Robot-assisted laparoscopic continent cutaneous urinary diversion in a single- center study; surgical technique and outcomes

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Materials & Methods: We conducted a retrospective study of all adults who underwent RALCCUD between 2017 and 2022 at a single tertiary reference center. Participant characteristics, clinical information and perioperative outcomes were recorded. All participants underwent pre and postoperative urodynamic evaluations. Functional outcomes were evaluated at 3 months, then yearly. Continence was defined as no stomal or urethral leakage. Results: Twelve patients, mostly women (n=11), median (IQR) age 47.4 (19-57) years underwent RALCCUD (4 Mitrofanoff, 4 Yang-Monti and 4 Casale). The main indication for surgery was inability to perform intermittent self-catheterization through the native urethra. Eleven patients (92%) had neurogenic lower urinary tract disease caused by spinal cord injury or spinal dysraphism. Median (IQR) operative time was 313 (285-367) min. Four patients (33%) underwent concomitant procedures: 3 supra-trigonal cystectomy with augmentation cystoplasty and 1 artificial urinary sphincter. No conversions to an open approach were required. Median (IQR) follow-up was 42.9 (34-53) months. One early postoperative complication occurred (Clavien grade III). The late postoperative complication rate was 17%, with 3 complications occurring in 2 patients. At the last follow up, all patients could self-catheterize through the tube, and the stomal and urethral continence rate was 100%. Conclusion: RALCCUD is feasible and safe in adults, with a high rate of stomal and urethral continence and a low complication rate. Continent Urinary diversion Robotic surgery Mitrofanoff procedure Laparoscopy Neurogenic bladder Introduction Guidelines for the treatment of people with neurogenic low urinary tract dyfunction (NLUTD) include the management of neurogenic detrusor overactivity (NDO) combined with intermittent self-catheterization (ISC) 1 . This treatment strategy aims to protect the upper urinary tract and maintain urinary continence by ensuring a low-pressure bladder reservoir 1–3 . However, some people who require ISC are unable to perform it through the native urethra because of upper-limb disability, difficulty reaching or finding the urethra, or urethral destruction. Cutaneous continent urinary diversion (CCUD) (Mitrofanoff 4 , Yang-Monti 5 or Casale 6 procedures) can be offered to such individuals to allow ISC. Several case-series studies have reported good long-term results from this technique in children 7 and adults 8 . Robot assisted laparoscopic cutaneous continent urinary diversion (RALCCUD) was developed in the 2000s 9 and provides the advantage of shorter length of hospital stay compared to the open approach 10 . Several studies with long-term follow-ups have demonstrated the feasibility and efficacy of(RALCCUD) in children 11,12 , but only a few small case-series have been published in adults 13,14 . The aim of the current study was to report the perioperative outcome and preliminary functional results using the RALCCUD technique in terms of continence, catheterization and repeat surgery. If concomitant AC was performed, a supra-trigonal cystectomy (SC) was performed with preservation of the posterolateral bladder-wall flap in which the efferent tube could be implanted according to the politano-leadbetter principle, as previously published, using an open approach 18,19 . Then the AC was sutured to the remaining bladder using 3/0 V-Lock running sutures. The watertightness was checked by filling the bladder with 180 mL saline solution. Stoma The stoma was always placed at the umbilical level. Before the anastomosis between the channel and the skin was performed, the bladder was sutured to the anterior abdominal wall with interrupted 2/0 sutures to avoid kinking of the channel and to minimize the extravesical portion as described for the open technique 20 . The distal efferent tube was sutured to the skin with a V-shaped skin flap using interrupted 4/0 polydioxanone sutures. A 14Fr Foley catheter was then placed in the tube as well as in the urethra, for 21 days. Materials & Methods We conducted a single center, retrospective, case-series study of individuals who underwent RALCCUD in our department between 2017 and 2022. Ethical approval was granted by our local ethical committee the Institutional Ethical and Clinical Research at Nantes Université (Groupe Nantais d'Ethique dans le Domaine de la Santé) review board (Nantes, 2022) number “AVIS 22-3-170”. Indications for the surgery were the inability to perform ISC through the urethra because of difficulty reaching or finding the urethra. Inclusion criteria for the study were age at least 15 years old and with a post-surgical follow-up of at least 3 months. Before surgery, all individuals underwent an assessment by a multidisciplinary team that included at least a urologist, a physical medicine and rehabilitation doctor and, if necessary, an occupational therapist. The ability to hold a catheter and to self-catheterize through an abdominal stoma was assessed during a short hospital stay prior to surgery. Individuals with traumatic spinal cord injury underwent MRI to rule out the presence of syringomyelia, which may be a contra-indication to the laparoscopic approach 15 . An assessment was performed preoperatively, at 3 months post-operatively and then yearly. The assessment included stomal and urethral continence, satisfaction, renal function and urodynamic function, outcomes and complications. The primary outcome was continence status at the last follow-up. Continence was defined as no leakage (no pad) from either the urethra or the stoma without the need for secondary incontinence surgery after RALCCUD 16 . The secondary outcomes were the rate of clinically significant post-operative complications (≥ grade 3 on the Clavien Dindo classification 17 ), classed as early (0–30 days post-operative) or late (> 30 days post-operative), and the rate of stomal complications requiring reintervention. The stomal complications requiring reintervention included stenosis, false route and incontinence after excluding other causes such as bladder overactivity. Statistical analysis: Continuous variables are expressed as medians and interquartile ranges (IQRs; 25th and 75th percentiles), and categorical variables as numbers and percentages. MannWhitney test or Student’s t-test was used to compare continuous variables according to normal distribution (Shapiro–Wilk’s test) and chi-square or Fischer’s exact test for categorical variables. A p < 0.05 was considered significant. SAS software (version 9.4, NC, USA) was used. Surgical Technique All the procedures were performed by two surgeons. The patient was placed in a modified lithotomy position with 25° of Trendelenburg to shift the bowel away from the pelvis. An 18Fr Foley catheter was placed in the bladder. The camera port (8 mm) was placed intraperitoneally via an open laparoscopy approach under the umbilicus, and pneumoperitoneum was established with 12 mmHg insufflation pressure. An 8-mm robotic port was placed on each side of the camera port and a fourth robotic port was placed in the right iliac fossa at the same level. The ports were placed at least 8 cm apart. An additional 12-mm port was inserted in the left iliac fossa for the assistant. After trocar placement, the robot (four-arm Da Vinci Xi Surgical System®, Intuitive Surgical, Inc., Sunnyvale, CA, USA) was docked. Bladder mobilization: The bladder was freed from the peritoneum and mobilized by sectioning the urachus and the two umbilical arteries. It is critical to ensure that the bladder is adequately mobilized and that it can easily be brought to the anterior abdominal wall near the camera port. Catheterisable tube preparation The preferred choice for tube formation was the appendix. It was identified after mobilizing the caecum, from which it was then separated with care taken to preserve the blood supply. Then, the length of the tube and the anatomical possibility to reach the planned stoma location were verified. A key issue for RALCCUD is an accurate evaluation of the distance between the implantation of the conduit in the bladder and the stomal anastomosis. The tip of the appendix was sectioned, and a 14 Fr feeding-tube was introduced to verify the patency of the whole appendix. In case of previous appendicectomy, or an unusable appendix, it is possible to use a retubularized tube, according to the Yang-Monti technique 5 . For this, a 3/0 polyglotone suture was placed on the ileum 30 cm from the ileocecal valve. The robot was undocked and performed a 4cm incision below the umbilical incision. A 2cm intestinal segment located 30 cm from the ileocecal valve was isolated extracorporeally to construct a retubularized tube. Then the tube was reintroduced in the abdomen and the robot was docked to carry on the surgery intraperitoneally. If the distance between the bladder and abdominal wall was long, a tube was prepared according to the Casale Principle 6 , after isolation of an ileal segment of 3.5cm in length. In case of concomitant augmentation cystoplasty (AC), a 30-cm ileal segment was isolated at 30 cm from the ileocecal valve at the same time. Anti-reflux anastomosis The tube was always implanted in the posterior bladder wall. If concomitant AC was not performed, the tube was implanted according to the Lich-Gregoir anti-reflux principle. The bladder was filled with 300mL of saline solution. The posterior wall of the bladder was opened sagittally with preservation of the bladder mucosa. Each side of the detrusor muscle was suspended to the anterior abdominal wall using a 3/0 polyglactin suture to provide adequate exposure. The catheterisable channel was sutured to the bladder mucosa with interrupted 5/0 polydioxanone sutures and the detrusor was closed with 3/0 polyglactin to create a submucosal anti-reflux mechanism at least 4 cm long. Results Patient characteristics and perioperative data Patient characteristics and outcomes are shown in Table 1 . Table 1 Patient characteristics and perioperative data Case number Age (years) Sex Diagnosis Type of CCUD Concomitant procedures 1 22 Female NLUTD and BPS Yang-Monti ileal conduit SC and AC 2 17 Female Spina bifida L2 Mitrofanoff conduit SC and AC 3 51 Female NLUTD due to SCI C5 Yang-Monti modified Casale ileal conduit SC and AC 4 67 Female NLUTD due to SCI T10 Yang-Monti ileal conduit AUS 5 52 Female NLUTD due to SCI T9 Yang-Monti modified Casale ileal conduit - 6 16 Female NLUTD due to SCI C6 Mitrofanoff conduit - 7 20 Female NLUTD due to SCI C3 Mitrofanoff conduit - 8 73 Female NLUTD due to SCI T4 Yang-Monti modified Casale ileal conduit - 9 67 Female NLUTD due to SCI C7 Yang-Monti ileal conduit - 10 55 Male NLUTD due to SCI T12 Yang-Monti ileal conduit - 11 43 Female NLUTD due to SCI C7 Yang-Monti modified Casale ileal conduit - 12 18 Female NLUTD due to SCI C5 Mitrofanoff conduit - Median Value (IQR) 47.4 (19;57.9) AC: Augmentation Cystoplasty – AUS: Artificial Urinary Sphincter - BPS: Bladder Pain Syndrome - CCUD: Cutaneous Continent Urinary Diversion - NLUTD: Neurogenic Low Urinary Tract Dysfunction – SC: Supratrigonal Cystectomy – SCI: Spinal Cord Injury Twelve patients were included; median (IQR) age was 47.4 (19.5–57.6) years (range 16–74 years), and 11 participants were female (92%). Eleven participants had NLUTD caused by spinal cord injury (SCI) or spinal dysraphism, and one had a history of bladder pain syndrome/interstitial cystitis (BPS/IC). None had renal insufficiency before or after the surgery. Four participants underwent a concomitant procedure: 3 SC with AC for poor bladder compliance, refractory neurogenic detrusor overactivity (NDO) or refractory severe IC. One female with SCI was provided with an artificial urinary sphincter (AUS) for stress urinary incontinence related to neurogenic intrinsic sphincter deficiency. Conversion to an open approach was not required for any participant. The median (IQR) operating time was 313 (285–367) min (range 224 to 643 and median (IQR) estimated blood loss was 100mL (100–150). The median (IQR) length of hospital stay for the 12 patients was 8 ( 7 – 11 ) days and was 13 days (range 10 to 16) for those who underwent concomitant procedures (p > 0.05). The median operating time was 635 (range to 392–643) min for the patients who underwent concomitant procedures (SC and AC or AUS) and was 300 min (range to 224–367) for those who did not (p = 0.03). Post-operative complications The median (IQR) follow-up duration was 42.9 (34-53.5) months (range 5 to 70.7). The early and late complication rates were 8% (1/12) and 17% (2/12) respectively. The stomal complication rate was 17% (2/12) with a complication rate of 25% for Mitrofanoff, 25% for Casale conduit and 0% for Yang-Monti. Details of the complications are provided in Table 2 . No complications were rated > grade 3 on the Clavien Dindo classification. Table 2 Complications, treatments and outcomes Case number Age (years) Sex Etiology Conduit Type of complication Clavien grade Onset of complications (months) Treatment Outcome 2 17 Female Spina bifida L2 Mitrofanoff Stomal stenosis & false route 3 35 Endoscopic dilatation ISC via stoma, continent 8 73 Female NLUTD due to SCI T4 Yang-Monti modified Casale ileal conduit Wound abscess 3 1 Surgical management Healing of the wound 8 73 Female NLUTD due to SCI T4 Yang-Monti modified Casale ileal conduit Stomal incontinence 3 10 Polydimethylsiloxane endoscopic injection twice at the distal end of the conduit ISC via stoma, continent 8 73 Female NLUTD due to SCI T4 Yang-Monti modified Casale ileal conduit Urethral incontinence 3 10 Peri-urethral balloons pro-ACT ISC via stoma, continent ACT: Adjustable Continence Therapy – ISC; Intermittent self-catheterization – NLUTD: Neurogenic Low Urinary Tract Dysfunction – SCI: Spinal Cord Injury One participant (case 1) with a history of BPS/IC underwent a cystectomy with ileal conduit 34 months after RALCCUD because of refractory chronic pelvic pain. The participant was continent and had no catheterization difficulties before this reoperation. Another participant (case 6) died from her initial disease (medullar glioblastoma) nearly 5 months after the surgery. No incontinence or catheterization difficulties were reported. Functional results The overall continence rate was 92% (11/12). The stomal continence rate was 92% (11/12). One participant (case 8) had stomal incontinence after insertion of a Casale conduit, which was treated by a bulking agent injection (Macroplastique® (Uroplasty) Laborie, Ontario, Canada). The urethral continence rate was 92% (11/12); the same participant (case 8) had urethral incontinence that was treated with a peri-urethral balloon (Adjustable Continence Therapy, ACT®) (Table 2 ). At the last follow-up, all participants reported stomal and urethral continence and performed ISC through the tube. No false passage or difficulty catheterizing the tube was reported. The overall reoperation rate (including to treat complications and improve continence) was 33% (4/12) (Table 2 ). Only one stomal stenosis occurred at 35 months (case 2) and was managed by endoscopic dilatation. No participants had renal insufficiency before or after the surgery. The median (IQR) pre-operative urodynamic characteristics were a bladder capacity of 475 (300–500) mL, a urethral closure pressure of 55 (37.5–120) cmH2O and bladder pressure at end of the filling of 21 (19–27) cmH2O. At the last follow-up, the median (IQR) post-operative bladder capacity was 400 mL (350–500) with a bladder compliance > 20. The bladder capacity of the 3 participants with an AC increased up to 300 ml and bladder compliance was > 20 in all 3. Discussion This study showed that all 12 participants who underwent RALCCUD were continent at the last follow up. Two participants experienced stomal complications and none experienced complications > Clavien 3. These data complete those from a study in children that found RALCCUD to be safe and comparable in terms of long-term functional outcomes with the results of traditional surgical procedures 10 . The arrival and development of robotic surgery was a watershed moment in the world of laparoscopic surgery. It led to the expansion of the laparoscopic approach to complex neuro-urology surgeries. Since the first RALCCUD reported in 2004 9 , the technique has been developed and standardized in both children and adults. Although robotic technology has been adopted for many urologic procedures in adults, only a few studies of RALCCUD have been performed in adults 13,14 . The median operating time was 313 min. This is comparable with other reports in adults 14 and children 10 ; however, the range is very large (224 to 643 min). We suggest 3 explanations for this. First, when no concomitant technique is performed, the standardization of the technique makes it short in duration. Galanski et al 10 showed that operative time reduced from around 500 min to 300 min after 10 years of experience. Second, RALCCUD associated with a AC is a real challenge 10 and requires a much longer operating time. The third reason is that a Casale or Yang-Monti conduit was used for most participants (66%), requiring an ileal conduit to be used to create the conduit. In most studies, Casale or Yang-Monti conduits were little used 10,13 . In our series, the appendix was used in only 33% of participants (4/12). Our results suggest that the creation of a Casale or a Yang-Monti conduit using robotic assistance is feasible and safe. Furthermore, the short-term functional results were very good. Indeed, the continence rate was high and the complications rate was low for all tube-types. In our series, the stomal continence rate without repeat surgery was very high (92%). It was higher than the 60% (6/10 participants) rate reported by Lecoanet et al 14 but was similar to rates in other tertiary centers of adult or pediatric urology 10,13 . We chose to implant the channel posteriorly on the bladder to reproduce de technique initially described by Mitrofanoff 4 . Although there are no published comparisons of posterior and anterior channels in adults, studies in children suggest that anterior and posterior channels have similar revision rates 21 . The management of incontinent CCUD with endoscopic injection of submucosal bulking agents is well known to provide good results. Recently, Riachy et al 22 found an 86% success rate (either achievement of continence or improvement in continence) in a retrospective study. The high rate of urethral continence (92%) may have resulted from good pre-operative screening and management. In our center, the intervention was always performed in the neuro-urology unit with uro-dynamic assessment. We believe that eligibility screening by a multidisciplinary team including a urologist and rehab physician is key to the success of the intervention. The rate of complications was low (17%) and was lower than that found in other recent studies in tertiary centers for open, laparoscopic or robot-assisted surgery 13,14 . In their comparative study of continent, cutaneous, catheterizable channels, Galanski et al 10 reported a complication rate of 43% and 38% for open and robot-assisted surgery respectively. Of note, that study was done in children, in whom complications are managed differently from adults. Only one stomal stenosis occurred during the follow-up period, and it was managed by endoscopic dilatation. This low rate of stomal stenosis could be attributed to the systematic use of the V-shaped skin flap to enlarge the circumference of the stoma as previously described 18 . This study has several limitations. The first is that it was a retrospective, single center study. However, to our knowledge, it is one the largest studies of RALCCUD in adults to date with 12 individuals included. So far, only 2 retrospective case-series have been published, with follow ups of less than 24 months 13,14 . The second limitation is the median follow-up of only 40.3 months; however, in a retrospective study of 119 stomas, Jacobson et al 23 found that stomal stenosis, false passage and first complications occurred within a mean 24.2 months. However, since complications can still occur more than 10 years after the surgery 7 , long-term follow-up is required. Conclusion RALCCUD with Mitrofanoff and Yang-Monti conduits with or without AC seems safe and feasible in adults with NLUTD who are unable to self-catheterize through the native urethra. It seems to provide a very high short-term rate of stomal and urethral continence with a low rate of complications. Multicenter, prospective studies are now required to confirm these results and to determine the place of RALCCUD in the management of these issues. Abbreviations AC= Augmentation Cystoplasty AUS= Artificial Urinary Sphincter BPS/IC= Bladder Pain Syndrome/Interstitial Cystitis CCUD= Continent Cutaneous Urinary Diversion ISC= Intermittent self-catheterization NDO= Neurogenic Detrusor Overactivity NLUTD= Neurogenic Low Urinary Tract Dysfunction RALCCUD= Robot Assisted Laparoscopic Continent Cutaneous Urinary Diversion SC= Supratrigonal Cystectomy SCI= Spinal Cord Injury Declarations Data Statement: The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Nantes Université, Nantes, France. Funding Statement: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of interest: The authors declare that they have no conflict of interest. Ethical Compliance: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Our study was approved by our local ethical committee the Institutional Ethical and Clinical Research at Nantes Université (Groupe Nantais d'Ethique dans le Domaine de la Santé) review board (Nantes, 2022) number “AVIS 22-3-170”. Patient consent statement: Informed consent was obtained from all individual participants included in the study. Permission to reproduce material from other sources: We have not used materials from other sources. Clinical trial registration: It is a retrospective study registered at our local ethical committee at Nantes Université “Groupe Nantais d'Ethique dans le Domaine de la Santé” (GNEDS) (AVIS 22-3-170). Author Contributions: T. Loubersac: Protocol/project development, Data collection and management, Data analysis, Manuscript writing/editing; E. Lavallée: Data analysis, Manuscript writing/editing; B. Reiss: Data collection and management, Manuscript writing/editing; MD. Leclair : Manuscript writing/editing ; P. Kieny: Data collection and management, Data analysis, Manuscript writing/editing ; M. Le Fort : Manuscript writing/editing, L. Lenormand: Manuscript writing/editing ; ; J. Rigaud : Manuscript writing/editing ; B. Perrouin – Verbe: Data collection and management, Manuscript writing/editing ; C. Lefevre: Manuscript writing/editing; M.A. Perrouin-Verbe Protocol/project development, Data analysis, Manuscript writing/editing References Groen J, Pannek J, Castro Diaz D, et al. 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Neurourol Urodyn . 2016;35(8):1046-1050. doi:10.1002/nau.22879 Karsenty G, Chartier-Kastler E, Mozer P, Even-Schneider A, Denys P, Richard F. A novel technique to achieve cutaneous continent urinary diversion in spinal cord-injured patients unable to catheterize through native urethra. Spinal Cord . 2008;46(4):305-310. doi:10.1038/sj.sc.3102104 VanderBrink BA, Kaefer M, Cain MP, Meldrum KK, Misseri R, Rink RC. Extravesical Implantation of a Continent Catheterizable Channel. J Urol . 2011;185(6S):2572-2575. doi:10.1016/j.juro.2011.01.027 Szymanski KM, Lopez PJ, Corbetta JP, et al. Do anterior catheterizable urinary channels have fewer complications than posterior channels? An international cohort study. J Pediatr Urol . 2018;14(1):48.e1-48.e7. doi:10.1016/j.jpurol.2017.06.020 Riachy E, Defoor WR, Reddy PP, et al. Endoscopic Treatment with Dextranomer/Hyaluronic Acid for Persistent Incontinence After Continent Urinary Reconstruction. J Endourol . 2015;29(2):137-140. doi:10.1089/end.2014.0326 Jacobson DL, Thomas JC, Pope J, et al. Update on Continent Catheterizable Channels and the Timing of their Complications. J Urol . 2017;197(3 Part 2):871-876. doi:10.1016/j.juro.2016.08.119 Additional Declarations No competing interests reported. Supplementary Files RALCCUDTable1JRS07112023.docx Cite Share Download PDF Status: Posted Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Loubersac","email":"data:image/png;base64,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","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Loubersac","suffix":""},{"id":248546865,"identity":"1f39c19c-e356-4aa0-bdbb-a666b656ca54","order_by":1,"name":"Etienne Lavallée","email":"","orcid":"","institution":"Université Laval","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Etienne","middleName":"","lastName":"Lavallée","suffix":""},{"id":248546866,"identity":"472f4deb-707a-41f4-b21f-1ba167d2ade5","order_by":2,"name":"Benedicte Reiss","email":"","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Benedicte","middleName":"","lastName":"Reiss","suffix":""},{"id":248546868,"identity":"0c46cc7c-56fe-42a9-9eb9-c5699cde6a5b","order_by":3,"name":"Marc Lefort","email":"","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Marc","middleName":"","lastName":"Lefort","suffix":""},{"id":248546869,"identity":"55538f03-d30c-4ed2-81fb-bad96a971b15","order_by":4,"name":"Pierre Kieny","email":"","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Pierre","middleName":"","lastName":"Kieny","suffix":""},{"id":248546870,"identity":"7a8de203-aa8d-4bb4-9b1c-804f66daff7e","order_by":5,"name":"Marc-David Leclair","email":"","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Marc-David","middleName":"","lastName":"Leclair","suffix":""},{"id":248546871,"identity":"34e9277b-7c49-4469-8d2c-f5bdf0ac528f","order_by":6,"name":"Jérôme Rigaud","email":"","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jérôme","middleName":"","lastName":"Rigaud","suffix":""},{"id":248546872,"identity":"586d296b-d025-4806-a28d-67c40a72af3f","order_by":7,"name":"Loic Le Normand","email":"","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Loic","middleName":"Le","lastName":"Normand","suffix":""},{"id":248546873,"identity":"0412828b-22a3-43cb-b889-82af2cefa96c","order_by":8,"name":"Brigitte Perrouin-Verbe","email":"","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Brigitte","middleName":"","lastName":"Perrouin-Verbe","suffix":""},{"id":248546874,"identity":"5adb44a0-4dd8-4e8d-b927-4e44cf8aae28","order_by":9,"name":"Chloe Lefevre","email":"","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chloe","middleName":"","lastName":"Lefevre","suffix":""},{"id":248546875,"identity":"a565c99e-4677-411a-8cc5-36ffbab2f14e","order_by":10,"name":"Marie-aimée Perrouin-Verbe","email":"","orcid":"","institution":"Nantes Université, Centre Hospitalo-Universitaire de Nantes","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Marie-aimée","middleName":"","lastName":"Perrouin-Verbe","suffix":""}],"badges":[],"createdAt":"2023-11-07 17:29:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3575709/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3575709/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":46706146,"identity":"e4ce9cb2-511b-4add-b171-2fb344e702dc","added_by":"auto","created_at":"2023-11-18 15:52:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":332174,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3575709/v1/f5c6d3ae-1159-44ed-9c35-f6bd8dd2b0d0.pdf"},{"id":46400817,"identity":"891a90a0-f457-4967-a5a7-abc00d8a8163","added_by":"auto","created_at":"2023-11-14 08:38:31","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15262,"visible":true,"origin":"","legend":"","description":"","filename":"RALCCUDTable1JRS07112023.docx","url":"https://assets-eu.researchsquare.com/files/rs-3575709/v1/98431cee340ef24d5ff422e3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robot-assisted laparoscopic continent cutaneous urinary diversion in a single- center study; surgical technique and outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGuidelines for the treatment of people with neurogenic low urinary tract dyfunction (NLUTD) include the management of neurogenic detrusor overactivity (NDO) combined with intermittent self-catheterization (ISC) \u003csup\u003e1\u003c/sup\u003e. This treatment strategy aims to protect the upper urinary tract and maintain urinary continence by ensuring a low-pressure bladder reservoir \u003csup\u003e1–3\u003c/sup\u003e. However, some people who require ISC are unable to perform it through the native urethra because of upper-limb disability, difficulty reaching or finding the urethra, or urethral destruction. Cutaneous continent urinary diversion (CCUD) (Mitrofanoff \u003csup\u003e4\u003c/sup\u003e, Yang-Monti \u003csup\u003e5\u003c/sup\u003e or Casale \u003csup\u003e6\u003c/sup\u003e procedures) can be offered to such individuals to allow ISC. Several case-series studies have reported good long-term results from this technique in children \u003csup\u003e7\u003c/sup\u003e and adults \u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRobot assisted laparoscopic cutaneous continent urinary diversion (RALCCUD) was developed in the 2000s \u003csup\u003e9\u003c/sup\u003e and provides the advantage of shorter length of hospital stay compared to the open approach \u003csup\u003e10\u003c/sup\u003e. Several studies with long-term follow-ups have demonstrated the feasibility and efficacy of(RALCCUD) in children \u003csup\u003e11,12\u003c/sup\u003e, but only a few small case-series have been published in adults \u003csup\u003e13,14\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe aim of the current study was to report the perioperative outcome and preliminary functional results using the RALCCUD technique in terms of continence, catheterization and repeat surgery.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003cp\u003eIf concomitant AC was performed, a supra-trigonal cystectomy (SC) was performed with preservation of the posterolateral bladder-wall flap in which the efferent tube could be implanted according to the politano-leadbetter principle, as previously published, using an open approach \u003csup\u003e18,19\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThen the AC was sutured to the remaining bladder using 3/0 V-Lock running sutures.\u003c/p\u003e \u003cp\u003eThe watertightness was checked by filling the bladder with 180 mL saline solution.\u003c/p\u003e \u003cp\u003eStoma\u003c/p\u003e \u003cp\u003eThe stoma was always placed at the umbilical level.\u003c/p\u003e \u003cp\u003eBefore the anastomosis between the channel and the skin was performed, the bladder was sutured to the anterior abdominal wall with interrupted 2/0 sutures to avoid kinking of the channel and to minimize the extravesical portion as described for the open technique \u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe distal efferent tube was sutured to the skin with a V-shaped skin flap using interrupted 4/0 polydioxanone sutures.\u003c/p\u003e \u003cp\u003eA 14Fr Foley catheter was then placed in the tube as well as in the urethra, for 21 days.\u003c/p\u003e \u003c/div\u003e"},{"header":"Materials \u0026 Methods","content":"\u003cp\u003eWe conducted a single center, retrospective, case-series study of individuals who underwent RALCCUD in our department between 2017 and 2022. Ethical approval was granted by our local ethical committee the Institutional Ethical and Clinical Research at Nantes Université (Groupe Nantais d'Ethique dans le Domaine de la Santé) review board (Nantes, 2022) number “AVIS 22-3-170”.\u003c/p\u003e\u003cp\u003eIndications for the surgery were the inability to perform ISC through the urethra because of difficulty reaching or finding the urethra. Inclusion criteria for the study were age at least 15 years old and with a post-surgical follow-up of at least 3 months.\u003c/p\u003e\u003cp\u003eBefore surgery, all individuals underwent an assessment by a multidisciplinary team that included at least a urologist, a physical medicine and rehabilitation doctor and, if necessary, an occupational therapist. The ability to hold a catheter and to self-catheterize through an abdominal stoma was assessed during a short hospital stay prior to surgery.\u003c/p\u003e\u003cp\u003eIndividuals with traumatic spinal cord injury underwent MRI to rule out the presence of syringomyelia, which may be a contra-indication to the laparoscopic approach \u003csup\u003e15\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAn assessment was performed preoperatively, at 3 months post-operatively and then yearly. The assessment included stomal and urethral continence, satisfaction, renal function and urodynamic function, outcomes and complications.\u003c/p\u003e\u003cp\u003eThe primary outcome was continence status at the last follow-up. Continence was defined as no leakage (no pad) from either the urethra or the stoma without the need for secondary incontinence surgery after RALCCUD \u003csup\u003e16\u003c/sup\u003e. The secondary outcomes were the rate of clinically significant post-operative complications (≥ grade 3 on the Clavien Dindo classification \u003csup\u003e17\u003c/sup\u003e), classed as early (0–30 days post-operative) or late (\u0026gt; 30 days post-operative), and the rate of stomal complications requiring reintervention. The stomal complications requiring reintervention included stenosis, false route and incontinence after excluding other causes such as bladder overactivity.\u003c/p\u003e\u003ch2\u003eStatistical analysis:\u003c/h2\u003e\u003cp\u003eContinuous variables are expressed as medians and interquartile ranges (IQRs; 25th and 75th percentiles), and categorical variables as numbers and percentages. MannWhitney test or Student’s t-test was used to compare continuous variables according to normal distribution (Shapiro–Wilk’s test) and chi-square or Fischer’s exact test for categorical variables. A p \u0026lt; 0.05 was considered significant. SAS software (version 9.4, NC, USA) was used.\u003c/p\u003e\u003cp\u003eSurgical Technique\u003c/p\u003e\u003cp\u003eAll the procedures were performed by two surgeons.\u003c/p\u003e\u003cp\u003eThe patient was placed in a modified lithotomy position with 25° of Trendelenburg to shift the bowel away from the pelvis. An 18Fr Foley catheter was placed in the bladder.\u003c/p\u003e\u003cp\u003eThe camera port (8 mm) was placed intraperitoneally via an open laparoscopy approach under the umbilicus, and pneumoperitoneum was established with 12 mmHg insufflation pressure. An 8-mm robotic port was placed on each side of the camera port and a fourth robotic port was placed in the right iliac fossa at the same level. The ports were placed at least 8 cm apart. An additional 12-mm port was inserted in the left iliac fossa for the assistant. After trocar placement, the robot (four-arm Da Vinci Xi Surgical System®, Intuitive Surgical, Inc., Sunnyvale, CA, USA) was docked.\u003c/p\u003e\u003cp\u003eBladder mobilization:\u003c/p\u003e\u003cp\u003eThe bladder was freed from the peritoneum and mobilized by sectioning the urachus and the two umbilical arteries. It is critical to ensure that the bladder is adequately mobilized and that it can easily be brought to the anterior abdominal wall near the camera port.\u003c/p\u003e\u003cp\u003eCatheterisable tube preparation\u003c/p\u003e\u003cp\u003eThe preferred choice for tube formation was the appendix. It was identified after mobilizing the caecum, from which it was then separated with care taken to preserve the blood supply.\u003c/p\u003e\u003cp\u003eThen, the length of the tube and the anatomical possibility to reach the planned stoma location were verified. A key issue for RALCCUD is an accurate evaluation of the distance between the implantation of the conduit in the bladder and the stomal anastomosis.\u003c/p\u003e\u003cp\u003eThe tip of the appendix was sectioned, and a 14 Fr feeding-tube was introduced to verify the patency of the whole appendix.\u003c/p\u003e\u003cp\u003eIn case of previous appendicectomy, or an unusable appendix, it is possible to use a retubularized tube, according to the Yang-Monti technique \u003csup\u003e5\u003c/sup\u003e. For this, a 3/0 polyglotone suture was placed on the ileum 30 cm from the ileocecal valve. The robot was undocked and performed a 4cm incision below the umbilical incision. A 2cm intestinal segment located 30 cm from the ileocecal valve was isolated extracorporeally to construct a retubularized tube.\u003c/p\u003e\u003cp\u003eThen the tube was reintroduced in the abdomen and the robot was docked to carry on the surgery intraperitoneally. If the distance between the bladder and abdominal wall was long, a tube was prepared according to the Casale Principle \u003csup\u003e6\u003c/sup\u003e, after isolation of an ileal segment of 3.5cm in length.\u003c/p\u003e\u003cp\u003eIn case of concomitant augmentation cystoplasty (AC), a 30-cm ileal segment was isolated at 30 cm from the ileocecal valve at the same time.\u003c/p\u003e\u003cp\u003eAnti-reflux anastomosis\u003c/p\u003e\u003cp\u003eThe tube was always implanted in the posterior bladder wall. If concomitant AC was not performed, the tube was implanted according to the Lich-Gregoir anti-reflux principle. The bladder was filled with 300mL of saline solution. The posterior wall of the bladder was opened sagittally with preservation of the bladder mucosa. Each side of the detrusor muscle was suspended to the anterior abdominal wall using a 3/0 polyglactin suture to provide adequate exposure. The catheterisable channel was sutured to the bladder mucosa with interrupted 5/0 polydioxanone sutures and the detrusor was closed with 3/0 polyglactin to create a submucosal anti-reflux mechanism at least 4 cm long.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatient characteristics and perioperative data\u003c/p\u003e \u003cp\u003ePatient characteristics and outcomes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics and perioperative data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eType of CCUD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eConcomitant\u003c/p\u003e \u003cp\u003eprocedures\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD and BPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSC and AC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSpina bifida L2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMitrofanoff conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSC and AC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI C5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti modified Casale ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSC and AC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI T10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAUS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI T9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti modified Casale ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI C6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMitrofanoff conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI C3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMitrofanoff conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI T4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti modified Casale ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI C7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI T12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI C7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti modified Casale ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI C5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMitrofanoff conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Value (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.4 (19;57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eAC: Augmentation Cystoplasty \u0026ndash; AUS: Artificial Urinary Sphincter - BPS: Bladder Pain Syndrome - CCUD: Cutaneous Continent Urinary Diversion - NLUTD: Neurogenic Low Urinary Tract Dysfunction \u0026ndash; SC: Supratrigonal Cystectomy \u0026ndash; SCI: Spinal Cord Injury\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTwelve patients were included; median (IQR) age was 47.4 (19.5\u0026ndash;57.6) years (range 16\u0026ndash;74 years), and 11 participants were female (92%). Eleven participants had NLUTD caused by spinal cord injury (SCI) or spinal dysraphism, and one had a history of bladder pain syndrome/interstitial cystitis (BPS/IC). None had renal insufficiency before or after the surgery.\u003c/p\u003e \u003cp\u003eFour participants underwent a concomitant procedure: 3 SC with AC for poor bladder compliance, refractory neurogenic detrusor overactivity (NDO) or refractory severe IC. One female with SCI was provided with an artificial urinary sphincter (AUS) for stress urinary incontinence related to neurogenic intrinsic sphincter deficiency.\u003c/p\u003e \u003cp\u003eConversion to an open approach was not required for any participant. The median (IQR) operating time was 313 (285\u0026ndash;367) min (range 224 to 643 and median (IQR) estimated blood loss was 100mL (100\u0026ndash;150).\u003c/p\u003e \u003cp\u003eThe median (IQR) length of hospital stay for the 12 patients was 8 (\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) days and was 13 days (range 10 to 16) for those who underwent concomitant procedures (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe median operating time was 635 (range to 392\u0026ndash;643) min for the patients who underwent concomitant procedures (SC and AC or AUS) and was 300 min (range to 224\u0026ndash;367) for those who did not (p\u0026thinsp;=\u0026thinsp;0.03).\u003c/p\u003e \u003cp\u003ePost-operative complications\u003c/p\u003e \u003cp\u003eThe median (IQR) follow-up duration was 42.9 (34-53.5) months (range 5 to 70.7).\u003c/p\u003e \u003cp\u003eThe early and late complication rates were 8% (1/12) and 17% (2/12) respectively. The stomal complication rate was 17% (2/12) with a complication rate of 25% for Mitrofanoff, 25% for Casale conduit and 0% for Yang-Monti. Details of the complications are provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. No complications were rated\u0026thinsp;\u0026gt;\u0026thinsp;grade 3 on the Clavien Dindo classification.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications, treatments and outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEtiology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConduit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eType of complication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eClavien grade\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOnset of complications (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSpina bifida L2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMitrofanoff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStomal stenosis \u0026amp; false route\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEndoscopic dilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eISC via stoma, continent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI T4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti modified Casale ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWound abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSurgical management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHealing of the wound\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI T4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti modified Casale ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStomal incontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePolydimethylsiloxane endoscopic injection twice at the distal end of the conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eISC via stoma, continent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNLUTD due to SCI T4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYang-Monti modified Casale ileal conduit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUrethral incontinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePeri-urethral balloons pro-ACT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eISC via stoma, continent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eACT: Adjustable Continence Therapy \u0026ndash; ISC; Intermittent self-catheterization \u0026ndash; NLUTD: Neurogenic Low Urinary Tract Dysfunction \u0026ndash; SCI: Spinal Cord Injury\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOne participant (case 1) with a history of BPS/IC underwent a cystectomy with ileal conduit 34 months after RALCCUD because of refractory chronic pelvic pain. The participant was continent and had no catheterization difficulties before this reoperation.\u003c/p\u003e \u003cp\u003eAnother participant (case 6) died from her initial disease (medullar glioblastoma) nearly 5 months after the surgery. No incontinence or catheterization difficulties were reported.\u003c/p\u003e \u003cp\u003eFunctional results\u003c/p\u003e \u003cp\u003eThe overall continence rate was 92% (11/12). The stomal continence rate was 92% (11/12). One participant (case 8) had stomal incontinence after insertion of a Casale conduit, which was treated by a bulking agent injection (Macroplastique\u0026reg; (Uroplasty) Laborie, Ontario, Canada). The urethral continence rate was 92% (11/12); the same participant (case 8) had urethral incontinence that was treated with a peri-urethral balloon (Adjustable Continence Therapy, ACT\u0026reg;) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). At the last follow-up, all participants reported stomal and urethral continence and performed ISC through the tube. No false passage or difficulty catheterizing the tube was reported.\u003c/p\u003e \u003cp\u003eThe overall reoperation rate (including to treat complications and improve continence) was 33% (4/12) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Only one stomal stenosis occurred at 35 months (case 2) and was managed by endoscopic dilatation.\u003c/p\u003e \u003cp\u003eNo participants had renal insufficiency before or after the surgery.\u003c/p\u003e \u003cp\u003eThe median (IQR) pre-operative urodynamic characteristics were a bladder capacity of 475 (300\u0026ndash;500) mL, a urethral closure pressure of 55 (37.5\u0026ndash;120) cmH2O and bladder pressure at end of the filling of 21 (19\u0026ndash;27) cmH2O. At the last follow-up, the median (IQR) post-operative bladder capacity was 400 mL (350\u0026ndash;500) with a bladder compliance\u0026thinsp;\u0026gt;\u0026thinsp;20. The bladder capacity of the 3 participants with an AC increased up to 300 ml and bladder compliance was \u0026gt;\u0026thinsp;20 in all 3.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed that all 12 participants who underwent RALCCUD were continent at the last follow up. Two participants experienced stomal complications and none experienced complications\u0026thinsp;\u0026gt;\u0026thinsp;Clavien 3.\u003c/p\u003e \u003cp\u003eThese data complete those from a study in children that found RALCCUD to be safe and comparable in terms of long-term functional outcomes with the results of traditional surgical procedures \u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe arrival and development of robotic surgery was a watershed moment in the world of laparoscopic surgery. It led to the expansion of the laparoscopic approach to complex neuro-urology surgeries. Since the first RALCCUD reported in 2004 \u003csup\u003e9\u003c/sup\u003e, the technique has been developed and standardized in both children and adults. Although robotic technology has been adopted for many urologic procedures in adults, only a few studies of RALCCUD have been performed in adults \u003csup\u003e13,14\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe median operating time was 313 min. This is comparable with other reports in adults \u003csup\u003e14\u003c/sup\u003e and children \u003csup\u003e10\u003c/sup\u003e; however, the range is very large (224 to 643 min). We suggest 3 explanations for this. First, when no concomitant technique is performed, the standardization of the technique makes it short in duration. Galanski et al \u003csup\u003e10\u003c/sup\u003e showed that operative time reduced from around 500 min to 300 min after 10 years of experience. Second, RALCCUD associated with a AC is a real challenge \u003csup\u003e10\u003c/sup\u003e and requires a much longer operating time. The third reason is that a Casale or Yang-Monti conduit was used for most participants (66%), requiring an ileal conduit to be used to create the conduit.\u003c/p\u003e \u003cp\u003eIn most studies, Casale or Yang-Monti conduits were little used \u003csup\u003e10,13\u003c/sup\u003e. In our series, the appendix was used in only 33% of participants (4/12). Our results suggest that the creation of a Casale or a Yang-Monti conduit using robotic assistance is feasible and safe. Furthermore, the short-term functional results were very good. Indeed, the continence rate was high and the complications rate was low for all tube-types.\u003c/p\u003e \u003cp\u003eIn our series, the stomal continence rate without repeat surgery was very high (92%). It was higher than the 60% (6/10 participants) rate reported by Lecoanet et al\u003csup\u003e14\u003c/sup\u003e but was similar to rates in other tertiary centers of adult or pediatric urology\u003csup\u003e10,13\u003c/sup\u003e. We chose to implant the channel posteriorly on the bladder to reproduce de technique initially described by Mitrofanoff \u003csup\u003e4\u003c/sup\u003e. Although there are no published comparisons of posterior and anterior channels in adults, studies in children suggest that anterior and posterior channels have similar revision rates \u003csup\u003e21\u003c/sup\u003e. The management of incontinent CCUD with endoscopic injection of submucosal bulking agents is well known to provide good results. Recently, Riachy et al \u003csup\u003e22\u003c/sup\u003e found an 86% success rate (either achievement of continence or improvement in continence) in a retrospective study.\u003c/p\u003e \u003cp\u003eThe high rate of urethral continence (92%) may have resulted from good pre-operative screening and management. In our center, the intervention was always performed in the neuro-urology unit with uro-dynamic assessment. We believe that eligibility screening by a multidisciplinary team including a urologist and rehab physician is key to the success of the intervention.\u003c/p\u003e \u003cp\u003eThe rate of complications was low (17%) and was lower than that found in other recent studies in tertiary centers for open, laparoscopic or robot-assisted surgery \u003csup\u003e13,14\u003c/sup\u003e. In their comparative study of continent, cutaneous, catheterizable channels, Galanski et al \u003csup\u003e10\u003c/sup\u003e reported a complication rate of 43% and 38% for open and robot-assisted surgery respectively. Of note, that study was done in children, in whom complications are managed differently from adults.\u003c/p\u003e \u003cp\u003eOnly one stomal stenosis occurred during the follow-up period, and it was managed by endoscopic dilatation. This low rate of stomal stenosis could be attributed to the systematic use of the V-shaped skin flap to enlarge the circumference of the stoma as previously described \u003csup\u003e18\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study has several limitations. The first is that it was a retrospective, single center study. However, to our knowledge, it is one the largest studies of RALCCUD in adults to date with 12 individuals included. So far, only 2 retrospective case-series have been published, with follow ups of less than 24 months \u003csup\u003e13,14\u003c/sup\u003e. The second limitation is the median follow-up of only 40.3 months; however, in a retrospective study of 119 stomas, Jacobson et al \u003csup\u003e23\u003c/sup\u003e found that stomal stenosis, false passage and first complications occurred within a mean 24.2 months. However, since complications can still occur more than 10 years after the surgery \u003csup\u003e7\u003c/sup\u003e, long-term follow-up is required.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRALCCUD with Mitrofanoff and Yang-Monti conduits with or without AC seems safe and feasible in adults with NLUTD who are unable to self-catheterize through the native urethra. It seems to provide a very high short-term rate of stomal and urethral continence with a low rate of complications. Multicenter, prospective studies are now required to confirm these results and to determine the place of RALCCUD in the management of these issues.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAC= Augmentation Cystoplasty\u003c/p\u003e\n\u003cp\u003eAUS= Artificial Urinary Sphincter\u003c/p\u003e\n\u003cp\u003eBPS/IC= Bladder Pain Syndrome/Interstitial Cystitis\u003c/p\u003e\n\u003cp\u003eCCUD= Continent Cutaneous Urinary Diversion\u003c/p\u003e\n\u003cp\u003eISC= Intermittent self-catheterization\u003c/p\u003e\n\u003cp\u003eNDO= Neurogenic Detrusor Overactivity\u003c/p\u003e\n\u003cp\u003eNLUTD= Neurogenic Low Urinary Tract Dysfunction\u003c/p\u003e\n\u003cp\u003eRALCCUD= Robot Assisted Laparoscopic Continent Cutaneous Urinary Diversion\u003c/p\u003e\n\u003cp\u003eSC= Supratrigonal Cystectomy\u003c/p\u003e\n\u003cp\u003eSCI= Spinal Cord Injury\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Nantes Universit\u0026eacute;, Nantes, France.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Compliance:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Our study was approved by our local ethical committee the Institutional Ethical and Clinical Research at Nantes Universit\u0026eacute; (Groupe Nantais d\u0026apos;Ethique dans le Domaine de la Sant\u0026eacute;) review board (Nantes, 2022) number \u0026ldquo;AVIS 22-3-170\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePermission to reproduce material from other sources:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe have not used materials from other sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is a retrospective study registered at our local ethical committee at Nantes Universit\u0026eacute; \u0026ldquo;Groupe Nantais d\u0026apos;Ethique dans le Domaine de la Sant\u0026eacute;\u0026rdquo; (GNEDS) (AVIS 22-3-170).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eT. Loubersac: Protocol/project development, Data collection and management, Data analysis, Manuscript writing/editing; E. Lavall\u0026eacute;e: Data analysis, Manuscript writing/editing; B. Reiss: Data collection and management, Manuscript writing/editing; MD. Leclair : Manuscript writing/editing ; P. Kieny: Data collection and management, Data analysis, Manuscript writing/editing ; M. Le Fort : Manuscript writing/editing, L. Lenormand: Manuscript writing/editing ; ; J. Rigaud : Manuscript writing/editing ; B. Perrouin \u0026ndash; Verbe: Data collection and management, Manuscript writing/editing ; C. Lefevre: Manuscript writing/editing; \u0026nbsp; M.A. Perrouin-Verbe Protocol/project development, Data analysis, Manuscript writing/editing\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGroen J, Pannek J, Castro Diaz D, et al. Summary of European Association of Urology (EAU) Guidelines on Neuro-Urology. \u003cem\u003eEur Urol\u003c/em\u003e. 2016;69(2):324-333. doi:10.1016/j.eururo.2015.07.071\u003c/li\u003e\n\u003cli\u003ePanicker JN, Fowler CJ, Kessler TM. Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. \u003cem\u003eLancet Neurol\u003c/em\u003e. 2015;14(7):720-732. doi:10.1016/S1474-4422(15)00070-8\u003c/li\u003e\n\u003cli\u003eWeld KJ, Dmochowski RR. Effect of bladder management on urological complications in spinal cord injured patients. \u003cem\u003eJ Urol\u003c/em\u003e. 2000;163(3):768-772.\u003c/li\u003e\n\u003cli\u003eMitrofanoff P. [Trans-appendicular continent cystostomy in the management of the neurogenic bladder]. \u003cem\u003eChir Pediatr\u003c/em\u003e. 1980;21(4):297-305.\u003c/li\u003e\n\u003cli\u003eMonti PR, Lara RC, Dutra MA, de Carvalho JR. New techniques for construction of efferent conduits based on the Mitrofanoff principle. \u003cem\u003eUrology\u003c/em\u003e. 1997;49(1):112-115. doi:10.1016/S0090-4295(96)00503-1\u003c/li\u003e\n\u003cli\u003eCasale AJ. A long continent ileovesicostomy using a single piece of bowel. \u003cem\u003eJ Urol\u003c/em\u003e. 1999;162(5):1743-1745.\u003c/li\u003e\n\u003cli\u003eLiard A, S\u0026eacute;guier-Lipszyc E, Mathiot A, Mitrofanoff P. The Mitrofanoff procedure: 20 years later. \u003cem\u003eJ Urol\u003c/em\u003e. 2001;165(6 Pt 2):2394-2398. doi:10.1097/00005392-200106001-00045\u003c/li\u003e\n\u003cli\u003ePh\u0026eacute; V, Boissier R, Blok BFM, et al. Continent catheterizable tubes/stomas in adult neuro-urological patients: A systematic review. \u003cem\u003eNeurourol Urodyn\u003c/em\u003e. 2017;36(7):1711-1722. doi:10.1002/nau.23213\u003c/li\u003e\n\u003cli\u003ePedraza R, Weiser A, Franco I. LAPAROSCOPIC APPENDICOVESICOSTOMY (MITROFANOFF PROCEDURE) IN A CHILD USING THE DA VINCI ROBOTIC SYSTEM. \u003cem\u003eJ Urol\u003c/em\u003e. 2004;171(4):1652-1653. doi:10.1097/01.ju.0000116066.72132.9a\u003c/li\u003e\n\u003cli\u003eGalansky L, Andolfi C, Adamic B, Gundeti MS. Continent Cutaneous Catheterizable Channels in Pediatric Patients: A Decade of Experience with Open and Robotic Approaches in a Single Center. \u003cem\u003eEur Urol\u003c/em\u003e. 2021;79(6):866-878. doi:10.1016/j.eururo.2020.08.013\u003c/li\u003e\n\u003cli\u003eFamakinwa OJ, Rosen AM, Gundeti MS. Robot-assisted Laparoscopic Mitrofanoff Appendicovesicostomy Technique and Outcomes of Extravesical and Intravesical Approaches. \u003cem\u003eEur Urol\u003c/em\u003e. 2013;64(5):831-836. doi:10.1016/j.eururo.2013.05.007\u003c/li\u003e\n\u003cli\u003eGundeti MS, Petravick ME, Pariser JJ, et al. A multi-institutional study of perioperative and functional outcomes for pediatric robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy. \u003cem\u003eJ Pediatr Urol\u003c/em\u003e. 2016;12(6):386.e1-386.e5. doi:10.1016/j.jpurol.2016.05.031\u003c/li\u003e\n\u003cli\u003eRey D, Helou E, Oderda M, Robbiani J, Lopez L, Piechaud PT. Laparoscopic and robot-assisted continent urinary diversions (Mitrofanoff and Yang-Monti conduits) in a consecutive series of 15 adult patients: the Saint Augustin technique: Laparoscopic and robot-assisted continent urinary diversions. \u003cem\u003eBJU Int\u003c/em\u003e. Published online September 2013:n/a-n/a. doi:10.1111/bju.12257\u003c/li\u003e\n\u003cli\u003eLecoanet P, Pascal G, Khaddad A, et al. Robot-assisted continent urinary diversion according to the Mitrofanoff principle: results of a bicentric study. \u003cem\u003eWorld J Urol\u003c/em\u003e. 2021;39(6):2073-2079. doi:10.1007/s00345-020-03361-2\u003c/li\u003e\n\u003cli\u003eCaremel R, Hamel O, Gerardin E, et al. Syringomy\u0026eacute;lie post-traumatique : ce que doit savoir l\u0026rsquo;urologue ? \u003cem\u003eProg En Urol\u003c/em\u003e. 2013;23(1):8-14. doi:10.1016/j.purol.2012.09.009\u003c/li\u003e\n\u003cli\u003eLloyd JC, Nseyo U, Madden-Fuentes RJ, Ross SS, Wiener JS, Routh JC. Reviewing definitions of urinary continence in the contemporary spina bifida literature: A call for clarity. \u003cem\u003eJ Pediatr Urol\u003c/em\u003e. 2013;9(5):567-574. doi:10.1016/j.jpurol.2013.02.006\u003c/li\u003e\n\u003cli\u003eMitropoulos D, Artibani W, Biyani CS, Bjerggaard Jensen J, Roupr\u0026ecirc;t M, Truss M. Validation of the Clavien-Dindo Grading System in Urology by the European Association of Urology Guidelines Ad Hoc Panel. \u003cem\u003eEur Urol Focus\u003c/em\u003e. 2018;4(4):608-613. doi:10.1016/j.euf.2017.02.014\u003c/li\u003e\n\u003cli\u003ePerrouin-Verbe MA, Chartier-Kastler E, Even A, Denys P, Roupr\u0026ecirc;t M, Ph\u0026eacute; V. Long-term complications of continent cutaneous urinary diversion in adult spinal cord injured patients: Continent Urinary Diversion in Neurological Patiens. \u003cem\u003eNeurourol Urodyn\u003c/em\u003e. 2016;35(8):1046-1050. doi:10.1002/nau.22879\u003c/li\u003e\n\u003cli\u003eKarsenty G, Chartier-Kastler E, Mozer P, Even-Schneider A, Denys P, Richard F. A novel technique to achieve cutaneous continent urinary diversion in spinal cord-injured patients unable to catheterize through native urethra. \u003cem\u003eSpinal Cord\u003c/em\u003e. 2008;46(4):305-310. doi:10.1038/sj.sc.3102104\u003c/li\u003e\n\u003cli\u003eVanderBrink BA, Kaefer M, Cain MP, Meldrum KK, Misseri R, Rink RC. Extravesical Implantation of a Continent Catheterizable Channel. \u003cem\u003eJ Urol\u003c/em\u003e. 2011;185(6S):2572-2575. doi:10.1016/j.juro.2011.01.027\u003c/li\u003e\n\u003cli\u003eSzymanski KM, Lopez PJ, Corbetta JP, et al. Do anterior catheterizable urinary channels have fewer complications than posterior channels? An international cohort study. \u003cem\u003eJ Pediatr Urol\u003c/em\u003e. 2018;14(1):48.e1-48.e7. doi:10.1016/j.jpurol.2017.06.020\u003c/li\u003e\n\u003cli\u003eRiachy E, Defoor WR, Reddy PP, et al. Endoscopic Treatment with Dextranomer/Hyaluronic Acid for Persistent Incontinence After Continent Urinary Reconstruction. \u003cem\u003eJ Endourol\u003c/em\u003e. 2015;29(2):137-140. doi:10.1089/end.2014.0326\u003c/li\u003e\n\u003cli\u003eJacobson DL, Thomas JC, Pope J, et al. Update on Continent Catheterizable Channels and the Timing of their Complications. \u003cem\u003eJ Urol\u003c/em\u003e. 2017;197(3 Part 2):871-876. doi:10.1016/j.juro.2016.08.119\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Continent Urinary diversion, Robotic surgery, Mitrofanoff procedure, Laparoscopy, Neurogenic bladder","lastPublishedDoi":"10.21203/rs.3.rs-3575709/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3575709/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRobot assisted laparoscopic cutaneous continent urinary diversion (RALCCUD) has been shown to be feasible; however, data on clinical outcomes in adults are lacking.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials \u0026amp; Methods:\u003c/strong\u003e\u003cbr\u003e\nWe conducted a retrospective study of all adults who underwent RALCCUD between 2017 and 2022 at a single tertiary reference center.\u003cbr\u003e\nParticipant characteristics, clinical information and perioperative outcomes were recorded. All participants underwent pre and postoperative urodynamic evaluations.\u003c/p\u003e\n\u003cp\u003eFunctional outcomes were evaluated at 3 months, then yearly. Continence was defined as no stomal or urethral leakage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u003cbr\u003e\nTwelve patients, mostly women (n=11), median (IQR) age 47.4 (19-57) years underwent RALCCUD (4 Mitrofanoff, 4 Yang-Monti and 4 Casale). The main indication for surgery was inability to perform intermittent self-catheterization through the native urethra.\u003cbr\u003e\nEleven patients (92%) had neurogenic lower urinary tract disease caused by spinal cord injury or spinal dysraphism. \u003cbr\u003e\nMedian (IQR) operative time was 313 (285-367) min. Four patients (33%) underwent concomitant procedures: 3 supra-trigonal cystectomy with augmentation cystoplasty and 1 artificial urinary sphincter. No conversions to an open approach were required. Median (IQR) follow-up was 42.9 (34-53) months. One early postoperative complication occurred (Clavien grade III). The late postoperative complication rate was 17%, with 3 complications occurring in 2 patients.\u003c/p\u003e\n\u003cp\u003eAt the last follow up, all patients could self-catheterize through the tube, and the stomal and urethral continence rate was 100%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003e\u003cbr\u003e\nRALCCUD is feasible and safe in adults, with a high rate of stomal and urethral continence and a low complication rate.\u003c/p\u003e","manuscriptTitle":"Robot-assisted laparoscopic continent cutaneous urinary diversion in a single- center study; surgical technique and outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-14 08:38:26","doi":"10.21203/rs.3.rs-3575709/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1551837a-39a8-4850-b3a2-506ac5f32125","owner":[],"postedDate":"November 14th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-11-18T15:44:17+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-14 08:38:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3575709","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3575709","identity":"rs-3575709","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}