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BACKGROUND: Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is associated with significant morbidity and mortality. We present an alternative technique that preserves the complete mesenteric vascularization during the isolation of the intestinal segment used in ICUD, including distal vessels. This approach aims to minimize the risk of ischemia in both the ileal anastomosis and the isolated loop at the diversion site. METHODS: This cohort study included 31 patients, both male and female, who underwent RARC with ICUD from February 2018 to November 2023, performed by a single surgeon. Intraoperative and postoperative complications data were retrieved for analysis, employing our proposed mesentery-sparing technique in all cases. The primary endpoint was the incidence of intraoperative and postoperative complications directly attributable to the mesentery-sparing approach in ICUD. Secondary endpoints included other postoperative variables not directly related to mesentery preservation, such as the incidence of postoperative ileus requiring parenteral nutrition and the duration of hospitalization. RESULTS: None of the patients experienced intraoperative or postoperative complications directly related to mesentery-sparing, such as intestinal fistulae or internal hernias. The median duration of hospitalization was 6 days, and postoperative ileus necessitating total parenteral nutrition occurred in 19% of the patients. Minor complications (Clavien-Dindo grades I-II) accounted for 27.6% of the cases and major complications (grades III-V) accounted for 20.6%. CONCLUSION: The mesentery-sparing technique outlined herein offers an alternative method for preserving the vascularization of intestinal segments and reducing the risk of intestinal complications in ICUD during RARC.

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Urethral atresia is a rare but clinically significant cause of congenital lower urinary tract obstruction. Initial management options include urinary diversion until definitive urethral reconstruction or progressive urethral dilation. Given the overall rarity of the condition, there are no evidence-based guidelines for the immediate and long-term management of urethral atresia, and clinical practice varies widely. We present an illustrative case managed with progressive urethral dilation alongside urinary diversion to highlight key factors in shared clinical decision making. Ultimately, pooled multi-institutional long-term outcomes data are needed to better guide practice for these patients and their families.

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INTRODUCTION: Robotic approach has shown its feasibility and safety with respect to open approach for radical cystectomy (1). The performances of HugoTM RAS system (Medtronic, Minneapolis, USA) have been demonstrated in several clinical scenarios (2-5). We report the feasibility and surgical settings of the first series of robot-assisted radical cystectomy (RARC) with intracorporeal ileal-conduit performed with HugoTM RAS system. METHODS: Two patients were submitted to RARC with ileal conduit at our institution. The trocar placement scheme and the operating room setting with docking angles of the four arms were already described (6). A 12-mm and a 5-mm trocar for the assistant were placed. In both cases, an ileal-conduit with a Wallace type-1 uretero-enteric derivation was performed intra-corporeally. RESULTS: The first patient was a 71-year-old male with a very-high risk non-muscle invasive bladder cancer(BC), and the second patient was a 64-year-old male with a diagnosis of T2 high-grade BC. Operative times were 360 and 420 minutes with a docking time of 12 and 9 minutes, respectively. No intraoperative complications occurred. The estimated blood loss was 200ml and 400ml, respectively. The second patient developed an ileus on postoperative day 4 (Clavien-Dindo grade 2). No positive surgical margins were recorded. No recurrence nor progression occurred during follow-up. CONCLUSION: RARC with intracorporeal ileal conduit urinary diversion is feasible with HugoTM RAS system. We provided insight into the surgical setting using this novel robotic platform to help new adopters to face this challenging procedure. These findings may help a wider distribution of robotic programs for BC treatment.

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INTRODUCTION: Mortality after radical cystectomy (RC) varies widely in the literature. In cohort studies, mortality rates can vary from as low as 0.5% in large-volume academic centers (2) to as high as 25% in developing countries series. This study aims to perform a systematic review of population-based studies reporting mortality after RC. METHODS: A Systematic search was performed in Medline (PubMed®), Embase, and Cochrane for epidemiologic studies reporting mortality after RC. Institutional cohorts and those reporting mortality for specific groups within populations were excluded. Case series and non-epidemiologic series were also excluded. The aim of this review is to evaluate in-hospital mortality (IHM), 30-day mortality (30M), and 90-day mortality (90M). RESULTS: Systematic search resulted in 42 papers comprising 449,661 patients who underwent RC from 1984 to 2017. Mean age was 66.1. Overall IHM, 30M, and 90M were 2.6%, 2.7%, and 4.9%, respectively, with 90M being 2.6 times higher than IHM on average. Lowest IHM was found in Canada and Australia (0.2% and 0.6%, respectively), while the highest IHM was 7.8% (Brazil). Canada and Spain showed the highest 90M (6.5%). 159,584 urinary diversions were analyzed, being mostly ileal conduits (76.8%). CONCLUSIONS: The majority of the studies available are from major developed economies with paucity of data in the developing world. 90M after RC tends to be at least twice as high as IHM. The knowledge of such epidemiologic data is vital to guide public policies, such as centralization, in order to reduce mortality.

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BACKGROUND: When urinary diversion is necessary for benign indications, the defunctionalized bladder is at risk of a number of severe complications such as bleeding, pain, pyocystis and secondary urothelial carcinoma. These complications occur in 54%-80% of patients left with native bladder after diversion, and these patients go on to require completion cystectomy 20%-25% of the time. Rowley et al. at the University of Michigan reported their experience in open simple cystectomy in 2011 in a series of 23 patients. This operation, to our knowledge, has not been previously adapted to the robotic platform despite the growing prevalence of robotic surgery including for complex reconstruction and urinary diversion. Here we report our novel adapted technique of performing robotic simple cystectomy in 2 index patients. OBJECTIVE: To visually demonstrate and report our technique of simple cystectomy, utilizing the robotic platform, including outcomes in 2 index patients. METHODS: Two index patients are presented, including outcomes: One female with spinal cord injury, smoking and chronic infections in the setting of suprapubic catheter diversion, and one male with multiply failed local treatments including radiation and cryotherapy for prostate cancer that have resulted in chronic fistula, prior Fournier's gangrene, and sympheseal osteomyelitis. RESULTS: he operations were completed without difficulty, in an expedient fashion (35-48 minutes) and without significant blood loss (10cc or less). The technique is illustrated in the accompanying video. CONCLUSION: This novel adapted robotically-assisted operation appears to be a rapid and reproducible operation that recapitulates the principles of open surgery with little time or blood loss, thus avoiding the morbidity of radical cystectomy or of delayed secondary operations, while at the same time providing all the benefits inherent to a robotic operation. Outcomes appear excellent. Further study is needed.

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OBJECTIVE: Robotic intracorporeal neobladder reconstruction is a complex procedure in which the approximation of the reservoir to the urethral stump can be a demanding step. The aim of the study is to evaluate the reproducibility of a modified posterior reconstruction (PR) during the reconfiguration of intracorporeal neobladder after robot assisted radical cystectomy (RARC). MATERIALS AND METHODS: From July 2021 to July 2022, 35 RARC were performed, and 17 patients underwent intracorporeal neobladder reconstruction. A PR was planned in males (14). Intra- and peri-operative data were collected. SURGICAL TECHNIQUE: RARC and node dissection are performed. Afterwards, 40-cm ileal segment is isolated; the portion with the more adequate mesenteric length is brought down to the pelvis. A modified PR is performed with a double-armed barbed suture: a first layer connects the Denonvillier's fascia to the rhabdosphincter in a running fashion; the second layer is created with the other arm and approximates the posterior side of the ileal segment towards the urethral stump. In the anterior caudal part of the ileum, a 1.5-cm incision is made to realize the neobladder neck; the neovesical-urethral anastomosis is performed with a second bidirectional suture. RESULTS: Anastomotic and PR time were 14 (range 7-20) and 5 minutes (4-8), respectively. A single Clavien IIIa complication was recorded in a patient who underwent NAC and had a C. albicans superinfection in the post-operative course. All patients were discharged with complete or acceptable bladder voiding. Twelve patients with follow-up >90-days reported a satisfying daytime continence. CONCLUSIONS: PR represents a simple technical refinement that improves neobladder-urethral anastomosis by favoring ileal approximation to the urethral stump and decreasing anastomotic tension.

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ABSTRACT Objective: Cystectomy with urinary diversion is the gold standard for muscle invasive bladder cancer. It also may be performed as part of pelvic exenteration for non-urologic malignancy, neurogenic bladder dysfunction, and chronic conditions that result in a non-functional bladder (e.g., interstitial cystitis, radiation cystitis). Our objective is to describe the surgical technique of urinary diversion using large intestine as a conduit whilst creating an end colostomy, thereby avoiding a primary bowel anastomosis and to show its applicability with respect to urologic conditions. Materials and Methods: We retrospectively reviewed five cases from a single institution that utilized the described method of urinary diversion with large intestine. We describe operative times, hospital length of stay (LOS), and describe post-operative complications. Results: Five patients with a variety of urologic and oncologic pathology underwent the described procedures. Their operative times ranged from 5 hours to 11 hours and one patient experienced a Clavien III complication. Conclusion: We describe five patients who underwent this procedure for various medical indications, and describe their outcomes, and believe dual diversion of urinary and gastrointestinal systems with colon as a urinary conduit to be an excellent surgical option for the appropriate surgical candidate.

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OBJECTIVE: Cystectomy with urinary diversion is the gold standard for muscle invasive bladder cancer. It also may be performed as part of pelvic exenteration for non-urologic malignancy, neurogenic bladder dysfunction, and chronic conditions that result in a non-functional bladder (e.g., interstitial cystitis, radiation cystitis). Our objective is to describe the surgical technique of urinary diversion using large intestine as a conduit whilst creating an end colostomy, thereby avoiding a primary bowel anastomosis and to show its applicability with respect to urologic conditions. MATERIALS AND METHODS: We retrospectively reviewed five cases from a single institution that utilized the described method of urinary diversion with large intestine. We describe operative times, hospital length of stay (LOS), and describe post-operative complications. RESULTS: Five patients with a variety of urologic and oncologic pathology underwent the described procedures. Their operative times ranged from 5 hours to 11 hours and one patient experienced a Clavien III complication. CONCLUSION: We describe five patients who underwent this procedure for various medical indications, and describe their outcomes, and believe dual diversion of urinary and gastrointestinal systems with colon as a urinary conduit to be an excellent surgical option for the appropriate surgical candidate.

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