolin (Clindamycin in case of allergy to Cephalosporin) at the beginning of the operation, which was repeated after 6 hours if the operation was still ongoing. Procedures started with adhesiolysis, distal ureterectomy, clipping and frozen section of the distal ureteric ends. The next step was cysto(prostate)ctomy, proceeding with a bilateral lymph node dissection (LND) if indicated, then isolation of the bowel segment, bowel anastomosis and creation of the urinary diversion. In case of ileal conduit: a 10cm bowel fragment was isolated, left ureter was tunneled and both ureters were implanted on the bowel segment using the Wallace plate technique (due to intraoperative factors, in 7 patients, ureters were implanted separately). Neobladders were created using the Wiklund technique (modified Studer) (19,20) and were closed with a Monocryl 3-0 running suture. Urethral anastomosis was performed with a 3-0 Stratafix suture. In female patients, the specimen was extracted through the vagina, in males at the end of the procedure through an enlarged left trocar incision (muscle splitting). We did not standardly perform an appendectomy. Stapled bowel anastomosis was performed with a robotic stapler (da Vinci Xi SureForm 60 – Intuitive Surgery) using 2 cartridges for the bowel isolation and 2 cartridges for the bowel anastomosis, thus using in total 4 cartridges per patient. In the case of a manually sutured anastomosis, bowel and mesenterium were cut robotically using cold scissors, after identifying mesenterical blood supply using ICG. As displayed in Figure 1, a one-layer bowel anastomosis was then performed end-to-end using 2 semicircular running Stratafix 3-0 15cm PDS sutures. An additional ‘goodnight-stitch’ using a Vicryl 3-0 suture was used in case of stapled anastomosis, but not in case of manually sutured anastomosis. 2.4 Data extraction All relevant data was extracted from hospital records using our electronic medical record program HiX (Chipsoft) and was added into an anonymized database. No blinding was performed. 2.5 Statistic Data analysis and visualization were performed using Graphpad Prism v.9 software. For contingency analyses, p- values were calculated using Chi-square tests (Table 1, 2 and Fig. 1) or Fisher’s exact tests (Table 3, 4 and Fig. 2). For numerical between-group comparisons, data represent median ± interquartile range and p -values were calculated using non-parametric two-sided Mann-Whitney U tests. Data for BMI were represented as mean ± standard deviation and the p- value was calculated using a parametric two-sided Student’s t-test. For outcome parameters, both in- and post-hospitalization data were used. 2.6 Funding No external funding was received for this study. 3. Results 3.1 Demographic results In total, ninety-two patients were included in the study. 59 patients received a manually sutured bowel anastomosis, the other 33 patients were stapled robotically. We did an extensive analysis of potential confounding factors, to make sure both groups were comparable, see Table 1. There were no statistical differences between both groups concerning age, sex, clinical and pathological TNM stages, neo-adjuvant chemotherapy, smoking history as defined in pack years, previous abdominal surgery (including both laparoscopic and open surgery), Charlson comorbidity index (CCI), diabetes mellitus type 2 (DM2), vascular disease (both peripheric and coronary) and chronic kidney disease (CKD). A graphic display of aforementioned parameters can be found in Figure 2. There was a small but statistically significant difference in body mass index (BMI) and American Society of Anesthesiologists (ASA) score. Patients in the stapled anastomosis group tended to have a higher BMI (p=0.0285) and a lower ASA score (p=0.0297). There were also no statistical differences in main surgical indications between both groups: bladder cancer (BC; 85 patients, 92.4%), invasive prostate cancer (2 patients, 2.2%) or functional complaints (8 patients, 8.7%). Some patients had multiple indications. In total, 30% of patients received an early cystectomy, 58% were for muscle-invasive bladder cancer. After an extensive analysis of the demographic and comorbidity data, we concluded both groups to be remarkably comparable and decided against a constriction of our patient numbers by creating a propensity score matching cohort. Table 1. Demographic and descriptive data . Comparison between sutured and stapled bowel anastomosis patient groups. Binary data are listed as number of patients ( n ) and proportion of patients (%), and p- values were calculated using Chi-square tests. Numerical data are listed as median and interquartile range, and p- values were calculated using non-parametric two-sided Mann-Whitney U tests. For BMI, data represent mean ± standard deviation and the p -value was calculated using a parametric two-sided Student’s t-test. Pathological T-stage as mentioned in the TUR bladder histopathological report, clinical TNM-stage as assessed by the primary surgeon based upon preoperative imaging. MIBC: muscle invasive bladder cancer, BMI: body mass index, SD: standard deviation, ASA: american society of anesthesiology, CCI: Charlson comorbidity score, DM2: diabetes mellitus type 2, CKD: chronic kidney disease, G: grade. Variable Total Sutured Stapled p -value Patients, n (%) 92 (100.00) 59 (64.13) 33 (35.87) Age, median (interquartile range) 71 (65.25-77) 71 (65-76) 70 (65-77) 0.8126 Sex, n males (%) 74 (80.43) 48 (81.36) 26 (78.79) 0.7659 Bladder cancer, n (%) 85 (92.39) 56 (94.92) 29 (87.88) 0.2221 Early, n (%) 28 (30.43) 21 (35.59) 7 (21.21) 0.1505 MIBC, n (%) 53 (57.61) 33 (55.93) 20 (60.61) 0.6635 Prostate invasive Cis, n (%) 4 (4.35) 2 (3.39) 2 (6.06) 0.5469 pT, n (%) ≤pTis 44 (47.83) 29 (49.15) 15 (45.45) 0.7334 >pTis 48 (52.17) 30 (50.85) 18 (54.55) cT, n (%) ≤cT2 74 (80.43) 51 (86.44) 23 (69.70) 0.0522 >cT2 18 (19.57) 8 (13.56) 10 (30.30) cN, n (%) No 81 (88.04) 54 (91.53) 27 (81.82) 0.1687 Yes (≥N1) 11 (11.96) 5 (8.47) 6 (18.18) cM, n (%) No 89 (96.74) 57 (96.61) 32 (96.97) 0.9258 Yes (≥M1a) 3 (3.26) 2 (3.39) 1 (3.03) Neo-adjuvant chemotherapy, n (%) 31 (33.70) 19 (32.20) 12 (36.36) 0.6855 BMI, mean (± SD) 26.73 (± 4.49) 25.97 (± 4.20) 28.09 (± 4.73) 0.0285 ASA, median (interquartile range) 3 (2-3) 3 (2-3) 2 (2-3) 0.0297 Pack years, median (interquartile range) 15 (0-40) 15 (0-35) 11 (0-54) 0.6974 Previous abdominal surgery, n (%) 48 (52.17) 30 (50.85) 18 (54.55) 0.7334 CCI (interquartile range) 5 (4-7) 5 (4-7) 5 (4-7.5) 0.8978 DM2, n (%) 18 (19.57) 10 (16.95) 8 (24.24) 0.3977 Vascular disease, n (%) 27 (29.35) 20 (33.90) 7 (21.21) 0.2000 CKD, n (%) ≤G2 69 (75.00) 43 (72.88) 26 (78.79) 0.5303 >G2 23 (25.00) 16 (27.12) 7 (21.21) 3.2 Procedural data We performed an analysis of all procedures, again, to exclude any significant differences between both groups; see table 2. In total, 83 out of the 92 cystectomy patients received an ileal conduit as diversion, whereas 9 out of 92 cystectomy patients received a neobladder as diversion. An equal proportion of both procedure types were performed with either a stapled or a sutured bowel anastomosis. There was a slightly larger proportion of the stapled group (6 patients, 19% vs 1 patient, 2%, p=0.0036) undergoing a separate implantation of the ureters on the bowel segment. This could be explained by the fact that in a stapled anastomosis the proximal end of the bowel segment is already stapled shut, making a separate uretero-enteral anastomosis here easier to perform than a Wallace plate. We performed several additional robot-assisted procedures during the same session as the cystectomy, e.g. two nephro-ureterectomies and a partial nephrectomy (all in the stapled group), 10 female anterior pelvic exenterations (6 in the sutured and 4 in the stapled group), two perineal urethrectomies (one in each group), one proximal urethrectomy (sutured group), one adrenalectomy (sutured group), one unilateral and one bilateral inguinal hernia correction (one in each group) and two ileocaecal resections (one in each group). There were slightly more patients undergoing a pelvic LND in the sutured group than in the stapled group. In total, LND was performed in 90.13% of patients. Concerning nerve sparing, blood loss and additional procedures, no statistical differences between both groups were seen. Nerve sparing was always done bilaterally, except in 1 case. Table 2. Procedural data. Comparison between sutured and stapled bowel anastomosis patient groups. Binary data are listed as number of patients ( n ) and proportion of patients (%), and p- values were calculated using Chi-square tests. Numerical data are listed as median and interquartile range, and the p- value was calculated using a non-parametric two-sided Mann-Whitney U test. We defined LND patterns to conform to the 2023 EAU MIBC guideline definitions (section 7.3.4) (2). LND: lymph node dissection. Variable Total Sutured Stapled p -value Operation type, n (%) Bricker 83 (90.22) 53 (89.83) 30 (90.91) 0.8674 Neobladder 9 (9.78) 6 (10.17) 3 (9.09) LND, n (%) No 10 (10.87) 3 (5.08) 7 (21.21) 0.0171 Limited 16 (17.39) 11 (18.64) 5 (15.15) 0.6716 Normal 4 (4.35) 0 (0.00) 4 (12.12) 0.0063 Extended 60 (65.22) 44 (74.58) 16 (48.48) 0.0117 Superextended 2 (2.17) 1 (1.69) 1 (3.03) 0.6736 Nerve sparing, n (%) 34 (36.96) 21 (35.59) 13 (40.63) 0.6357 Ureter anastomosis, n (%) Wallace plate 84 (92.31) 58 (98.31) 26 (81.25) 0.0036 Separate 7 (7.69) 1 (1.69) 6 (18.75) Blood loss, median (interquartile range) 250 (150-350) 250 (150-350) 225 (150-475) 0.6072 Additional operation, n (%) 25 (27.47) 15 (25.42) 10 (31.25) 0.5522 3.3 Primary outcome parameters Table 3. Primary outcome parameters. Comparison between sutured and stapled bowel anastomosis patients. Binary data are listed as number of patients ( n ) and proportion of patients (%). p- values were calculated using Fisher’s exact tests. Numerical data are listed as median and interquartile range, and the p- value was calculated using a non-parametric two-sided Mann-Whitney U test. Both in-hospital and post-hospitalization data up to 3 months after discharge were included. GI: gastro-intestinal, GT: gastric tube. TPN: Total parenteral nutrition. Variable Total Sutured Stapled p -value GI complications, n (%) 23 (25.00) 16 (27.12) 7 (21.21) 0.6206 Complication type, n (%) Peritonitis 1 (1.09) 1 (1.69) 0 (0.00) >0.9999 Mechanic ileus 5 (5.43) 3 (5.08) 2 (6.06) >0.9999 Paralytic ileus 16 (17.39) 11 (18.64) 5 (15.15) 0.7793 Dehiscence 1 (1.09) 1 (1.69) 0 (0.00) >0.9999 Total blowout 1 (1.09) 1 (1.69) 0 (0.00) >0.9999 Bleeding at anastomosis 1 (1.09) 1 (1.69) 0 (0.00) >0.9999 GI treatments, n (%) 22 (23.91) 15 (25.42) 7 (21.21) 0.8001 GI treatment type Gastric tube, n (%) 15 (16.30) 9 (15.25) 6 (18.18) 0.7724 GT reinsertion duration in days, median (interquartile range) 3 (1-4.25) 3 (1.25-4.75) 3 (0-6.5) 0.7862 Medication, n (%) 12 (13) 9 (15.25) 3 (9.09) 0.5268 Explorative laparotomy, n (%) 1 (1.09) 1 (1.69) 0 (0.00) >0.9999 TPN, n (%) 3 (3.26) 3 (5.08) 0 (0.00) 0.5504 As projected in Table 3 and Figure 3, gastrointestinal (GI) complications were seen in 25% of patients. Most of those had a paralytic ileus (17% of patients), usually treated conservatively or by (re-)insertion of a gastric tube, on average for about 3 days. 5 patients were radiologically diagnosed with a mechanical ileus, for which only 1 explorative laparotomy had to be performed. This particular instance involved a patient with a manually sutured bowel anastomosis, who, following a standard postoperative recovery and discharge on day 5, returned on day 8 with a blowout of the bowel anastomosis. Subsequent interventions were necessitated, including an open reconstruction of the bowel anastomosis, which unfortunately resulted in a second bowel dehiscence. Notably, this case occurred early in the adoption of sutured bowel anastomosis procedures and was an isolated occurrence, suggesting a potential learning curve challenge. All four other cases of mechanical ileus were managed conservatively. We found no statistically significant differences between both surgical techniques in any of the mentioned GI complications or their treatments. 3.4 Secondary outcome parameters Secondary outcome parameters are listed in Table 4 and graphically presented in Figure 4. Operation duration was 300 min per procedure on average. Although not statistically significant (p=0.12), stapled procedures were about 13 minutes longer than sutured procedures. This shows that manually suturing the bowel back together does not necessarily prolong the procedure and can even shorten it, when performed by experienced hands. Length of stay was, as could be expected, similar for both techniques (p=0.38). There were more readmissions in the sutured anastomosis group (p=0.02), of whom most were caused by non-GI complications such as leakage of the ileo-ureteric anastomosis (3 out of 17 cases) and infectious complications (11 out of 17 cases). Remarkably, 3 patients presented with an urosepsis due to an obstructive urolithiasis (all in the sutured group). Most complications were Clavien Dindo grade ≤2 (55%). Most grade 3 complications were due to dislocation of either the catheter or one of the ureteric stents - or due to paralytic ileus necessitating the reinsertion of a gastric tube. The one patient with a grade 4b complication was hospitalized in the ICU because of a urosepsis with multi-organ failure due to an obstructive urolithiasis (sutured group). The one patient with a grade 4a complication had a cerebrovascular accident (CVA) at home and died afterwards (sutured group). We reported a 3-month mortality of 3.26% (3 cases). None of the deaths were due to a GI complication and all occurred outside of the hospital. 1 Patient (stapled group) died of respiratory septic shock with an underlying COPD stage Gold 4 and another (stapled group) of dyspnea, no invasive measures were undertaken because of rapidly progressive liver metastasis and pleural metastasis respectively. The reason for the death of the third patient (sutured group) is not documented, but occurred after a CVA at home as mentioned before. There were no statistically significant differences in time to intake, time to extraction of the drainage, time to flatus or time to defecation. Table 4. Secondary outcome parameters. Comparison of secondary outcome parameters between sutured and stapled bowel anastomosis groups. Binary data are listed as number of patients ( n ) and proportion of patients (%). p- values were calculated using Fisher’s exact tests. Numerical data are listed as median and interquartile range, and p- values were calculated using non-parametric two-sided Mann-Whitney U tests. ICU: intensive care unit. Variable Total Sutured Stapled p -value Operation duration in min, median (interquartile range) 300 (240-330) 300 (240-315) 313 (247.5-373.8) 0.1243 Length of stay in days, median (interquartile range) 8 (6-10.75) 7 (6-10) 8 (5.5-13) 0.3842 ICU stay in days, median (interquartile range) 1 (0-1) 0 (0-1) 1 (0-1) 0.0508 Readmission, n (%) 17 (18.48) 15 (25.42) 2 (6.06) 0.0254 Readmission stay in days, median (interquartile range) 7 (2.5-8) 7 (2-8) 7.5 (7-8) 0.6544 Maximum Clavien Dindo grade, median (interquartile range) 2 (0-3a) 2 (0-3a) 2 (0-2) 0.2172 Clavien Dindo grade, n (%) 0 29 (31.52) 17 (28.81) 12 (36.36) 0.4892 1 8 (8.70) 4 (6.78) 4 (12.12) 0.4510 2 27 (29.35) 17 (28.81) 10 (30.30) >0.9999 3a 19 (20.65) 15 (25.42) 4 (12.12) 0.1812 3b 4 (4.35) 3 (5.08) 1 (3.03) >0.9999 4a 1 (1.09) 1 (1.69) 0 (0.00) >0.9999 4b 1 (1.09) 1 (1.69) 0 (0.00) >0.9999 5 3 (3.26) 1 (1.69) 2 (6.06) 0.2915 Time to intake in days, median (interquartile range) 1 (1-1) 1 (1-2) 1 (1-1) 0.5064 Time to flatus in days, median (interquartile range) 3 (2-4) 3 (2-4) 3 (2-4) 0.5496 Time to defecation in days, median (interquartile range) 5 (4-6) 5 (4-6) 5 (4-7) 0.8978 Time to drain ex in days, median (interquartile range) 4.5 (3-6) 4 (3-6) 5 (3.25-7.75) 0.3496 4. Discussion 4.1 Background The increasing use of robotics in urological surgery poses challenges of cost-effectiveness for urologists worldwide. As mentioned by the international robotic cystectomy consortium, the use of intracorporeal urinary diversion in RARC has increased and using this technique could reduce GI complications (19). The sutured ileo-ileal anastomosis technique is well-known in GI surgery and is considered safe. (11-17). There are only a few studies reporting on robotically sutured ileo-ileal anastomosis within the urological field. Loertzer et al. were first to describe a series of 48 patients in whom this technique was used and found it feasible with a low complication ratio. In 2020, Aljabery et al. compared a robot-sewn ileo-ileal anastomosis with its stapled variant in 155 patients in a single-centre retrospective analysis. They found no significant difference in operative time, median hospital stay and complication ratio. 4.2 Results We performed a retrospective analysis of all RARC procedures in our center since the start of the robotic cystectomy program in 2021, including 92 patients, of which 59 received a robotically sutured anastomosis and 33 received a robotically stapled anastomosis. Both groups were remarkably similar in demographic and procedural data. Demographic, procedural and outcome data were consistent with data found in literature (20,21). We found no significant differences between both groups in GI-specific postoperative courses, no increase in GI complication rate and no increase in overall complication rate when changing from a standard stapled anastomosis to a robotically sutured anastomosis. We even saw a reduction in operation duration of about 13 minutes. As was the case in Aljabery’s study, there was a higher readmission rate in the sutured anastomosis group, but this could not be allocated to GI-related complications. We reported a 3.26% mortality rate at 3 months after discharge, which is consistent with data found in literature (20,21). We suggest a prospective randomized controlled trial with larger sample sizes to validate these findings and guide surgical decision-making. 4.3 Cost analysis Robot-assisted staplers used in our department (da Vinci Sureform 60) cost €252 per cartridge. The stapler (including seal and trocar reducer) costs about €492 per procedure. Using 4 cartridges per bowel anastomosis (some surgeons use 3), total cost in our centre amounts to €1500-2000 per procedure, which is comparable to European averages. (9) When comparing this to a total material cost of €12000-16500 per procedure, this represents a significant part of the costs. By comparison, a manually sutured bowel anastomosis in our centre, using only 2 barbed V-Loc sutures, costs about €54, a factor 30 cheaper than using a robotic stapler. (10) This substantial cost difference between using robotic staplers and manually suturing bowel anastomosis makes a compelling argument for favoring robotic suturing techniques. 5. Conclusion In conclusion, our study confirms that robotically sutured ileo-ileal anastomosis in robot-assisted radical cystectomy yields comparable outcomes to stapled techniques, with no significant increase in GI complications or in operation duration. Moreover, the cost analysis reveals a substantial financial advantage in favor of manual suturing, highlighting the importance of considering cost-effectiveness in surgical decision-making. Abbreviations ASA American society of anesthesiologists BMI body mass index CCI charlson comorbidity score CKD chronic kidney disease COPD chronic obstructive pulmonary disease CVA cerebrovascular accident DM2 diabetes mellitus type II GI gastro-intestinal GT gastric tube ICG indocyanin green ICU intensive care unit LND lymph node dissection MIBC muscle invasive bladder cancer RARC robot-assisted radical cystectomy TPN total parenteral nutrition Declarations Ethics approval and consent to participate This study was approved by the ethical committee of Ziekenhuis Oost-Limburg (ID Number Z2024049). As this was a retrospective, non-interventional study, the need for consent to participate was waived by the ethical committee. Consent for publication Not applicable. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to privacy concerns but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no relevant competing interests. Funding No funding was received for this study. Publication charges and open access fees were paid via the urology department’s third party funds account, which in turn is privately sponsored by patients and benefactors. Authors’ contributions The study was conceptualized and the study protocol was written by TH and YR. TH and SM gathered all retrospective data into an extensive database. GS performed all statistical analyses and created relevant figures and tables. The manuscript was written by TH and was then read and corrected by all authors (GS, SM and YR). All authors (TH, GS, SM and YR) approved of the final version. Acknowledgements Not applicable. References Gontero P, Compérat E, Dominguez JL, Liedberg F, Mariappan P, Masson-Lecomte A, et al. Non-muscle-invasive Bladder Cancer (TaT1 and CIS) EAU Guidelines on. 2023; Updated 2023 EAU guidelines on muscle-invasive and metastatic bladder cancer. Edn. presented at the EAU Annual Congress Milan 2023. ISBN 978-94-92671-19-6. Menon M, Hemal AK, Tewari A, Shrivastava A, Shoma AM, El-Tabey NA, et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int [Internet]. 2003 Aug [cited 2024 Jan 6];92(3):232–6. Available from: https://pubmed.ncbi.nlm.nih.gov/12887473/ Chesnut GT, Rentea RM, Leslie SW. Urinary Diversions and Neobladders. StatPearls [Internet]. 2023 Jul 25 [cited 2024 Jan 6]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK560483/ Gaidry AD, Tremblay L, Nakayama D, Ignacio RC. The history of surgical staplers: A combination of Hungarian, Russian, and American innovation. Vol. 85, American Surgeon. 2019. Teo NZ, Chi J, Ngu Y. A Comparison between the da Vinci Xi Endowrist Stapler and a conventional Laparoscopic Stapler in Rectal Transection: A Randomized Controlled Trial. 2022 [cited 2024 Jan 6]; Available from: https://doi.org/10.21203/rs.3.rs-2071813/v1 Chekan E, Whelan RL. Surgical stapling device-tissue interactions: what surgeons need to know to improve patient outcomes. Medical Devices: Evidence and Research [Internet]. 2014 [cited 2024 Jan 6];7:305–18. Available from: http://dx.doi.org/10.2147/MDER.S67338 Licari LC, Bologna E, Proietti F, Flammia RS, Bove AM, D’annunzio S, et al. Exploring the Applications of Indocyanine Green in Robot-Assisted Urological Surgery: A Comprehensive Review of Fluorescence-Guided Techniques. Sensors. 2023 Jun 11;23(12):5497. Mjaess G, Diamand R, Aoun F, Assenmacher G, Assenmacher C, Verhoest G, et al. Cost-analysis of robot-assisted radical cystectomy in Europe: A cross-country comparison. 2022 [cited 2024 Jan 6]; Available from: https://doi.org/10.1016/j.ejso.2022.07.023 Loertzer P, Siemer S, Stöckle M, Ohlmann CH. Robot-sewn ileoileal anastomosis during robot-assisted cystectomy. World J Urol [Internet]. 2018 Jul 1 [cited 2024 Jan 6];36(7):1079–84. Available from: https://pubmed.ncbi.nlm.nih.gov/29500511/ Korolija D. The current evidence on stapled versus hand‐sewn anastomoses in the digestive tract. Minimally Invasive Therapy & Allied Technologies [Internet]. 2008 [cited 2024 Jan 6];17(3):151–4. Available from: https://www.tandfonline.com/doi/abs/10.1080/13645700802103423 Cajozzo M, Compagno G, DiTora P, Spallitta SI, Bazan P. Advantages and disadvantages of mechanical vs. manual anastomosis in colorectal surgery. A prospective study. Acta Chir Scand. 1990 Feb;156(2):167–9. Catena F, La Donna M, Gagliardi S, Avanzolini A, Taffurelli M. Stapled versus hand-sewn anastomoses in emergency intestinal surgery: results of a prospective randomized study. Surg Today [Internet]. 2004 [cited 2024 Jan 6];34(2):123–6. Available from: https://pubmed.ncbi.nlm.nih.gov/14745611/ Gonzalez EM, Selas PR, Molina DM, Sanz RG, Martinez RR, Gonzalez JS, et al. Results of surgery for cancer of the rectum with sphincter conservation. A randomized study on instrumental versus manual anastomosis. Acta Oncol [Internet]. 1989 [cited 2024 Jan 6];28(2):241–4. Available from: https://pubmed.ncbi.nlm.nih.gov/2736113/ Castro PM arcela V, Ribeiro FP iccarone G, Rocha A de F, Mazzurana M, Alvarez GA ntunes. Hand-sewn versus stapler esophagogastric anastomosis after esophageal ressection: systematic review and meta-analysis. Arq Bras Cir Dig [Internet]. 2014 Jul 1 [cited 2024 Jan 6];27(3):216–21. Available from: https://pubmed.ncbi.nlm.nih.gov/25184776/ Guadagni S, Palmeri M, Bianchini M, Gianardi D, Furbetta N, Minichilli F, et al. Ileo-colic intra-corporeal anastomosis during robotic right colectomy: a systematic literature review and meta-analysis of different techniques. Int J Colorectal Dis [Internet]. 2021 Jun 1 [cited 2024 Jan 6];36(6):1097–110. Available from: https://pubmed.ncbi.nlm.nih.gov/33486533/ Hur H, Kim JY, Cho YK, Han SU. Technical Feasibility of Robot-Sewn Anastomosis in Robotic Surgery for Gastric Cancer. https://home.liebertpub.com/lap [Internet]. 2010 Oct 12 [cited 2024 Jan 6];20(8):693–7. Available from: https://www.liebertpub.com/doi/10.1089/lap.2010.0246 Aljabery F, Jancke G, Skoglund P, Hallbook O. Stapled versus robot-sewn ileo-ileal anastomosis during robot-assisted radical cystectomy: a review of outcomes in urinary bladder cancer patients. Scand J Urol [Internet]. 2021 [cited 2024 Jan 6];55(1):41–5. Available from: https://pubmed.ncbi.nlm.nih.gov/33169655/ Hussein AA, May PR, Jing Z, Weiburg CJ, Canda AE, Dasgupta P, Khan MS, Menon M, Peabody JO, Hosseini A, Kelly J, Mottrie A, Kaouk J, Hemal A, Wiklund P, Guru KA. Outcomes of intracorporeal urinary diversion after robot-assisted radical cystectomy: results from the international robotic cystectomy consortium. J Urol 2018;199(5):1302-1311.May PMID: PMID: 29275112 Tyritzis SI, Hosseini A, Collins J, Nyberg T, Jonsson MN, Laurin O, Khazaeli D, Adding C, Schumacher M, Wiklund NP. Oncologic, functional, and complications outcomes of robot-assisted radical cystectomy with totally intracorporeal neobladder diversion. Eur Urol. 2013 Nov;64(5):734-41. doi: 10.1016/j.eururo.2013.05.050. Epub 2013 Jun 6. PMID: 23768634. Clement KD, Pearce E, Gabr AH, Rai BP, Al-Ansari A, Aboumarzouk OM. Perioperative outcomes and safety of robotic vs open cystectomy: a systematic review and meta-analysis of 12,640 cases. World J Urol. 2021 Jun;39(6):1733-1746. doi: 10.1007/s00345-020-03385-8. Epub 2020 Jul 30. PMID: 32734460. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Apr, 2025 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 15 Dec, 2024 Reviews received at journal 06 Dec, 2024 Reviewers agreed at journal 04 Dec, 2024 Reviews received at journal 15 Oct, 2024 Reviewers agreed at journal 13 Oct, 2024 Reviewers invited by journal 13 Oct, 2024 Editor invited by journal 16 Aug, 2024 Editor assigned by journal 28 Jun, 2024 Submission checks completed at journal 28 Jun, 2024 First submitted to journal 22 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4621377","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":323431173,"identity":"e0391eb7-c793-46b1-a006-2b29370ee403","order_by":0,"name":"Thomas Hermans","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYDACCTB5AMozsAESjI0HcCgGAx5ULQVpIC0NpGj5cBiFixXYSzcf3fDjzx0582mHnz38YXDebm37YaAtNTbROG2ROZZ2s7ftmbHM7TRzYx6D28nbziQCtRxLy23A6bAcsxu8DYcTZ0gnmEkzALWYHQBqYWw4jFfLzT9/DtfPkE7/JvnD4Fyy2fmHhLXc5mE7nCAhnWMmwWNwwM7sBiFbbqSl3ZZtO2w4QzqnTJrHIDnB7AbQlgQ8fmGfkXzs5ps/h+UlpNO3Sf74Y2dvdj794YMPNTY4tWCARLDKBGKVg4A9KYpHwSgYBaNgZAAAzh5lPT95yQEAAAAASUVORK5CYII=","orcid":"","institution":"Ziekenhuis Oost-Limburg","correspondingAuthor":true,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Hermans","suffix":""},{"id":323431174,"identity":"2a229642-8c00-483c-adda-5b4940df4a59","order_by":1,"name":"Giel Schevenels","email":"","orcid":"","institution":"Université libre de Bruxelles (ULB)","correspondingAuthor":false,"prefix":"","firstName":"Giel","middleName":"","lastName":"Schevenels","suffix":""},{"id":323431175,"identity":"6cb5ba5f-87ac-4bb7-8f3d-884b0dc0d9dc","order_by":2,"name":"Steve Motmans","email":"","orcid":"","institution":"Ziekenhuis Oost-Limburg","correspondingAuthor":false,"prefix":"","firstName":"Steve","middleName":"","lastName":"Motmans","suffix":""},{"id":323431176,"identity":"836179c7-99e1-4424-b093-ac6742295c84","order_by":3,"name":"Yannic Raskin","email":"","orcid":"","institution":"Ziekenhuis Oost-Limburg","correspondingAuthor":false,"prefix":"","firstName":"Yannic","middleName":"","lastName":"Raskin","suffix":""}],"badges":[],"createdAt":"2024-06-22 10:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4621377/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4621377/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-025-01763-1","type":"published","date":"2025-04-11T16:05:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60810718,"identity":"25314118-87ad-495f-a23e-df96e416805c","added_by":"auto","created_at":"2024-07-22 10:49:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2802954,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIn-surgery image of a manually sutured anastomosis.\u003c/strong\u003eBoth ends of the bowel are correctly positioned with the help of the third robotic arm. Suturing starts at the posterior wall with the positioning of both Stratafix PDS 3-0 sutures (A). The two semicircular running sutures ultimately rejoin each other at the anterior wall of the anastomosis and are then knotted to one another (B).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4621377/v1/3d173f6e9afd8a3e61ac5602.png"},{"id":60810717,"identity":"468fe9b4-d852-444f-a4f8-8e442345b85e","added_by":"auto","created_at":"2024-07-22 10:49:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":841752,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDemographic and descriptive data. A-E, \u003c/strong\u003ebar graphs of age in years (\u003cstrong\u003eA\u003c/strong\u003e), body mass index (BMI, \u003cstrong\u003eB\u003c/strong\u003e), American Society of Anesthesiologists (ASA) score (\u003cstrong\u003eC\u003c/strong\u003e), smoking pack years (\u003cstrong\u003eD\u003c/strong\u003e), and Charlson Comorbidity Index (CCI, \u003cstrong\u003eE\u003c/strong\u003e). For A, C-E: Data represent median ± interquartile range and \u003cem\u003ep\u003c/em\u003e-values were calculated using non-parametric two-sided Mann-Whitney U tests. For B, data represent mean ± standard deviation and the \u003cem\u003ep\u003c/em\u003e-value was calculated using a parametric two-sided Student’s t-test. \u003cstrong\u003eF-N, \u003c/strong\u003eStacked bar graphs showing proportion of patients per sex (\u003cstrong\u003eF\u003c/strong\u003e), with or without bladder cancer (\u003cstrong\u003eG\u003c/strong\u003e), ‘early’ cystectomy (\u003cstrong\u003eH\u003c/strong\u003e), muscle-invasive bladder cancer (MIBC) (\u003cstrong\u003eI\u003c/strong\u003e), prostate-invasive Cis (\u003cstrong\u003eJ\u003c/strong\u003e), previous abdominal surgery (\u003cstrong\u003eK\u003c/strong\u003e), diabetes mellitus type 2 (DM2, \u003cstrong\u003eL\u003c/strong\u003e), vascular disease (\u003cstrong\u003eM\u003c/strong\u003e), chronic kidney disease (CKD, \u003cstrong\u003eN\u003c/strong\u003e). \u003cem\u003ep-\u003c/em\u003eValues were calculated using Chi-square tests.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4621377/v1/957c932ea8d797d33b6bdd99.png"},{"id":60810719,"identity":"44ccdf74-7410-4a3a-bff9-b160e3e158cc","added_by":"auto","created_at":"2024-07-22 10:49:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":57014,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGastro-intestinal (GI) complications.\u003c/strong\u003eComparison of GI complication prevalence between sutured and stapled bowel anastomosis groups. Data represent proportion (%) of patients having the respective complication.\u003cem\u003e p-\u003c/em\u003evalues were calculated using Fisher’s exact tests. Both in-hospital and post-hospitalization data up to 3 months after discharge were included.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4621377/v1/f01b81432a0a861404260707.png"},{"id":60810715,"identity":"123783a6-7be5-4e56-a59f-14453055ef2b","added_by":"auto","created_at":"2024-07-22 10:49:53","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":111263,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSecondary outcome parameters.\u003c/strong\u003e \u003cstrong\u003eA-C, \u003c/strong\u003eBar graphs of stays in days (\u003cstrong\u003eA\u003c/strong\u003e), Maximal Clavien Dindo scores (\u003cstrong\u003eB\u003c/strong\u003e) and time before intake, flatus, defecation and drain ex (\u003cstrong\u003eC) \u003c/strong\u003efor sutured and stapled bowel anastomosis groups. Data represent median and interquartile range, and \u003cem\u003ep-\u003c/em\u003evalues were calculated using non-parametric two-sided Mann-Whitney U tests. ICU: intensive care unit.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4621377/v1/453720d4eb7afa89ad2dee89.png"},{"id":80558831,"identity":"b8fbb8d5-1ec6-489f-8b7d-64d3c43245e8","added_by":"auto","created_at":"2025-04-14 16:16:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7464245,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4621377/v1/5c68e3cd-6650-4fdb-b74a-06d81a4e13dd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Stapled vs Manually Sutured Bowel Anastomosis in Robot-Assisted Radical Cystectomy: a single-center retrospective analysis","fulltext":[{"header":"1. Introduction/Background","content":"\u003cp\u003eRadical cystectomy stands as the gold standard treatment for patients afflicted with muscle-invasive bladder cancer and select cases of high-risk non-muscle-invasive disease that are unresponsive to more conservative therapies. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe primary indications for radical cystectomy are multifaceted, encompassing muscle-invasive bladder cancer that extends beyond the mucosa, carcinoma in situ refractory to intravesical therapy, and recurrent high-grade non-muscle-invasive tumors that do not respond to conservative measures. It is also performed for a wide range of functional complaints such as therapy refractory bladder pain syndrome and radiocystitis. In cases where patients are deemed unfit for radical surgery or have personal preferences that align with bladder preservation, alternative therapies such as trimodal therapy may be considered. However, radical cystectomy remains the cornerstone for achieving optimal oncologic outcomes and long-term disease control.\u003c/p\u003e \u003cp\u003eThis surgical intervention involves the removal of the urinary bladder, surrounding lymph nodes (when performed for malignancies), and adjacent structures such as the distal ureters and sometimes the urethra, aiming to achieve both oncological efficacy and functional preservation. While traditional open surgery has been the historical approach, the advent of robotic-assisted cystectomy techniques (RARC) has revolutionized the landscape of radical cystectomies, offering enhanced precision and a minimally invasive alternative. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOver the years, several surgical techniques and urinary diversions have been developed. The most frequently used diversion is currently the ileal conduit, but there are several alternatives such as orthotopic neobladder construction, catheterisable pouches and ureterocutaneostomies. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFor the creation of most of these diversions, a part of the distal ileum is used. The creation of an effective bowel anastomosis is therefore a critical aspect of the surgical procedure, influencing both short-term recovery and long-term quality of life. Traditionally, the anastomosis between the ileum and the urinary conduit or neobladder has been executed using manual suturing, an intricate and time-consuming process. Since the 1960\u0026rsquo;s medical devices for the stapling of bowel tissue have been introduced as an alternative technique, offering potential advantages in terms of reduced operative times, decreased complications, and enhanced standardization (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). These staplers have slowly become the standard of care for bowel anastomosis.\u003c/p\u003e \u003cp\u003eDespite the potential advantages associated with stapled bowel anastomosis in RARC, it is crucial to acknowledge and critically evaluate the inherent drawbacks of these devices. With the dawn of minimally invasive cystectomies, in many centres the creation of the urinary diversion as well as the bowel anastomosis is now also performed intracorporeally. Laparoscopic, as well as robot-assisted staplers, are usually quite bulky and more difficult to manoeuvre and articulate than their counterparts in open surgery. This is mostly due to lack of space when working intra-abdominally. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFurthermore, the mechanical nature of stapling introduces a risk of compromised blood supply and tissue ischemia at the anastomotic site.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) This could contribute to an increased risk of anastomotic leaks or necrosis, a complication with severe consequences in the postoperative period. Using the \u003cem\u003eda Vinci\u003c/em\u003e Fluorescence Imaging Vision System (Firefly) to identify blood supply in the bowel mesenterium with Indocyanin Green (ICG), could help to selectively avoid cutting through these vessels. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAnother noteworthy concern pertains to the limited adaptability of staplers in managing variations in tissue thickness and quality. Unlike the tactile feedback available during manual suturing, stapling devices do not provide the same level of sensitivity to tissue characteristics. This limitation can be particularly relevant in cases where the bowel tissue is friable, fibrotic, or otherwise challenging to manipulate.\u003c/p\u003e \u003cp\u003eThe most notable disadvantage however, lies in the cost and resource implications associated with the utilization of surgical staplers. Stapling devices, though efficient, are expensive and contribute to increased overall procedural costs. This economic consideration becomes particularly pertinent in healthcare settings with constrained resources, raising questions about the cost-effectiveness of stapled bowel anastomosis compared to traditional manual suturing.\u003c/p\u003e \u003cp\u003eHaving experience with manually sutured bowel anastomoses in open surgery, the primary bladder surgeon in our centre uses both robotical stapling as well as manual suturing in RARC. Initially, the majority of patients underwent stapled anastomosis. However, over time, there was a gradual transition towards manual suturing, with the surgeon increasingly favoring this technique. Eventually, robotic stapling was reserved for specific indications (e.g. for very short ureters or a unique kidney, where a separate uretero-enteral anastomosis is easier), reflecting the surgeon's growing confidence and proficiency in manual suturing during RARC procedures.\u003c/p\u003e \u003cp\u003eWe conducted an extensive literature search and concluded that there is almost no recent evidence on this topic. Most studies comparing both techniques are more than 20 years old and only very few are from the era of minimally invasive surgery. (\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) Comparisons between robot-assisted staplers and robot-assisted manually suturing have been made, but there are almost no studies from the field of urology. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) We only found two studies comparing robot-assisted stapling with manual anastomosis in RARC: one retrospective study and one prospective feasibility study, showing no significant short-term disadvantages of using the manually suturing technique. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWe therefore decided to retrospectively compare our manually sutured with our stapled approaches, seeking to elucidate differences in terms of safety, efficacy, and postoperative outcomes. With this article, we aimed to get a better understanding of the benefits of both techniques.\u003c/p\u003e"},{"header":"2. Material and methods","content":"\u003cp\u003e2.1 Patients\u003c/p\u003e\n\u003cp\u003eWe carried out an extensive analysis of all patients that underwent RARC in our centre between March 2021 (start of RARC program) and November 2023. Patients that underwent an open (n=9) or partial cystectomy (n=17) were excluded, as well as patients that had to be converted to open during the procedure (n=1). Other exclusion criteria were if no bowel anastomosis was performed (eg. ureterocutaneostomy, n=0), if bowel anastomosis was performed extracorporeally (n=0) and emergency cystectomies (n=4). We finally also decided to exclude one patient in which the anastomosis was performed using a laparoscopic stapler (handled by a bedside assistant). We thus identified a total of 124 RARC patients, of whom 32 were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.2. Outcome parameters\u003c/p\u003e\n\u003cp\u003ePrimary outcome parameter was bowel-related complications (in-hospital and after discharge). Secondary outcome parameters were operation duration, length of hospital stay, intensive care unit (ICU) stay, readmissions, complications (all-type), time to intake, time to flatus, time to defecation and time to extraction of the drain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe predefined a limited follow-up of three months after discharge, not expecting relevant bowel-related complications after that period of time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll kinds of food ingestion, fluid or solid, exceeding mere water were accepted as \u0026lsquo;intake\u0026rsquo;. Flatulence was defined as audible bowel movements in combination with experienced expulsion of gas. Under defecation, all kinds of stool production were accepted. We defined (paralytic) ileus as abdominal distension with the presence of nausea or vomiting, requiring at least the cessation of oral intake. Mechanical ileus was a radiological diagnosis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.3 \u0026nbsp; \u0026nbsp;Surgical technique\u003c/p\u003e\n\u003cp\u003eAll RARC procedures were carried out by the same high-volume surgeon (\u0026gt;500 robotic cases) using a four-arm Da Vinci Xi surgical robot setup (Intuitive Surgery) and a 30\u0026deg; camera. Instruments used for dissection were a Maryland bipolar forceps, a ProGrasp forceps and curved scissors, for suturing and handling of bowel tissue a needle driver and either a normal fenestrated bipolar forceps or the Cadiere forceps as well as the ProGrasp were used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll procedures were performed completely intracorporeally and in a standardized manner, using a 15-20\u0026deg; Trendelenburg position and an abdominal insufflation pressure of 9-12 mmHg. Standard protocol included a single shot of Cefazolin (Clindamycin in case of allergy to Cephalosporin) at the beginning of the operation, which was repeated after 6 hours if the operation was still ongoing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProcedures started with adhesiolysis, distal ureterectomy, clipping and frozen section of the distal ureteric ends. The next step was cysto(prostate)ctomy, proceeding with a bilateral lymph node dissection (LND) if indicated, then isolation of the bowel segment, bowel anastomosis and creation of the urinary diversion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn case of ileal conduit: a 10cm bowel fragment was isolated, left ureter was tunneled and both ureters were implanted on the bowel segment using the Wallace plate technique (due to intraoperative factors, in 7 patients, ureters were implanted separately).\u0026nbsp;\u003cbr\u003e\u0026nbsp;Neobladders were created using the Wiklund technique (modified Studer) (19,20) and were closed with a Monocryl 3-0 running suture. Urethral anastomosis was performed with a 3-0 Stratafix suture.\u003cbr\u003e\u0026nbsp;In female patients, the specimen was extracted through the vagina, in males at the end of the procedure through an enlarged left trocar incision (muscle splitting). We did not standardly perform an appendectomy.\u003c/p\u003e\n\u003cp\u003eStapled bowel anastomosis was performed with a robotic stapler (da Vinci Xi SureForm 60 \u0026ndash; Intuitive Surgery) using 2 cartridges for the bowel isolation and 2 cartridges for the bowel anastomosis, thus using in total 4 cartridges per patient. In the case of a manually sutured anastomosis, bowel and mesenterium were cut robotically using cold scissors, after identifying mesenterical blood supply using ICG. As displayed in Figure 1, a one-layer bowel anastomosis was then performed end-to-end using 2 semicircular running Stratafix 3-0 15cm PDS sutures. An additional \u0026lsquo;goodnight-stitch\u0026rsquo; using a Vicryl 3-0 suture was used in case of stapled anastomosis, but not in case of manually sutured anastomosis. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.4 \u0026nbsp; \u0026nbsp;Data extraction\u003c/p\u003e\n\u003cp\u003eAll relevant data was extracted from hospital records using our electronic medical record program HiX (Chipsoft) and was added into an anonymized database. No blinding was performed.\u003c/p\u003e\n\u003cp\u003e2.5 \u0026nbsp; \u0026nbsp;Statistic\u003c/p\u003e\n\u003cp\u003eData analysis and visualization were performed using Graphpad Prism v.9 software. For contingency analyses, \u003cem\u003ep-\u003c/em\u003evalues were calculated using Chi-square tests (Table 1, 2 and Fig. 1) or Fisher\u0026rsquo;s exact tests (Table 3, 4 and Fig. 2). For numerical between-group comparisons, data represent median \u0026plusmn; interquartile range and \u003cem\u003ep\u003c/em\u003e-values were calculated using non-parametric two-sided Mann-Whitney U tests. Data for BMI were represented as mean \u0026plusmn; standard deviation and the \u003cem\u003ep-\u003c/em\u003evalue was calculated using a parametric two-sided Student\u0026rsquo;s t-test. For outcome parameters, both in- and post-hospitalization data were used.\u003c/p\u003e\n\u003cp\u003e2.6 \u0026nbsp; \u0026nbsp;Funding\u003c/p\u003e\n\u003cp\u003eNo external funding was received for this study.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e3.1 Demographic results\u003c/p\u003e\n\u003cp\u003eIn total, ninety-two patients were included in the study. 59 patients received a manually sutured bowel anastomosis, the other 33 patients were stapled robotically.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe did an extensive analysis of potential confounding factors, to make sure both groups were comparable, see Table 1. There were no statistical differences between both groups concerning age, sex, clinical and pathological TNM stages, neo-adjuvant chemotherapy, smoking history as defined in pack years, previous abdominal surgery (including both laparoscopic and open surgery), Charlson comorbidity index (CCI), diabetes mellitus type 2 (DM2), vascular disease (both peripheric and coronary) and chronic kidney disease (CKD). A graphic display of aforementioned parameters can be found in Figure 2. There was a small but statistically significant difference in body mass index (BMI) and American Society of Anesthesiologists (ASA) score. Patients in the stapled anastomosis group tended to have a higher BMI (p=0.0285) and a lower ASA score (p=0.0297).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were also no statistical differences in main surgical indications between both groups: bladder cancer (BC; 85 patients, 92.4%), invasive prostate cancer (2 patients, 2.2%) or functional complaints (8 patients, 8.7%). Some patients had multiple indications. In total, 30% of patients received an early cystectomy, 58% were for muscle-invasive bladder cancer.\u003c/p\u003e\n\u003cp\u003eAfter an extensive analysis of the demographic and comorbidity data, we concluded both groups to be remarkably comparable and decided against a constriction of our patient numbers by creating a propensity score matching cohort. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Demographic and descriptive data\u003c/strong\u003e. Comparison between sutured and stapled bowel anastomosis patient groups. Binary data are listed as number of patients (\u003cem\u003en\u003c/em\u003e) and proportion of patients (%), and \u003cem\u003ep-\u003c/em\u003evalues were calculated using Chi-square tests. Numerical data are listed as median and interquartile range, and \u003cem\u003ep-\u003c/em\u003evalues were calculated using non-parametric two-sided Mann-Whitney U tests. For BMI, data represent mean \u0026plusmn; standard deviation and the \u003cem\u003ep\u003c/em\u003e-value was calculated using a parametric two-sided Student\u0026rsquo;s t-test. Pathological T-stage as mentioned in the TUR bladder histopathological report, clinical TNM-stage as assessed by the primary surgeon based upon preoperative imaging. MIBC: muscle invasive bladder cancer, BMI: body mass index, SD: standard deviation, ASA: american society of anesthesiology, CCI: Charlson comorbidity score, DM2: diabetes mellitus type 2, CKD: chronic kidney disease, G: grade.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSutured\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStapled\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e92 (100.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e59 (64.13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e33 (35.87)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eAge, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e71 (65.25-77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e71 (65-76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e70 (65-77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.8126\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eSex, \u003cem\u003en\u003c/em\u003e males (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e74 (80.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e48 (81.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e26 (78.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.7659\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eBladder cancer, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e85 (92.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e56 (94.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e29 (87.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.2221\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Early, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e28 (30.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e21 (35.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e7 (21.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.1505\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;MIBC, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e53 (57.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e33 (55.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e20 (60.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.6635\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Prostate invasive Cis, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e4 (4.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.5469\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003epT, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026le;pTis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e44 (47.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e29 (49.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e15 (45.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.7334\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026gt;pTis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e48 (52.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e30 (50.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e18 (54.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003ecT, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026le;cT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e74 (80.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e51 (86.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e23 (69.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.0522\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026gt;cT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e18 (19.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e8 (13.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e10 (30.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003ecN, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e81 (88.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e54 (91.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e27 (81.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.1687\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Yes (\u0026ge;N1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e11 (11.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e5 (8.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e6 (18.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003ecM, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e89 (96.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e57 (96.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e32 (96.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.9258\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Yes (\u0026ge;M1a)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (3.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eNeo-adjuvant chemotherapy, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e31 (33.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e19 (32.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e12 (36.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.6855\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eBMI, mean (\u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e26.73 (\u0026plusmn; 4.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e25.97 (\u0026plusmn; 4.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e28.09 (\u0026plusmn; 4.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.0285\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eASA, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (2-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (2-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e2 (2-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.0297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003ePack years, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e15 (0-40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e15 (0-35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e11 (0-54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.6974\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious abdominal surgery, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e48 (52.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e30 (50.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e18 (54.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.7334\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eCCI (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e5 (4-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e5 (4-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e5 (4-7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.8978\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eDM2, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e18 (19.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e10 (16.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e8 (24.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.3977\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eVascular disease, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e27 (29.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e20 (33.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e7 (21.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.2000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003eCKD, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026le;G2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e69 (75.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e43 (72.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e26 (78.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.5303\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.41721854304636%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;G2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e23 (25.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e16 (27.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e7 (21.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.2 Procedural data\u003c/p\u003e\n\u003cp\u003eWe performed an analysis of all procedures, again, to exclude any significant differences between both groups; see table 2. In total, 83 out of the 92 cystectomy patients received an ileal conduit as diversion, whereas 9 out of 92 cystectomy patients received a neobladder as diversion. An equal proportion of both procedure types were performed with either a stapled or a sutured bowel anastomosis. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was a slightly larger proportion of the stapled group (6 patients, 19% vs 1 patient, 2%, p=0.0036) undergoing a separate implantation of the ureters on the bowel segment. This could be explained by the fact that in a stapled anastomosis the proximal end of the bowel segment is already stapled shut, making a separate uretero-enteral anastomosis here easier to perform than a Wallace plate. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe performed several additional robot-assisted procedures during the same session as the cystectomy, e.g. two nephro-ureterectomies and a partial nephrectomy (all in the stapled group), 10 female anterior pelvic exenterations (6 in the sutured and 4 in the stapled group), two perineal urethrectomies (one in each group), one proximal urethrectomy (sutured group), one adrenalectomy (sutured group), one unilateral and one bilateral inguinal hernia correction (one in each group) and two ileocaecal resections (one in each group).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were slightly more patients undergoing a pelvic LND in the sutured group than in the stapled group. In total, LND was performed in 90.13% of patients.\u003c/p\u003e\n\u003cp\u003eConcerning nerve sparing, blood loss and additional procedures, no statistical differences between both groups were seen. Nerve sparing was always done bilaterally, except in 1 case.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Procedural data.\u003c/strong\u003e Comparison between sutured and stapled bowel anastomosis patient groups. Binary data are listed as number of patients (\u003cem\u003en\u003c/em\u003e) and proportion of patients (%), and \u003cem\u003ep-\u003c/em\u003evalues were calculated using Chi-square tests. Numerical data are listed as median and interquartile range, and the \u003cem\u003ep-\u003c/em\u003evalue was calculated using a non-parametric two-sided Mann-Whitney U test. We defined LND patterns to conform to the 2023 EAU MIBC guideline definitions (section 7.3.4) (2). LND: lymph node dissection.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSutured\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStapled\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eOperation type, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eBricker\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e83 (90.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e53 (89.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e30 (90.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.8674\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eNeobladder\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e9 (9.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e6 (10.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (9.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eLND, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e10 (10.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e7 (21.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.0171\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Limited\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e16 (17.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e11 (18.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e5 (15.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.6716\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Normal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e4 (4.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e4 (12.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.0063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Extended\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e60 (65.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e44 (74.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e16 (48.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.0117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Superextended\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e2 (2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.6736\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eNerve sparing, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e34 (36.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e21 (35.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e13 (40.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.6357\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eUreter anastomosis, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eWallace plate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e84 (92.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e58 (98.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e26 (81.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.0036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eSeparate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e7 (7.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e6 (18.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eBlood loss, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e250 (150-350)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e250 (150-350)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e225 (150-475)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.6072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.78145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eAdditional operation, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e25 (27.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e15 (25.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e10 (31.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e0.5522\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e3.3 Primary outcome parameters\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Primary outcome parameters.\u003c/strong\u003e Comparison between sutured and stapled bowel anastomosis patients. Binary data are listed as number of patients (\u003cem\u003en\u003c/em\u003e) and proportion of patients (%). \u003cem\u003ep-\u003c/em\u003evalues were calculated using Fisher\u0026rsquo;s exact tests. Numerical data are listed as median and interquartile range, and the \u003cem\u003ep-\u003c/em\u003evalue was calculated using a non-parametric two-sided Mann-Whitney U test. Both in-hospital and post-hospitalization data up to 3 months after discharge were included. GI: gastro-intestinal, GT: gastric tube. TPN: Total parenteral nutrition.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSutured\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStapled\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eGI complications, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e23 (25.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e16 (27.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e7 (21.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.6206\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eComplication type, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003ePeritonitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eMechanic ileus\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e5 (5.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eParalytic ileus\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e16 (17.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e11 (18.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e5 (15.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.7793\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eDehiscence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eTotal blowout\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eBleeding at anastomosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eGI treatments, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e22 (23.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e15 (25.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e7 (21.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.8001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eGI treatment type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eGastric tube, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e15 (16.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e9 (15.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e6 (18.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.7724\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eGT reinsertion duration in days, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e3 (1-4.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (1.25-4.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (0-6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.7862\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eMedication, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e12 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e9 (15.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (9.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.5268\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eExplorative laparotomy, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.9271523178808%\" valign=\"top\"\u003e\n \u003cp\u003eTPN, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e3 (3.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.927152317880795%\" valign=\"top\"\u003e\n \u003cp\u003e0.5504\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAs projected in Table 3 and Figure 3, gastrointestinal (GI) complications were seen in 25% of patients. Most of those had a paralytic ileus (17% of patients), usually treated conservatively or by (re-)insertion of a gastric tube, on average for about 3 days. 5 patients were radiologically diagnosed with a mechanical ileus, for which only 1 explorative laparotomy had to be performed. This particular instance involved a patient with a manually sutured bowel anastomosis, who, following a standard postoperative recovery and discharge on day 5, returned on day 8 with a blowout of the bowel anastomosis. Subsequent interventions were necessitated, including an open reconstruction of the bowel anastomosis, which unfortunately resulted in a second bowel dehiscence. Notably, this case occurred early in the adoption of sutured bowel anastomosis procedures and was an isolated occurrence, suggesting a potential learning curve challenge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll four other cases of mechanical ileus were managed conservatively.\u003c/p\u003e\n\u003cp\u003eWe found no statistically significant differences between both surgical techniques in any of the mentioned GI complications or their treatments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.4 Secondary outcome parameters\u003c/p\u003e\n\u003cp\u003eSecondary outcome parameters are listed in Table 4 and graphically presented in Figure 4.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOperation duration was 300 min per procedure on average. Although not statistically significant (p=0.12), stapled procedures were about 13 minutes longer than sutured procedures. This shows that manually suturing the bowel back together does not necessarily prolong the procedure and can even shorten it, when performed by experienced hands.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLength of stay was, as could be expected, similar for both techniques (p=0.38). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were more readmissions in the sutured anastomosis group (p=0.02), of whom most were caused by non-GI complications such as leakage of the ileo-ureteric anastomosis (3 out of 17 cases) and infectious complications (11 out of 17 cases). Remarkably, 3 patients presented with an urosepsis due to an obstructive urolithiasis (all in the sutured group). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost complications were Clavien Dindo grade \u0026le;2 (55%). Most grade 3 complications were due to dislocation of either the catheter or one of the ureteric stents - or due to paralytic ileus necessitating the reinsertion of a gastric tube.\u003c/p\u003e\n\u003cp\u003eThe one patient with a grade 4b complication was hospitalized in the ICU because of a urosepsis with multi-organ failure due to an obstructive urolithiasis (sutured group). The one patient with a grade 4a complication had a cerebrovascular accident (CVA) at home and died afterwards (sutured group).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe reported a 3-month mortality of 3.26% (3 cases). None of the deaths were due to a GI complication and all occurred outside of the hospital. 1 Patient (stapled group) died of respiratory septic shock with an underlying COPD stage Gold 4 and another (stapled group) of dyspnea, no invasive measures were undertaken because of rapidly progressive liver metastasis and pleural metastasis respectively. The reason for the death of the third patient (sutured group) is not documented, but occurred after a CVA at home as mentioned before. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere were no statistically significant differences in time to intake, time to extraction of the drainage, time to flatus or time to defecation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e \u003cstrong\u003eSecondary outcome parameters.\u003c/strong\u003e Comparison of secondary outcome parameters between sutured and stapled bowel anastomosis groups. Binary data are listed as number of patients (\u003cem\u003en\u003c/em\u003e) \u0026nbsp;and proportion of patients (%). \u003cem\u003ep-\u003c/em\u003evalues were calculated using Fisher\u0026rsquo;s exact tests. Numerical data are listed as median and interquartile range, and \u003cem\u003ep-\u003c/em\u003evalues were calculated using non-parametric two-sided Mann-Whitney U tests. ICU: intensive care unit.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSutured\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStapled\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eOperation duration in min, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e300 (240-330)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e300 (240-315)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e313 (247.5-373.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.1243\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eLength of stay in days, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e8 (6-10.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e7 (6-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e8 (5.5-13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.3842\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eICU stay in days, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.0508\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eReadmission, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e17 (18.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e15 (25.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.0254\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eReadmission stay in days, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e7 (2.5-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e7 (2-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e7.5 (7-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.6544\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eMaximum Clavien Dindo grade, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0-3a)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0-3a)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.2172\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eClavien Dindo grade, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e29 (31.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e17 (28.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e12 (36.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.4892\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e8 (8.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e4 (6.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e4 (12.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.4510\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003e2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e27 (29.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e17 (28.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e10 (30.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003e3a\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e19 (20.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e15 (25.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e4 (12.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.1812\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003e3b\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e4 (4.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003e4a\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003e4b\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;0.9999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003e5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e3 (3.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e2 (6.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.2915\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eTime to intake in days, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.5064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eTime to flatus in days, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e3 (2-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e3 (2-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e3 (2-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.5496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eTime to defecation in days, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e5 (4-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e5 (4-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e5 (4-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.8978\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.14876033057851%\" valign=\"top\"\u003e\n \u003cp\u003eTime to drain ex in days, median (interquartile range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.049586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e4.5 (3-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.702479338842975%\" valign=\"top\"\u003e\n \u003cp\u003e4 (3-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1900826446281%\" valign=\"top\"\u003e\n \u003cp\u003e5 (3.25-7.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.909090909090908%\" valign=\"top\"\u003e\n \u003cp\u003e0.3496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e4.1 Background\u003c/p\u003e\n\u003cp\u003eThe increasing use of robotics in urological surgery poses challenges of cost-effectiveness for urologists worldwide. As mentioned by the international robotic cystectomy consortium, the use of intracorporeal urinary diversion in RARC has increased and using this technique could reduce GI complications (19). The sutured ileo-ileal anastomosis technique is well-known in GI surgery and is considered safe. (11-17). There are only a few studies reporting on robotically sutured ileo-ileal anastomosis within the urological field.\u0026nbsp;\u003cbr\u003e\u0026nbsp;Loertzer et al. were first to describe a series of 48 patients in whom this technique was used and found it feasible with a low complication ratio. In 2020, Aljabery et al. compared a robot-sewn ileo-ileal anastomosis with its stapled variant in 155 patients in a single-centre retrospective analysis. They found no significant difference in operative time, median hospital stay and complication ratio.\u003c/p\u003e\n\u003cp\u003e4.2 Results\u003c/p\u003e\n\u003cp\u003eWe performed a retrospective analysis of all RARC procedures in our center since the start of the robotic cystectomy program in 2021, including 92 patients, of which 59 received a robotically sutured anastomosis and 33 received a robotically stapled anastomosis. Both groups were remarkably similar in demographic and procedural data. Demographic, procedural and outcome data were consistent with data found in literature (20,21).\u0026nbsp;\u003cbr\u003e\u0026nbsp;We found no significant differences between both groups in GI-specific postoperative courses, no increase in GI complication rate and no increase in overall complication rate when changing from a standard stapled anastomosis to a robotically sutured anastomosis. We even saw a reduction in operation duration of about 13 minutes.\u0026nbsp;\u003cbr\u003e\u0026nbsp;As was the case in Aljabery\u0026rsquo;s study, there was a higher readmission rate in the sutured anastomosis group, but this could not be allocated to GI-related complications. We reported a 3.26% mortality rate at 3 months after discharge, which is consistent with data found in literature (20,21).\u0026nbsp;\u003cbr\u003e\u0026nbsp;We suggest a prospective randomized controlled trial with larger sample sizes to validate these findings and guide surgical decision-making.\u003c/p\u003e\n\u003cp\u003e4.3 Cost analysis\u003c/p\u003e\n\u003cp\u003eRobot-assisted staplers used in our department (da Vinci Sureform 60) cost \u0026euro;252\u0026nbsp;per cartridge. The stapler (including seal and trocar reducer) costs about \u0026euro;492\u0026nbsp;per procedure. Using 4 cartridges per bowel anastomosis (some surgeons use 3), total cost in our centre amounts to \u0026euro;1500-2000 per procedure, which is comparable to European averages. (9) When comparing this to a total material cost of \u0026euro;12000-16500 per procedure, this represents a significant part of the costs. By comparison, a manually sutured bowel anastomosis in our centre, using only 2 barbed V-Loc sutures, costs about \u0026euro;54, a factor 30 cheaper than using a robotic stapler. (10)\u0026nbsp;\u003cbr\u003e\u0026nbsp;This substantial cost difference between using robotic staplers and manually suturing bowel anastomosis makes a compelling argument for favoring robotic suturing techniques.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn conclusion, our study confirms that robotically sutured ileo-ileal anastomosis in robot-assisted radical cystectomy yields comparable outcomes to stapled techniques, with no significant increase in GI complications or in operation duration. Moreover, the cost analysis reveals a substantial financial advantage in favor of manual suturing, highlighting the importance of considering cost-effectiveness in surgical decision-making.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASA American society of anesthesiologists\u003c/p\u003e\n\u003cp\u003eBMI body mass index\u003c/p\u003e\n\u003cp\u003eCCI charlson comorbidity score\u003c/p\u003e\n\u003cp\u003eCKD chronic kidney disease\u003c/p\u003e\n\u003cp\u003eCOPD chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003eCVA cerebrovascular accident\u003c/p\u003e\n\u003cp\u003eDM2 diabetes mellitus type II\u003c/p\u003e\n\u003cp\u003eGI gastro-intestinal\u003c/p\u003e\n\u003cp\u003eGT gastric tube\u003c/p\u003e\n\u003cp\u003eICG indocyanin green\u003c/p\u003e\n\u003cp\u003eICU intensive care unit\u003c/p\u003e\n\u003cp\u003eLND lymph node dissection\u003c/p\u003e\n\u003cp\u003eMIBC muscle invasive bladder cancer\u003c/p\u003e\n\u003cp\u003eRARC robot-assisted radical cystectomy \u003c/p\u003e\n\u003cp\u003eTPN total parenteral nutrition\u003c/p\u003e\n\n\n"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003cbr\u003e\u0026nbsp;This study was approved by the ethical committee of Ziekenhuis Oost-Limburg (ID Number Z2024049). As this was a retrospective, non-interventional study, the need for consent to participate was waived by the ethical committee.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003cbr\u003e\u0026nbsp;The datasets generated and analysed during the current study are not publicly available due to privacy concerns but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003cbr\u003e\u0026nbsp;The authors declare that they have no relevant competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003cbr\u003e\u0026nbsp;No funding was received for this study. Publication charges and open access fees were paid via the urology department\u0026rsquo;s third party funds account, which in turn is privately sponsored by patients and benefactors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003cbr\u003e\u0026nbsp;The study was conceptualized and the study protocol was written by TH and YR. TH and SM gathered all retrospective data into an extensive database. GS performed all statistical analyses and created relevant figures and tables. The manuscript was written by TH and was then read and corrected by all authors (GS, SM and YR). All authors (TH, GS, SM and YR) approved of the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003cbr\u003e\u0026nbsp;Not applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGontero P, Comp\u0026eacute;rat E, Dominguez JL, Liedberg F, Mariappan P, Masson-Lecomte A, et al. Non-muscle-invasive Bladder Cancer (TaT1 and CIS) EAU Guidelines on. 2023;\u003c/li\u003e\n\u003cli\u003eUpdated 2023 EAU guidelines on muscle-invasive and metastatic bladder cancer. Edn. presented at the EAU Annual Congress Milan 2023. ISBN 978-94-92671-19-6.\u003c/li\u003e\n\u003cli\u003eMenon M, Hemal AK, Tewari A, Shrivastava A, Shoma AM, El-Tabey NA, et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int [Internet]. 2003 Aug [cited 2024 Jan 6];92(3):232\u0026ndash;6. Available from: https://pubmed.ncbi.nlm.nih.gov/12887473/\u003c/li\u003e\n\u003cli\u003eChesnut GT, Rentea RM, Leslie SW. Urinary Diversions and Neobladders. StatPearls [Internet]. 2023 Jul 25 [cited 2024 Jan 6]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK560483/\u003c/li\u003e\n\u003cli\u003eGaidry AD, Tremblay L, Nakayama D, Ignacio RC. The history of surgical staplers: A combination of Hungarian, Russian, and American innovation. Vol. 85, American Surgeon. 2019.\u003c/li\u003e\n\u003cli\u003eTeo NZ, Chi J, Ngu Y. A Comparison between the da Vinci Xi Endowrist Stapler and a conventional Laparoscopic Stapler in Rectal Transection: A Randomized Controlled Trial. 2022 [cited 2024 Jan 6]; Available from: https://doi.org/10.21203/rs.3.rs-2071813/v1\u003c/li\u003e\n\u003cli\u003eChekan E, Whelan RL. Surgical stapling device-tissue interactions: what surgeons need to know to improve patient outcomes. Medical Devices: Evidence and Research [Internet]. 2014 [cited 2024 Jan 6];7:305\u0026ndash;18. Available from: http://dx.doi.org/10.2147/MDER.S67338\u003c/li\u003e\n\u003cli\u003eLicari LC, Bologna E, Proietti F, Flammia RS, Bove AM, D\u0026rsquo;annunzio S, et al. Exploring the Applications of Indocyanine Green in Robot-Assisted Urological Surgery: A Comprehensive Review of Fluorescence-Guided Techniques. Sensors. 2023 Jun 11;23(12):5497.\u003c/li\u003e\n\u003cli\u003eMjaess G, Diamand R, Aoun F, Assenmacher G, Assenmacher C, Verhoest G, et al. Cost-analysis of robot-assisted radical cystectomy in Europe: A cross-country comparison. 2022 [cited 2024 Jan 6]; Available from: https://doi.org/10.1016/j.ejso.2022.07.023\u003c/li\u003e\n\u003cli\u003eLoertzer P, Siemer S, St\u0026ouml;ckle M, Ohlmann CH. Robot-sewn ileoileal anastomosis during robot-assisted cystectomy. World J Urol [Internet]. 2018 Jul 1 [cited 2024 Jan 6];36(7):1079\u0026ndash;84. Available from: https://pubmed.ncbi.nlm.nih.gov/29500511/\u003c/li\u003e\n\u003cli\u003eKorolija D. The current evidence on stapled versus hand‐sewn anastomoses in the digestive tract. Minimally Invasive Therapy \u0026amp; Allied Technologies [Internet]. 2008 [cited 2024 Jan 6];17(3):151\u0026ndash;4. Available from: https://www.tandfonline.com/doi/abs/10.1080/13645700802103423\u003c/li\u003e\n\u003cli\u003eCajozzo M, Compagno G, DiTora P, Spallitta SI, Bazan P. Advantages and disadvantages of mechanical vs. manual anastomosis in colorectal surgery. A prospective study. Acta Chir Scand. 1990 Feb;156(2):167\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eCatena F, La Donna M, Gagliardi S, Avanzolini A, Taffurelli M. Stapled versus hand-sewn anastomoses in emergency intestinal surgery: results of a prospective randomized study. Surg Today [Internet]. 2004 [cited 2024 Jan 6];34(2):123\u0026ndash;6. Available from: https://pubmed.ncbi.nlm.nih.gov/14745611/\u003c/li\u003e\n\u003cli\u003eGonzalez EM, Selas PR, Molina DM, Sanz RG, Martinez RR, Gonzalez JS, et al. Results of surgery for cancer of the rectum with sphincter conservation. A randomized study on instrumental versus manual anastomosis. Acta Oncol [Internet]. 1989 [cited 2024 Jan 6];28(2):241\u0026ndash;4. Available from: https://pubmed.ncbi.nlm.nih.gov/2736113/\u003c/li\u003e\n\u003cli\u003eCastro PM arcela V, Ribeiro FP iccarone G, Rocha A de F, Mazzurana M, Alvarez GA ntunes. Hand-sewn versus stapler esophagogastric anastomosis after esophageal ressection: systematic review and meta-analysis. Arq Bras Cir Dig [Internet]. 2014 Jul 1 [cited 2024 Jan 6];27(3):216\u0026ndash;21. Available from: https://pubmed.ncbi.nlm.nih.gov/25184776/\u003c/li\u003e\n\u003cli\u003eGuadagni S, Palmeri M, Bianchini M, Gianardi D, Furbetta N, Minichilli F, et al. Ileo-colic intra-corporeal anastomosis during robotic right colectomy: a systematic literature review and meta-analysis of different techniques. Int J Colorectal Dis [Internet]. 2021 Jun 1 [cited 2024 Jan 6];36(6):1097\u0026ndash;110. Available from: https://pubmed.ncbi.nlm.nih.gov/33486533/\u003c/li\u003e\n\u003cli\u003eHur H, Kim JY, Cho YK, Han SU. Technical Feasibility of Robot-Sewn Anastomosis in Robotic Surgery for Gastric Cancer. https://home.liebertpub.com/lap [Internet]. 2010 Oct 12 [cited 2024 Jan 6];20(8):693\u0026ndash;7. Available from: https://www.liebertpub.com/doi/10.1089/lap.2010.0246\u003c/li\u003e\n\u003cli\u003eAljabery F, Jancke G, Skoglund P, Hallbook O. Stapled versus robot-sewn ileo-ileal anastomosis during robot-assisted radical cystectomy: a review of outcomes in urinary bladder cancer patients. Scand J Urol [Internet]. 2021 [cited 2024 Jan 6];55(1):41\u0026ndash;5. Available from: https://pubmed.ncbi.nlm.nih.gov/33169655/\u003c/li\u003e\n\u003cli\u003eHussein AA, May PR, Jing Z, Weiburg CJ, Canda AE, Dasgupta P, Khan MS, Menon M, Peabody JO, Hosseini A, Kelly J, Mottrie A, Kaouk J, Hemal A, Wiklund P, Guru KA. Outcomes of intracorporeal urinary diversion after robot-assisted radical cystectomy: results from the international robotic cystectomy consortium. J Urol 2018;199(5):1302-1311.May\u003cbr\u003e PMID: PMID: 29275112\u003c/li\u003e\n\u003cli\u003eTyritzis SI, Hosseini A, Collins J, Nyberg T, Jonsson MN, Laurin O, Khazaeli D, Adding C, Schumacher M, Wiklund NP. Oncologic, functional, and complications outcomes of robot-assisted radical cystectomy with totally intracorporeal neobladder diversion. Eur Urol. 2013 Nov;64(5):734-41. doi: 10.1016/j.eururo.2013.05.050. Epub 2013 Jun 6. PMID: 23768634.\u003c/li\u003e\n\u003cli\u003eClement KD, Pearce E, Gabr AH, Rai BP, Al-Ansari A, Aboumarzouk OM. Perioperative outcomes and safety of robotic vs open cystectomy: a systematic review and meta-analysis of 12,640 cases. World J Urol. 2021 Jun;39(6):1733-1746. doi: 10.1007/s00345-020-03385-8. Epub 2020 Jul 30. PMID: 32734460.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bowel anastomosis, robot-assisted radical cystectomy, stapled, sutured, muscle-invasive bladder cancer, cost","lastPublishedDoi":"10.21203/rs.3.rs-4621377/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4621377/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eRadical cystectomy is the primary treatment for muscle-invasive bladder cancer and certain cases of high-risk non-muscle-invasive disease. Robot-assisted cystectomy techniques (RARC) have emerged as a minimally invasive alternative to traditional open surgery, offering enhanced precision. The creation of an effective bowel anastomosis is critical in these procedures, with manually sutured anastomosis being a good and significantly cheaper alternative to the standard stapled anastomosis.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective study of 92 patients who underwent RARC between March 2021 and November 2023. Bowel anastomosis was performed using either stapled or manually sutured techniques. Outcome parameters included bowel-related complications, operation duration, length of hospital stay, intensive care unit (ICU) stay, readmissions, and postoperative recovery metrics.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eOf the patients, 59 received manually sutured bowel anastomosis, while 33 received stapled anastomosis. Demographic analysis showed no significant differences between the groups. Gastrointestinal (GI) complications occurred in 25% of patients, predominantly paralytic ileus. There were no statistically significant differences in complication rates between the two techniques. Readmissions were higher in the sutured group, mainly due to non-GI complications. Operation duration and length of stay were similar in both groups.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThis study found comparable outcomes between stapled and manually sutured bowel anastomosis in RARC, with no significant increase in GI complications or in operation duration in manually sutured anastomosis. Considering the substantial financial advantage in favor of manual suturing, this technique could become the new standard.\u003c/p\u003e","manuscriptTitle":"Stapled vs Manually Sutured Bowel Anastomosis in Robot-Assisted Radical Cystectomy: a single-center retrospective analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-22 10:49:48","doi":"10.21203/rs.3.rs-4621377/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-16T03:28:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-06T05:27:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133931603127864552109614437939053836343","date":"2024-12-05T01:43:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-15T11:14:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180226733032686195356871472601382810625","date":"2024-10-13T09:52:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-13T06:20:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-16T17:50:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-28T08:50:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-28T08:50:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-06-22T09:59:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9cd3dee7-3e11-4c48-85e8-8e0a7548653c","owner":[],"postedDate":"July 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-14T16:12:13+00:00","versionOfRecord":{"articleIdentity":"rs-4621377","link":"https://doi.org/10.1186/s12894-025-01763-1","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2025-04-11 16:05:08","publishedOnDateReadable":"April 11th, 2025"},"versionCreatedAt":"2024-07-22 10:49:48","video":"","vorDoi":"10.1186/s12894-025-01763-1","vorDoiUrl":"https://doi.org/10.1186/s12894-025-01763-1","workflowStages":[]},"version":"v1","identity":"rs-4621377","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4621377","identity":"rs-4621377","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}