Natural History, Predictors and Management of Ureteroenteric Strictures after Robot Assisted Radical Cystectomy

Abstract

PURPOSE: Ureteroenteric strictures represent the most common complication requiring reoperation after radical cystectomy. We investigated the prevalence, outcomes, predictors and management of ureteroenteric strictures. MATERIALS AND METHODS: We retrospectively reviewed our quality assurance, robot assisted radical cystectomy database to identify patients in whom ureteroenteric strictures developed. Data were reviewed for demographics, perioperative outcomes and ureteroenteric stricture characteristics. The Kaplan-Meier method was used to calculate time to ureteroenteric stricture and multivariable stepwise regression was done to evaluate predictors of ureteroenteric strictures. RESULTS: Ureteroenteric strictures developed in 12%, 16% and 19% of 51 patients (13%) at 1, 3 and 5 years after robot assisted radical cystectomy, respectively. All patients were initially treated endoscopically or percutaneously, including 57% treated only endoscopically or percutaneously and 43% who required surgery, which was open repair in 6 and robot assisted repair in 16. At a median followup of 23 months 33 patients (65%) were free of disease, including 13 after endoscopic or percutaneous treatment, 15 after robot assisted repair and 5 after open revision. Open and robot assisted revisions showed comparable perioperative outcomes. On multivariable analysis the predictors of ureteroenteric anastomotic strictures were body mass index (OR 1.07, 95% CI 1.01-1.13, p = 0.02), intracorporeal urinary diversion (OR 3.28, 95% CI 1.41-7.61, p = 0.006), length of the right resected ureter (OR 0.66, 95% CI 0.50-0.88, p = 0.004), estimated glomerular filtration rate 30 days after assisted radical cystectomy (OR 0.85, 95% CI 0.74-0.98, p = 0.03), urinary tract infection (OR 2.68, 95% CI 1.31-5.49, p = 0.007) and leakage (OR 3.85, 95% CI 1.05-14.1, p = 0.04). Male gender (OR 0.19, 95% CI 0.04-0.96, p = 0.04) and higher body mass index (OR 0.85, 95% CI 0.72-0.996, p = 0.05) were associated with lower odds of successful endoscopic management. CONCLUSIONS: Multiple modifiable factors were associated with ureteroenteric anastomotic strictures following robot assisted radical cystectomy. Surgical revision can provide a definitive management with comparable outcomes for open and robotic repairs.