Tubeless Ureteroenteric Anastomosis in Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion does not increase the risk of anastomotic stenosis or postoperative complications

Tubeless Ureteroenteric Anastomosis in Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion does not increase the risk of anastomotic stenosis or postoperative complications | 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 Tubeless Ureteroenteric Anastomosis in Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion does not increase the risk of anastomotic stenosis or postoperative complications Zachariah Taylor, Sami Musallam, Kayla Meyer, Iman Elkhashab, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4900841/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Oct, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Objective To demonstrate that omitting ureteral stent placement in robotic intracorporeal urinary diversion does not lead to increased risk of perioperative complications, namely ureteral strictures or anastomotic leaks. Methods We retrospectively reviewed the records of 68 consecutive patients who underwent robotic radical cystectomy with ileal conduit creation or orthotopic neobladder by a single surgeon between January 2020 and September 2023. Chronologically, the first cohort of patients had ureteral stents placed to bridge the ureteroenteric anastomosis and in the second cohort stenting was omitted. Results Cohort 1 consisted of 28 patients with surgeries performed between January 2020 and April 2021, while cohort 2 had 40 patients who underwent surgery from April 2021 to September 2023. The cohorts were well matched with regards to patient age, gender, ASA score and rate of neoadjuvant chemotherapy. The choice of urinary diversion was left to surgeon and patient preference and there was no significant difference in the proportion of ileal conduits versus orthotopic neobladders within each cohort. Estimated blood loss, total operative time, inpatient length of stay and pathologic T and N staging did not statistically differ between cohorts. Overall, there was no difference in the rates of postoperative ileus, ureteral stricture, anastomotic leak, infectious complications, and 30-day readmission rates between the groups. Conclusions Tubeless ureteroenteric anastomosis in patients undergoing robotic radical cystectomy with intracorporeal diversion doesn’t appear to increase the risk of anastomotic strictures or postoperative complications. Further prospective evaluation is warranted. robotic surgery radical cystectomy ureteroenteric anastomosis ureteral stricture ureteral leak Introduction The standard of care for patients with muscle-invasive bladder cancer eligible for surgery is radical cystectomy (RC) with urinary diversion. Among diversion types, ileal conduit (IC) and orthotopic ileal neobladder (NB) are most commonly used [ 1 ]. Despite advancements in minimally invasive techniques, radical cystectomy with urinary diversion is still associated with significant perioperative morbidity and a wide array of potential complications, including ileus, bleeding, anastomotic leak, and infection [ 2 , 3 ]. The 30-day and 90-day readmission rates for this procedure are approximately 24% and 39%, respectively [ 4 ]. Long-term complications such as ureteral stricture and recurrent urinary tract infections are also common and can significantly impact quality of life [ 5 , 6 ]. Traditionally stenting of the ureterointestinal anastomosis was thought to minimize anastomotic complications by diverting urine and providing a scaffolding for healing. However, minimal data exists demonstrating the benefit of ureteral stenting on postoperative outcomes [ 7 ]. There is now a growing body of evidence that reduced duration or even omission of ureteral stents is safe and feasible [ 8 , 9 , 10 , 11 ]. In this study, we aim to provide further evidence that omission of ureteral stenting during robotic intracorporeal urinary diversion does not increase the rates of anastomotic stenosis or postoperative complications. Methods A retrospective review was conducted to identify consecutive patients who underwent radical cystectomy with robotic intracorporeal ileal conduit or orthotopic neobladder by a single surgeon between January 2020 and September 2023. No patients were excluded from the study. None of the patients had previous pelvic radiation therapy and none of the patient has preoperative hydronephrosis or duplex collecting system. All cases were performed at a single institution using the Da Vinci Xi surgical system. Ileal conduits were constructed from 20 cm of distal ileum, and ureters were spatulated and anastomosed independently in an end-to-side fashion. Orthotopic neobladders consisted of 40–50 cm of detubularized ileum reconfigured in a spherical shape, with ureters spatulated and anastomosed to the lateral edges. All ureteroenteric anastomoses were performed intracorporeally. Intraoperative indocyanine green was not used. The study comprised two cohorts. In cohort one (C1), 8 French feeding tubes were inserted across the ureterointestinal anastomosis during surgery and removed after approximately 2 weeks regardless if they had IC or NB creation. The patients in cohort two (C2) did not have any tube utilized in the creation of their anastomosis and did not have an indwelling ureteral stent placed intraoperatively. Patient demographics, perioperative, pathological, and postoperative data were extracted and analyzed. Indexed perioperative variables included age, BMI, ASA score, pathologic tumor and nodal stage, estimated blood loss, operative time, and ureteral stent placement (C1 vs. C2). Postoperative variables included the rate of anastomotic urinary leak, postoperative ileus, ureteral stricture, postoperative UTI, and 30-day readmission. Statistical analysis was conducted using R statistical Software (v4.1.2; R Core Team 2021). Significance was set at the 5% level, and all statistical tests were two-sided. Demographic and disease characteristics were summarized using means and standard deviations for normally distributed continuous data, and medians with interquartile range for categorical data. Primary outcomes included the rates of anastomotic leak, ureteral stricture, UTI, and 30-day readmission for C1 versus C2. Results Sixty-eight patients, totaling 136 renal units, were included in the study. Among them, 25 patients underwent RC with NB formation, while 43 underwent RC with IC. The cohort comprised 54 male and 14 female patients, with an average BMI of 27.3 (SD = 5.1). There were no significant differences between C1 and C2 in terms of age (74.1 (SD = 8.9) vs 74.3 (SD = 8.3), p = 0.885), gender (85.7% male vs 75.0% male, p = 0.319), ASA score (75.0% ASA 3 vs 87.5% ASA 3, p = 0.279), or rates of preoperative neoadjuvant chemotherapy (32.1% vs 32.5%, p = 0.975). Table 1 : Demographic and Disease Characteristics Table 1 patient, operative, and oncologic characteristicsSD = standard deviation, BMI = body mass index, ASA = American anesthesia score, EBL = estimated blood loss Variable Total Ureteral Stents (C1) No Stents (C2) P-Value Patients 68 28 40 Renal Units 136 56 80 Age (SD) 74.1 (8.9) 74.3 (8.3) 74.0 (9.5) 0.89 Sex 0.32 M 54 24 (85.7%) 30 (75.0%) F 14 4 (14.3%) 10 (25.0%) BMI (SD) 27.3 (5.1) 26.2 (4.4) 28.1 (4.4) 0.08 ASA Score (%) 0.34 2 11 6 (21.4%) 5 (12.5%) 3 56 21 (75.0%) 35 (87.5%) 4 1 1 (3.6%) 0 Previous Pelvic Radiation 0 0 0 Neoadjuvant (%) 0.98 Yes 22 9 (32.1%) 13 (32.5%) No 46 19 (68.9%) 27 (67.5%) Operative Time (SD) 391.0 (73.0) 392 (80.8) 399.8 (67.4) 0.80 EBL (SD) 350.7 (257.6) 339.3 (232.3) 330.0 (192.4) 0.64 Hospital days (SD) 8.9 (3.70) 8.3 (3.4) 8.8 (3.3) 0.55 Urinary diversion Type 0.38 Orthotopic Neobladder (%) 25 12 (42.9%) 13 (32.5%) Ileal Conduit (%) 43 16 (57.1%) 27 (67.5%) Pathologic T Stage (%) 0.836 ≤pT2 (organ confined) 46 20 (71.4%) 26 (65.0%) ≥pT3 (locally advanced) 22 8 (28.6%) 14 (35.0%) Pathologic N stage (%) 0.562 N0/Nx 51 22 (78.6%) 29 (72.5%) N1-3 17 6 (21.4%) 11 (27.5%) Follow-up, months (SD) 16.3 (13.6) 25.1 (15.7) 10.9 (7.9) < 0.0001 The average operative time for all cases was 391.0 (SD = 73.0) minutes, with an average estimated blood loss of 350.7 (SD = 257.6) mL. There was no difference between C1 and C2 regarding operative time (392.0 (SD = 80.8) vs 399.8 (SD = 67.4), p = 0.801) or estimated blood loss (339.3 (SD = 232.3) vs 330.0 (SD = 192.4), p = 0.636). The average length of stay was 8.3 days for C1 and 8.8 days for C2, with no statistical significance found (p = 0.55). The distribution of urinary diversion types also showed no significant difference (57.1% IC for C1 vs. 67.5% IC for C2, p = 0.383). Regarding pathologic characteristics, 67.6% of total cases had organ-confined disease (≤ pT2), with no significant difference between cohorts (71.4% of C1 and 65.0% of C2, p = 0.836). Similarly, there was no difference in pathologic nodal stage between the two cohorts, with 78.6% of C1 and 72.5% of C2 being N0 or Nx (p = 0.562). Table 2 Rates of postoperative complications C1 (28) C2 (40) P-Value C1 with IC (16) C2 with IC (27) P Value C1 with NB (12) C2 with NB (13) P-Value Ileus (%) 0.43 0.66 0.38 Yes 11 (39.2) 12 (30.0) 7 (43.8) 10 (37.0) 4 (33.3) 2 (18.2) No 17 (40.8) 28 (70.0) 9 (56.2) 17 (63.0) 8 (67.7) 11(81.8) Stricture (%) 0.76 0.70 1.0 Yes 1 (3.6) 2 (5.0) 1 (6.3) 1 (3.7) 0 (0.0) 1 (7.7) No 27 (96.4) 38 (95.0) 15 (93.7) 26 (96.3) 12 (100.0) 12 (92.3) Leak (%) 0.96 0.28 0.22 Yes 2 (7.1) 3 (7.5) 0 (0.0) 3 (11.1) 2 (16.7) 0 (0.0) No 26 (92.9) 37 (92.5) 16 (100.0) 24 (88.9) 10 (83.3) 13 (100.0) Infection (%) 0.5 0.52 1.0 Yes 1 (3.6) 3 (7.5) 0 (0.0) 2 (7.4) 1 (8.3) 1 (7.7) No 27 (96.4) 37 (92.5) 16 (100.0) 25 (92.6) 11 (91.7) 12 (92.3) 30-day Readmission (%) 0.74 1.0 0.38 Yes 8 (28.6) 10 (25.0) 4 (25.0) 8 (29.6) 4 (33.3) 2 (18.2) No 20 (71.4) 30 (75.0) 12 (75.0) 19 (70.4) 8 (67.7) 11(81.8) Postoperative ileus occurred in 39.3% of patients in C1 compared to 30.0% in C2 (p = 0.43). Only 7.7% of patients in C1 and 7.5% in C2 experienced an anastomotic leak (p = 0.96). Additionally, 3.6% of C1 patients and 5.0% of C2 patients were diagnosed with ureteral stricture from surgery to the most recent follow-up (p = 0.76). There was no statistical difference in the rate of 30-day infectious complications, such as urinary tract infection, sepsis, or abdominal abscess, with only 3.6% of patients in C1 and 7.5% in C2 experiencing infection within this period (p = 0.50). Furthermore, there was no significant difference in 30-day readmission rates between cohorts (28.6% in C1 versus 25.0% in C2, p = 0.74). A subanalysis of postoperative complications stratified by the type of urinary diversion is also presented in Table 2 . In patients with both ileal conduits and orthotopic neobladders, the rates of ileus, infection, 30-day readmission, and ureteral stricture were independent of stent usage. Discussion Radical cystectomy and urinary diversion remain associated with significant morbidity, much of which arises from complications related to urinary diversion and ureteroenteric anastomosis. Traditionally, many urologists have utilized ureteral stents to mitigate these complications. Our study contributes to the growing body of evidence indicating that forgoing ureteral stent placement at the time of urinary diversion does not elevate rates of readmission, postoperative complications, anastomotic leak, or anastomotic stenosis. These findings held true for patients undergoing either incontinent or continent orthotopic urinary diversion. In our study, three patients developed ureteral strictures. All patients were diagnosed with hydronephrosis through routine surveillance imaging. Further evaluations included diversion-specific imaging (loopogram), functional assessment of the kidneys using a Lasix renal scan, and endoscopic evaluation (looposcopy, retrograde pyelography, and ureteroscopy). All patients exhibited either partial or complete obstruction on their renal scans. One patient, who underwent NB creation without ureteral stent placement, was diagnosed with a stricture approximately 6 months after cystectomy. The stricture was located at the level of the pelvic inlet and has been managed with endoscopic balloon dilation and ureteral stent placement. Another patient, who underwent IC creation with ureteral stent placement, was diagnosed with a ureteral stricture 19 months after cystectomy. The stricture was identified at the level of the ureteroenteric anastomosis. The patient is asymptomatic from the stricture, and functional evaluation of the affected kidney revealed minimal contribution. Given these findings, the patient has not undergone further intervention for the ureteral stricture. The final patient, who underwent IC creation without ureteral stent placement, was diagnosed with a stricture approximately 9 months following cystectomy. Loopogram and looposcopy were unable to identify the obstructed ureter, suggesting the obstruction was at the level of the ureteroenteric anastomosis. The patient has deferred nephrostomy tube placement and has opted for monitoring of renal function and serial imaging to track the progression of hydronephrosis. Readmission rates following radical cystectomy are high, with recent studies reporting 30-day readmission rates of up to 23.5% [ 4 ]. This imposes a significant burden on patients, healthcare providers, and the healthcare system [12]. Recent findings have shown that healthcare costs are 1.42 times higher for those readmitted within 30 days following surgery [13]. Our study suggests that omission of ureteral stent placement does not increase readmission rates. Interestingly, patients with stented anastomosis during orthotopic urinary diversion had a higher readmission rate compared to those without. This observation may be attributed to increased bacterial colonization, impaired mucus drainage, or higher rates of transient bacteremia during stent removal. Further prospective investigation with a larger sample size is warranted. Ureteroenteric anastomotic complications remain a significant concern for surgeons. In our study, we evaluated both anastomotic leak and ureteral stricture rate. Neither complication was significantly higher in the tubeless anastomosis group. Traditionally, ureteral stents at the time of urinary diversion were believed to minimize these complications, though recent literature does not support this hypothesis [ 10 ]. Previous studies have indicated that suture type and running anastomosis can increase anastomotic stricture risk. In our study, each ureteroenteric anastomosis was sutured in an interrupted fashion, and all but one of the anastomotic complications occurred on the left side [ 10 ]. This aligns with previous literature detailing a high risk of stricture on the left, likely due to increased tension and ureteral ischemia associated with passing the left ureter beneath the sigmoid mesentery [ 10 ] Urinary tract infections are prevalent in patients who have undergone radical cystectomy with urinary diversion, with recent studies demonstrating infection rates as high as 17% [ 3 ]. These infections lead to a significant number of readmissions and septic events. A recent study by Donat et al. showed that forgoing ureteral stenting at the time of cystectomy results in a lower rate of urinary tract infection. Only 14% of patients in the tubeless group in their study developed a symptomatic urinary tract infection within 30 days, significantly lower than the stented group with a urinary tract infection rate of 32% [ 9 ]. Furthermore, they found that the risk of bacteremia and urinary tract infection peaked within 24 hours of stent removal [ 9 ]. Although we did not find any statistically significant difference in infectious complications, the rate of perioperative infections in our tubeless cohort was not significantly lower. Our study has several limitations. We acknowledge the inherent selection bias of the retrospective study design. Furthermore, our conclusions are limited by a small sample size, resulting in insufficient power to detect significant differences. The rate of stricture development can increase over time, the short follow-up in our study may not account for development of strictures further from their operation. Studies with longer follow-up time should be conducted to better detail risk of stricture development. Our findings are concept-generating only, and further investigation, ideally through a prospective multi-institutional trial with a larger sample size, longer follow-up, and validated patient-related outcomes, is necessary. Conclusion Contrary to the prevailing dogma, our experience has demonstrated that omission of ureteral stenting does not increase the risk of postsurgical complications in patients undergoing robotic urinary diversion. Our results align with other contemporary series suggesting that ureteral stents may be safely omitted. Declarations Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author contributions: All authors significantly contributed to the study conception and design. Material preparation and data collection were primarily performed by Sami Musallam, Kayla Meyer, Brian Thomas, Iman Elkhashab, and Zachariah Taylor. The first draft of the manuscript was written by Zachariah Taylor and Zachary Snow. All authors contributed to the editing of the manuscript for clarity, grammar, and content. All authors read and approved the final manuscript. Ethics approval: This is an observational study. The Main Line Health research ethics committee has determined it to be exempt. References Almassi N, Bochner BH. Ileal conduit or orthotopic neobladder: selection and contemporary patterns of use. Curr Opin Urol. 2020;30(3):415–420. doi: 10.1097/MOU.0000000000000738 . PMID: 32141937; PMCID: PMC8261790. Yuh BE, Nazmy M, Ruel NH, Jankowski JT, Menchaca AR, Torrey RR, Linehan JA, Lau CS, Chan KG, Wilson TG. Standardized analysis of frequency and severity of complications after robot-assisted radical cystectomy. Eur Urol. 2012;62(5):806–13. doi: 10.1016/j.eururo.2012.06.007 . Epub 2012 Jun 13. PMID: 22705382. Katsimperis S, Tzelves L, Tandogdu Z, Ta A, Geraghty R, Bellos T, Manolitsis I, Pyrgidis N, Schulz GB, Sridhar A, Shaw G, Kelly J, Skolarikos A. Complications After Radical Cystectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials with a Meta-regression Analysis. Eur Urol Focus. 2023;9(6):920–929. doi: 10.1016/j.euf.2023.05.002. Epub 2023 May 26. PMID: 37246124. Chappidi MR, Escobar D, Meng MV, Washington SL 3rd, Porten SP. Readmissions trends following radical cystectomy for bladder cancer unchanged in the era of enhanced recovery after surgery (ERAS) protocols. Urol Oncol. 2023;41(8):355.e19-355.e28. doi: 10.1016/j.urolonc.2023.05.010 . Epub 2023 May 30. PMID: 37258373. Shimko MS, Tollefson MK, Umbreit EC, Farmer SA, Blute ML, Frank I. Long-term complications of conduit urinary diversion. J Urol. 2011;185(2):562–7. doi: 10.1016/j.juro.2010.09.096 . Epub 2010 Dec 18. PMID: 21168867. Browne E, Lawrentschuk N, Jack GS, Davis NF. A systematic review and meta-analysis of the long-term outcomes of ileal conduit and orthotopic neobladder urinary diversion. Can Urol Assoc J. 2021;15(1):E48-E57. doi: 10.5489/cuaj.6466 . PMID: 32701445; PMCID: PMC7769520. Matin SF, Gill IS. Laparoscopic radical cystectomy with urinary diversion: completely intracorporeal technique. J Endourol. 2002;16(6):335 – 41; discussion 341. doi: 10.1089/089277902760261338 . PMID: 12227904. Beano H, He J, Hensel C, Worrilow W, Townsend W, Gaston K, Clark PE, Riggs S. Safety of decreasing ureteral stent duration following radical cystectomy. World J Urol. 2021;39(2):473–479. doi: 10.1007/s00345-020-03191-2 . Epub 2020 Apr 17. PMID: 32303901. Donat SM, Tan KS, Jibara G, Dalbagni G, Carlon VA, Sandhu J. Intraoperative Ureteral Stent Use at Radical Cystectomy is Associated with Higher 30-Day Complication Rates. J Urol. 2021;205(2):483–490. doi: 10.1097/JU.0000000000001329 . Epub 2020 Aug 17. PMID: 33238829; PMCID: PMC8162033. Lee CU, Lee JH, Lee DH, Song W. Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder. J Clin Med. 2021;10(22):5372. doi: 10.3390/jcm10225372 . PMID: 34830652; PMCID: PMC8624446. Tan WP, Whelan P, Deane LA. Intentional Omission of Ureteral Stents During Robotic-assisted Intracorporeal Ureteroenteric Anastomosis: Is It Safe and Feasible? Urology. 2017;102:116–120. doi: 10.1016/j.urology.2017.01.014 . Epub 2017 Jan 19. PMID: 28111222. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Oct, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 14 Sep, 2024 Reviews received at journal 10 Sep, 2024 Reviewers agreed at journal 08 Sep, 2024 Reviewers agreed at journal 06 Sep, 2024 Reviewers agreed at journal 06 Sep, 2024 Reviewers invited by journal 06 Sep, 2024 Editor assigned by journal 14 Aug, 2024 Submission checks completed at journal 14 Aug, 2024 First submitted to journal 12 Aug, 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. 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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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-4900841","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":352022905,"identity":"2440333d-7aa5-4b65-a294-5302d4c5b520","order_by":0,"name":"Zachariah Taylor","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYHACxgNAQo6BnYdI9SB1IC3GDMykaklsIFqLPfsZgwMf99Slr23mPfyBoeKeXQNBW3hyDA7OeMaWu+0wX5oEw5niZMJaGHIMDvMc4AFq4TFjYGxLSCboMB7+NyAtEulmh3mMPxCnRQJsi0ECUIuBBFCLHWEtN54VHJxxIMEQ5DCJhDMJCQS1sPcnb3zw4UCdvNnxHuMPHyoS7AlqYWDgMECwE0ARRFgL+wMULjG2jIJRMApGwQgDAIL1O2smI9kVAAAAAElFTkSuQmCC","orcid":"","institution":"Main Line Health","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Zachariah","middleName":"","lastName":"Taylor","suffix":""},{"id":352022906,"identity":"9c7a7433-d849-42d8-8497-18f91fea45f0","order_by":1,"name":"Sami Musallam","email":"","orcid":"","institution":"Main Line Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sami","middleName":"","lastName":"Musallam","suffix":""},{"id":352022907,"identity":"ffbd1a45-7b29-4334-9356-80533c8955d2","order_by":2,"name":"Kayla Meyer","email":"","orcid":"","institution":"Philadelphia College of Osteopathic Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kayla","middleName":"","lastName":"Meyer","suffix":""},{"id":352022908,"identity":"e3562eb4-738c-41b8-b409-e28e16c7319f","order_by":3,"name":"Iman Elkhashab","email":"","orcid":"","institution":"Philadelphia College of Osteopathic Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Iman","middleName":"","lastName":"Elkhashab","suffix":""},{"id":352022909,"identity":"8e840945-15cc-428b-b79b-0fc8d71e74d5","order_by":4,"name":"Brian Thomas","email":"","orcid":"","institution":"Main Line Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Thomas","suffix":""},{"id":352022910,"identity":"f15416c1-20d2-42b4-839b-00fcaa171c21","order_by":5,"name":"Zachary Snow","email":"","orcid":"","institution":"Main Line Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zachary","middleName":"","lastName":"Snow","suffix":""},{"id":352022911,"identity":"23b7e303-3fb8-4f18-abae-69e2cb60f442","order_by":6,"name":"Ilia Zeltser","email":"","orcid":"","institution":"Bryn Mawr Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ilia","middleName":"","lastName":"Zeltser","suffix":""}],"badges":[],"createdAt":"2024-08-12 13:21:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4900841/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4900841/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-024-02116-0","type":"published","date":"2024-10-05T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66096666,"identity":"d8bfeec1-9ac9-4ff8-873d-e6ebf4140456","added_by":"auto","created_at":"2024-10-07 16:06:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":461398,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4900841/v1/87081f05-72c2-402b-979d-9e4789328fc3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tubeless Ureteroenteric Anastomosis in Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion does not increase the risk of anastomotic stenosis or postoperative complications","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe standard of care for patients with muscle-invasive bladder cancer eligible for surgery is radical cystectomy (RC) with urinary diversion. Among diversion types, ileal conduit (IC) and orthotopic ileal neobladder (NB) are most commonly used [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite advancements in minimally invasive techniques, radical cystectomy with urinary diversion is still associated with significant perioperative morbidity and a wide array of potential complications, including ileus, bleeding, anastomotic leak, and infection [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The 30-day and 90-day readmission rates for this procedure are approximately 24% and 39%, respectively [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Long-term complications such as ureteral stricture and recurrent urinary tract infections are also common and can significantly impact quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTraditionally stenting of the ureterointestinal anastomosis was thought to minimize anastomotic complications by diverting urine and providing a scaffolding for healing. However, minimal data exists demonstrating the benefit of ureteral stenting on postoperative outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. There is now a growing body of evidence that reduced duration or even omission of ureteral stents is safe and feasible [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In this study, we aim to provide further evidence that omission of ureteral stenting during robotic intracorporeal urinary diversion does not increase the rates of anastomotic stenosis or postoperative complications.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eA retrospective review was conducted to identify consecutive patients who underwent radical cystectomy with robotic intracorporeal ileal conduit or orthotopic neobladder by a single surgeon between January 2020 and September 2023. No patients were excluded from the study. None of the patients had previous pelvic radiation therapy and none of the patient has preoperative hydronephrosis or duplex collecting system. All cases were performed at a single institution using the Da Vinci Xi surgical system. Ileal conduits were constructed from 20 cm of distal ileum, and ureters were spatulated and anastomosed independently in an end-to-side fashion. Orthotopic neobladders consisted of 40–50 cm of detubularized ileum reconfigured in a spherical shape, with ureters spatulated and anastomosed to the lateral edges. All ureteroenteric anastomoses were performed intracorporeally. Intraoperative indocyanine green was not used. The study comprised two cohorts. In cohort one (C1), 8 French feeding tubes were inserted across the ureterointestinal anastomosis during surgery and removed after approximately 2 weeks regardless if they had IC or NB creation. The patients in cohort two (C2) did not have any tube utilized in the creation of their anastomosis and did not have an indwelling ureteral stent placed intraoperatively. Patient demographics, perioperative, pathological, and postoperative data were extracted and analyzed. Indexed perioperative variables included age, BMI, ASA score, pathologic tumor and nodal stage, estimated blood loss, operative time, and ureteral stent placement (C1 vs. C2). Postoperative variables included the rate of anastomotic urinary leak, postoperative ileus, ureteral stricture, postoperative UTI, and 30-day readmission.\u003c/p\u003e\u003cp\u003eStatistical analysis was conducted using R statistical Software (v4.1.2; R Core Team 2021). Significance was set at the 5% level, and all statistical tests were two-sided. Demographic and disease characteristics were summarized using means and standard deviations for normally distributed continuous data, and medians with interquartile range for categorical data. Primary outcomes included the rates of anastomotic leak, ureteral stricture, UTI, and 30-day readmission for C1 versus C2.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSixty-eight patients, totaling 136 renal units, were included in the study. Among them, 25 patients underwent RC with NB formation, while 43 underwent RC with IC. The cohort comprised 54 male and 14 female patients, with an average BMI of 27.3 (SD\u0026thinsp;=\u0026thinsp;5.1). There were no significant differences between C1 and C2 in terms of age (74.1 (SD\u0026thinsp;=\u0026thinsp;8.9) vs 74.3 (SD\u0026thinsp;=\u0026thinsp;8.3), p\u0026thinsp;=\u0026thinsp;0.885), gender (85.7% male vs 75.0% male, p\u0026thinsp;=\u0026thinsp;0.319), ASA score (75.0% ASA 3 vs 87.5% ASA 3, p\u0026thinsp;=\u0026thinsp;0.279), or rates of preoperative neoadjuvant chemotherapy (32.1% vs 32.5%, p\u0026thinsp;=\u0026thinsp;0.975).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: Demographic and Disease Characteristics\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, operative, and oncologic characteristicsSD\u0026thinsp;=\u0026thinsp;standard deviation, BMI\u0026thinsp;=\u0026thinsp;body mass index, ASA\u0026thinsp;=\u0026thinsp;American anesthesia score, EBL\u0026thinsp;=\u0026thinsp;estimated blood loss\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUreteral Stents (C1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo Stents (C2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal Units\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.1 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.3 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74.0 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\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=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (85.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (75.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.3 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.2 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA Score (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\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=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.34\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\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (21.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\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\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (75.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (87.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\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\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious Pelvic Radiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\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=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\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\u003e9 (32.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (32.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (68.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (67.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative Time (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e391.0 (73.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e392 (80.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e399.8 (67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEBL (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e350.7 (257.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e339.3 (232.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e330.0 (192.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital days (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.9 (3.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.8 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary diversion Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\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=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthotopic Neobladder (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (32.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleal Conduit (%)\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\u003e16 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (67.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathologic T Stage (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\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=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.836\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;pT2 (organ confined)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (71.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (65.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;pT3 (locally advanced)\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\u003e8 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (35.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathologic N stage (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\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=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN0/Nx\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\u003e22 (78.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (72.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN1-3\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\u003e6 (21.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (27.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up, months (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.3 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.1 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.9 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe average operative time for all cases was 391.0 (SD\u0026thinsp;=\u0026thinsp;73.0) minutes, with an average estimated blood loss of 350.7 (SD\u0026thinsp;=\u0026thinsp;257.6) mL. There was no difference between C1 and C2 regarding operative time (392.0 (SD\u0026thinsp;=\u0026thinsp;80.8) vs 399.8 (SD\u0026thinsp;=\u0026thinsp;67.4), p\u0026thinsp;=\u0026thinsp;0.801) or estimated blood loss (339.3 (SD\u0026thinsp;=\u0026thinsp;232.3) vs 330.0 (SD\u0026thinsp;=\u0026thinsp;192.4), p\u0026thinsp;=\u0026thinsp;0.636). The average length of stay was 8.3 days for C1 and 8.8 days for C2, with no statistical significance found (p\u0026thinsp;=\u0026thinsp;0.55). The distribution of urinary diversion types also showed no significant difference (57.1% IC for C1 vs. 67.5% IC for C2, p\u0026thinsp;=\u0026thinsp;0.383).\u003c/p\u003e \u003cp\u003eRegarding pathologic characteristics, 67.6% of total cases had organ-confined disease (\u0026le;\u0026thinsp;pT2), with no significant difference between cohorts (71.4% of C1 and 65.0% of C2, p\u0026thinsp;=\u0026thinsp;0.836). Similarly, there was no difference in pathologic nodal stage between the two cohorts, with 78.6% of C1 and 72.5% of C2 being N0 or Nx (p\u0026thinsp;=\u0026thinsp;0.562).\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\u003eRates of postoperative complications\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC1 (28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eC2 (40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC1 with IC (16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eC2 with IC (27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eC1 with NB (12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eC2 with NB (13)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIleus (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003cp\u003e(39.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10 (37.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (40.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (56.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17 (63.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8 (67.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e11(81.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStricture (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (96.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (95.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15 (93.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26 (96.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e12 (92.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeak (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (92.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e13 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (96.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (92.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25 (92.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e11 (91.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e12 (92.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day Readmission (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19 (70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e8 (67.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e11(81.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostoperative ileus occurred in 39.3% of patients in C1 compared to 30.0% in C2 (p\u0026thinsp;=\u0026thinsp;0.43). Only 7.7% of patients in C1 and 7.5% in C2 experienced an anastomotic leak (p\u0026thinsp;=\u0026thinsp;0.96). Additionally, 3.6% of C1 patients and 5.0% of C2 patients were diagnosed with ureteral stricture from surgery to the most recent follow-up (p\u0026thinsp;=\u0026thinsp;0.76). There was no statistical difference in the rate of 30-day infectious complications, such as urinary tract infection, sepsis, or abdominal abscess, with only 3.6% of patients in C1 and 7.5% in C2 experiencing infection within this period (p\u0026thinsp;=\u0026thinsp;0.50). Furthermore, there was no significant difference in 30-day readmission rates between cohorts (28.6% in C1 versus 25.0% in C2, p\u0026thinsp;=\u0026thinsp;0.74).\u003c/p\u003e \u003cp\u003eA subanalysis of postoperative complications stratified by the type of urinary diversion is also presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In patients with both ileal conduits and orthotopic neobladders, the rates of ileus, infection, 30-day readmission, and ureteral stricture were independent of stent usage.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRadical cystectomy and urinary diversion remain associated with significant morbidity, much of which arises from complications related to urinary diversion and ureteroenteric anastomosis. Traditionally, many urologists have utilized ureteral stents to mitigate these complications. Our study contributes to the growing body of evidence indicating that forgoing ureteral stent placement at the time of urinary diversion does not elevate rates of readmission, postoperative complications, anastomotic leak, or anastomotic stenosis. These findings held true for patients undergoing either incontinent or continent orthotopic urinary diversion.\u003c/p\u003e \u003cp\u003eIn our study, three patients developed ureteral strictures. All patients were diagnosed with hydronephrosis through routine surveillance imaging. Further evaluations included diversion-specific imaging (loopogram), functional assessment of the kidneys using a Lasix renal scan, and endoscopic evaluation (looposcopy, retrograde pyelography, and ureteroscopy). All patients exhibited either partial or complete obstruction on their renal scans.\u003c/p\u003e \u003cp\u003eOne patient, who underwent NB creation without ureteral stent placement, was diagnosed with a stricture approximately 6 months after cystectomy. The stricture was located at the level of the pelvic inlet and has been managed with endoscopic balloon dilation and ureteral stent placement. Another patient, who underwent IC creation with ureteral stent placement, was diagnosed with a ureteral stricture 19 months after cystectomy. The stricture was identified at the level of the ureteroenteric anastomosis. The patient is asymptomatic from the stricture, and functional evaluation of the affected kidney revealed minimal contribution. Given these findings, the patient has not undergone further intervention for the ureteral stricture. The final patient, who underwent IC creation without ureteral stent placement, was diagnosed with a stricture approximately 9 months following cystectomy. Loopogram and looposcopy were unable to identify the obstructed ureter, suggesting the obstruction was at the level of the ureteroenteric anastomosis. The patient has deferred nephrostomy tube placement and has opted for monitoring of renal function and serial imaging to track the progression of hydronephrosis.\u003c/p\u003e \u003cp\u003eReadmission rates following radical cystectomy are high, with recent studies reporting 30-day readmission rates of up to 23.5% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This imposes a significant burden on patients, healthcare providers, and the healthcare system [12]. Recent findings have shown that healthcare costs are 1.42 times higher for those readmitted within 30 days following surgery [13]. Our study suggests that omission of ureteral stent placement does not increase readmission rates. Interestingly, patients with stented anastomosis during orthotopic urinary diversion had a higher readmission rate compared to those without. This observation may be attributed to increased bacterial colonization, impaired mucus drainage, or higher rates of transient bacteremia during stent removal. Further prospective investigation with a larger sample size is warranted.\u003c/p\u003e \u003cp\u003eUreteroenteric anastomotic complications remain a significant concern for surgeons. In our study, we evaluated both anastomotic leak and ureteral stricture rate. Neither complication was significantly higher in the tubeless anastomosis group. Traditionally, ureteral stents at the time of urinary diversion were believed to minimize these complications, though recent literature does not support this hypothesis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Previous studies have indicated that suture type and running anastomosis can increase anastomotic stricture risk. In our study, each ureteroenteric anastomosis was sutured in an interrupted fashion, and all but one of the anastomotic complications occurred on the left side [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This aligns with previous literature detailing a high risk of stricture on the left, likely due to increased tension and ureteral ischemia associated with passing the left ureter beneath the sigmoid mesentery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eUrinary tract infections are prevalent in patients who have undergone radical cystectomy with urinary diversion, with recent studies demonstrating infection rates as high as 17% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These infections lead to a significant number of readmissions and septic events. A recent study by Donat et al. showed that forgoing ureteral stenting at the time of cystectomy results in a lower rate of urinary tract infection. Only 14% of patients in the tubeless group in their study developed a symptomatic urinary tract infection within 30 days, significantly lower than the stented group with a urinary tract infection rate of 32% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, they found that the risk of bacteremia and urinary tract infection peaked within 24 hours of stent removal [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although we did not find any statistically significant difference in infectious complications, the rate of perioperative infections in our tubeless cohort was not significantly lower.\u003c/p\u003e \u003cp\u003eOur study has several limitations. We acknowledge the inherent selection bias of the retrospective study design. Furthermore, our conclusions are limited by a small sample size, resulting in insufficient power to detect significant differences. The rate of stricture development can increase over time, the short follow-up in our study may not account for development of strictures further from their operation. Studies with longer follow-up time should be conducted to better detail risk of stricture development. Our findings are concept-generating only, and further investigation, ideally through a prospective multi-institutional trial with a larger sample size, longer follow-up, and validated patient-related outcomes, is necessary.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eContrary to the prevailing dogma, our experience has demonstrated that omission of ureteral stenting does not increase the risk of postsurgical complications in patients undergoing robotic urinary diversion. Our results align with other contemporary series suggesting that ureteral stents may be safely omitted.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eCompeting Interests: The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eAuthor contributions: All authors significantly contributed to the study conception and design. Material preparation and data collection were primarily performed by Sami Musallam, Kayla Meyer, Brian Thomas, Iman Elkhashab, and Zachariah Taylor. The first draft of the manuscript was written by Zachariah Taylor and Zachary Snow. All authors contributed to the editing of the manuscript for clarity, grammar, and content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eEthics approval: This is an observational study. The Main Line Health research ethics committee has determined it to be exempt.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlmassi N, Bochner BH. Ileal conduit or orthotopic neobladder: selection and contemporary patterns of use. Curr Opin Urol. 2020;30(3):415\u0026ndash;420. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MOU.0000000000000738\u003c/span\u003e\u003cspan address=\"10.1097/MOU.0000000000000738\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 32141937; PMCID: PMC8261790.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuh BE, Nazmy M, Ruel NH, Jankowski JT, Menchaca AR, Torrey RR, Linehan JA, Lau CS, Chan KG, Wilson TG. 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PMID: 32303901.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonat SM, Tan KS, Jibara G, Dalbagni G, Carlon VA, Sandhu J. Intraoperative Ureteral Stent Use at Radical Cystectomy is Associated with Higher 30-Day Complication Rates. J Urol. 2021;205(2):483\u0026ndash;490. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/JU.0000000000001329\u003c/span\u003e\u003cspan address=\"10.1097/JU.0000000000001329\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2020 Aug 17. PMID: 33238829; PMCID: PMC8162033.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee CU, Lee JH, Lee DH, Song W. Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder. 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PMID: 28111222.\u003c/span\u003e\u003c/li\u003e\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":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"robotic surgery, radical cystectomy, ureteroenteric anastomosis, ureteral stricture, ureteral leak","lastPublishedDoi":"10.21203/rs.3.rs-4900841/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4900841/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo demonstrate that omitting ureteral stent placement in robotic intracorporeal urinary diversion does not lead to increased risk of perioperative complications, namely ureteral strictures or anastomotic leaks.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e We retrospectively reviewed the records of 68 consecutive patients who underwent robotic radical cystectomy with ileal conduit creation or orthotopic neobladder by a single surgeon between January 2020 and September 2023. Chronologically, the first cohort of patients had ureteral stents placed to bridge the ureteroenteric anastomosis and in the second cohort stenting was omitted.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCohort 1 consisted of 28 patients with surgeries performed between January 2020 and April 2021, while cohort 2 had 40 patients who underwent surgery from April 2021 to September 2023. The cohorts were well matched with regards to patient age, gender, ASA score and rate of neoadjuvant chemotherapy. The choice of urinary diversion was left to surgeon and patient preference and there was no significant difference in the proportion of ileal conduits versus orthotopic neobladders within each cohort. Estimated blood loss, total operative time, inpatient length of stay and pathologic T and N staging did not statistically differ between cohorts. Overall, there was no difference in the rates of postoperative ileus, ureteral stricture, anastomotic leak, infectious complications, and 30-day readmission rates between the groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eTubeless ureteroenteric anastomosis in patients undergoing robotic radical cystectomy with intracorporeal diversion doesn\u0026rsquo;t appear to increase the risk of anastomotic strictures or postoperative complications. Further prospective evaluation is warranted.\u003c/p\u003e","manuscriptTitle":"Tubeless Ureteroenteric Anastomosis in Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion does not increase the risk of anastomotic stenosis or postoperative complications","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-11 07:33:38","doi":"10.21203/rs.3.rs-4900841/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-14T16:47:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-10T11:47:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298403694180956952435942771559690591696","date":"2024-09-08T16:53:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180226733032686195356871472601382810625","date":"2024-09-06T18:47:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201722545498555167590044707188524205392","date":"2024-09-06T15:53:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-06T15:44:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-14T16:19:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-14T06:59:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2024-08-12T13:18:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"757b8022-b1b2-4967-9d75-13895884e672","owner":[],"postedDate":"September 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-07T15:59:00+00:00","versionOfRecord":{"articleIdentity":"rs-4900841","link":"https://doi.org/10.1007/s11701-024-02116-0","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2024-10-05 15:56:57","publishedOnDateReadable":"October 5th, 2024"},"versionCreatedAt":"2024-09-11 07:33:38","video":"","vorDoi":"10.1007/s11701-024-02116-0","vorDoiUrl":"https://doi.org/10.1007/s11701-024-02116-0","workflowStages":[]},"version":"v1","identity":"rs-4900841","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4900841","identity":"rs-4900841","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}