Robot-assisted radical cystectomy (RARC) is a complex procedure with high postoperative morbidity, especially when combined with neobladder reconstruction, which has a higher complication rate compared to other urinary diversions. To minimise these complications, it is crucial to understand their nature and frequency. Few studies have comprehensively evaluated complications post-RARC with intracorporeal neobladder, often using nonstandardised reporting methods. This study aimed to characterise these complications to improve perioperative management and reduce morbidity. A multi-institutional database was created by the European Association of Urology (EAU) Robotic Urology Section, including 980 patients from 16 European centres (2003–2022). After excluding those with incomplete postoperative data, 858 patients were analysed. Complications were categorised using 3 the Clavien-Dindo classification and divided into early (<30 days) and late (31–90 days) occurrences. The impact of neoadjuvant therapy (nadjT) and surgical experience on complication rates was also assessed. Most patients were male (87%) and healthy (76% with ASA score ≤2), with a median age of 64 years and BMI of 26kg/m². The majority underwent pelvic lymphadenectomy (98%), with the Studer / Wiklund neobladder being the most common reconstruction technique (65%). The median operating time was 366 minutes, and the median hospital stay was 10 days. Overall, 60% experienced at least one complication, and 26% had severe complications within three months. Early complications were more frequent (52% vs. 20%). Urinary tract infection (UTI) was the most common complication at both time points, though often not severe. Severe early complications included urinary leakage / fistula and device mispositioning, while late severe complications included ureteric stricture and lymphocele / lymphorrhea. No significant difference in overall or severe complication rates was found between patients who did and did not receive nadjT. However, nadjT was associated with higher rates of fever of unknown origin and paralytic ileus. Increased surgical experience was associated with lower overall and severe complication rates, while longer operating times were linked to higher overall complications. The study highlights the need for improved surgical techniques and perioperative management, particularly for bowel function recovery and ureteric-neobladder anastomosis. Implementing enhanced recovery protocols and careful urinary device management could reduce complications. Despite its strengths, the study’s limitations include its focus on experienced centres and potential underestimation of complication rates. Future research should aim to further optimise RARC and intracorporeal neobladder procedures to reduce complications.
How can we reduce morbidity after RARC with intracorporeal neobladder?
Reviewed by Asif H Ansari
How can we reduce morbidity after robot-assisted radical cystectomy with intracorporeal neobladder? A report on postoperative complications by the European Association of Urology Robotic Urology Section Scientific Working Group.
