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Ureter-enteric strictures post RARC: Current evidence

Dr Karandeep Guleria

Aakash Healthcare, Dwarka, New Delhi

Uretero-enteric strictures (UES) is one of the dreaded complications of radical cystectomy and can result in chronic kidney damage. With the advent of robotics, more and more cystectomies are being performed robotically, with some advantages over the open surgery. However, as we embark on embracing robot assisted radical cystectomy (RARC), there is an unmet need evaluate lesser discussed complications such as UES, both for extra-corporeal and intra-corporeal urinary diversions (ECUD & IUD).

UES, post RARC, has been reported in 6.5-25.3% of the patients. Initial large volume retrospective analysis comparing open radical cystectomy (ORC) with RARC with ECUD showed a significantly higher incidence of UES post RARC (15% vs 9.5%; HR-1.64).(1) In a similar study comparing ORC to RARC with ICUD, the UES rate was higher after RARC & ICUD (25% vs 13%).(2) A recent meta-analysis compiled the data of the three studies comparing UES rates after ORC, RARC with ECUD and RARC with ICUD and revealed that the UES rates were highest after RARC with ICUD (14%) followed by RARC with ECUD (12.4%) and ORC (9.6%).(3)

The most simple explanation for a higher rate of UES post RARC is the learning curve, as shown by Resnik et al, who noted a whopping 47% incidence of UES in the 1st year after the introduction of RARC at their center.(2) Excessive handling of the ureter with robotic instruments that lack haptic feedback may explain these findings. However, Faraj et al noted lower incidence of UES post ICUD as compared to ECUD and ascribed it to lesser stretching of the ureters and more accurate anastomosis in ICUD.(4) Pre-operative hydronephrosis, high BMI, eGFR at 30 days post-op, UTI and leakage are the other independent risk factors of UES post RARC.(5)

Several technical modifications have been suggested to reduce the rate of UES post RARC. One of the most promising method is using Indo-cyanine green (ICG) to confirm vascularity of the ureter prior to anastomosis. Ahmadi et al reported a reduction in UES rate in their series once they started using ICG (from 10.6% to 0%).(6) Similarly, another study reported a 0% incidence of UES with ICG.(7) Using a longer ileal conduit to avoid tension at uretero-enteric anastomosis, creating a buttonhole-like instead of a slit-like enterotomy and retroperitonization the anastomosis are the other methods descried to prevent UES.(5)

The preliminary data, from non-randomised studies, suggest higher incidence of UES post RARC primarily because of learning curve and various preventive measures have been described. This highlights the need to pay special attention to uretero-enteric anastomosis and need to establish a standardised surgical protocol so as to avoid UES.

Table 2: Select studies comparing UES after ORC & RARC


UES after OBC

UES after RARC with ECUD

UES after RARC with ICUD

Ericson et al(8)




Lone et al(9)




Faraz et al(4)








Technical modifications to prevent UES

ICG to confirm vascularity

Button hole opening in bowel Longer ileal conduit

Retro-peritonisation of anastomosis

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North Zone Chapter of Urological Society of India






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