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Balzano et al. Mini-invasive Surg 2021;5:41 https://dx.doi.org/10.20517/2574-1225.2021.49 Page 3 of 8

In addition to longer operative times, performing extracorporeal diversions allows the surgeon to keep all
diversion options available to patients. For example, if a surgeon is most comfortable with only the
intracorporeal ileal conduit, they may be reticent to discuss a continent diversion option, orthotopic or
cutaneous. This is critically important when discussing open and robotic diversions. Given the steep
learning curve of robotic diversions, it is not unreasonable to think that many surgeons are prone to
perform the procedure they are more comfortable and adept at rather than what may be best for the patient.

COMPLICATIONS
Ureteroenteric stricture formation
Stricture formation at the site of the anastomosis from the ureter to the bowel is a potentially catastrophic
complication. These patients frequently require surgical intervention including invasive anastomotic
revisions. Rates of ureteroenteric anastomotic stricture (UEAS) are reported to occur in 2.6%-13% of cases
[16]
[17]
depending on the definition used . Goh et al. evaluated stricture formation between RARC and open
radical cystectomy. They found that there was a higher stricture rate in the RARC group, however, this also
related to the hospital volume, yet again emphasizing the steepness of the learning curve associated with
these procedures. Of note, 84% of their diversions were incontinent diversions that were all performed
extracorporeally.

Ericson et al. evaluated UEAS rates in open radical cystectomy, RARC with extracorporeal diversion, and
[16]
RARC with intracorporeal diversion. Their cohort of an impressive 968 patients reported an overall 11.3%
stricture rate. Their subsets were broken down to a 9%, 11.3%, and 13% rate for open, extracorporeal, and
intracorporeal respectively with a statistically significant difference. What must be noted, however, is that
the intracorporeal rate decreased from 17.5% to 4.9% after 75 cases; which again emphasizes the steep and
long learning curve associated with these procedures. Also important to note in this cohort is that only 13%
of their diversions were continent for the intracorporeal subset compared to 27% of their extracorporeal
subset.

Ahmadi et al. looked at UEAS rates in intracorporeal diversions with and without the use of indocyanine
[18]
green (ICG) for perfusion evaluation of the distal ureter. What they found was that not only was there a
much greater amount of distal ureter excised before anastomosis (> 5 cm in some cases) but that the ICG
group had a 0% stricture formation at 12 months of follow up compared to the 10.6% per patient rate in the
non-ICG group. Shen et al. evaluated the stricture rate with extracorporeal diversions utilizing ICG with
[19]
SPY fluorescence to evaluate for distal perfusion. They found the stricture rate again to be 0% in the ICG
group vs. 7.5% in the non-ICG group. They also reported a longer excision of the distal ureter as well with
3.8 cm in the ICG group vs. 2.2 cm in the non-ICG group. These studies lead us to believe that perhaps the
rate of UEAS is not dependent on the method of diversion creation, but rather distal ureteral perfusion .
[19]

Gastrointestinal complications
Gastrointestinal complications continue to be a major cause of morbidity in the cystectomy patient.
Patient’s hospital stays are prolonged with ileus, jaundice, and hematochezia as well as readmissions for
similar issues. Shim et al. looked at complications between intracorporeal urinary diversion and
[15]
extracorporeal urinary diversion in 362 patients. They found that gastrointestinal complications were
significantly higher in the extracorporeal urinary diversion group. Zhang et al. also found a significantly
[14]
lower gastrointestinal complication rate with the intracorporeal urinary diversion compared to both the
extracorporeal urinary diversion and the open cystectomy. They found that the TPN requirement was
highest for open cases. Hussein et al. , however, found no significant difference in gastrointestinal
[5]
complications between the intracorporeal urinary diversion and extracorporeal urinary diversion group,