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Page 4 of 8 Balzano et al. Mini-invasive Surg 2021;5:41 https://dx.doi.org/10.20517/2574-1225.2021.49

[20]
looking at 972 patients. Feng et al. found fewer gastrointestinal complications with intracorporeal urinary
[21]
diversions with 60% being continent diversions. Ahmed et al. found that 10% of intracorporeal diversions
had gastrointestinal complications compared to 23% of those who underwent extracorporeal diversion.

The lower gastrointestinal complication rates associated with intracorporeal diversions are thought to be
due to less bowel manipulation, exposure and mobilization . Shim et al. defined gastrointestinal
[21]
[15]
[14]
complications to include ileus, jaundice and hematochezia. Zhang et al. by contrast defined
gastrointestinal complications as ileus, diarrhea, gastrointestinal bleeding, gastritis and/or Clostridium
difficile. These subtle differences in inclusion criteria and definitions of what constitutes a gastrointestinal
complication may begin to explain why these results are inconsistent across so many different studies.

POSTOPERATIVE PARAMETERS
Postoperative parameters including length of stay, infections, and overall complications are consistent
metrics evaluated when discussing the benefits of robotic surgery. With ERAS protocols integrated into
most systems now, the time to discharge has significantly decreased after large abdominal procedures
including radical cystectomy . Hussein et al. evaluated intracorporeal vs. extracorporeal diversion after
[5]
[22]
RARC outcome parameters in 972 patients and found that the intracorporeal diversion had more
complications and readmissions, however, these were not high-grade complications. They also noted that
that there were more infectious complications associated with the intracorporeal diversions. There was also
a 1 day longer admission with the intracorporeal diversion subset.

Shim et al. also examined the outcomes of intracorporeal urinary diversion vs. extracorporeal urinary
[15]
diversion. They found that the intracorporeal urinary diversion group had significantly shorter recovery
parameters including time to passage of flatus, the start of oral intake, and length of hospital stay.
[23]
Mazzone et al. did not find any difference in length of stay between intracorporeal urinary diversion and
[10]
extracorporeal urinary diversion. Lenfant et al. also found that there was no difference in length of stay
between the two groups. The data regarding length of hospital stay remains highly variable and
inconclusive. Tables 1 and 2 show intraoperative and post-operative parameters between intracorporeal and
extracorporeal urinary diversions.

FUNCTIONAL OUTCOMES
There continues to be limited data on functional outcomes for intracorporeal urinary diversion. Functional
outcomes are influenced by many factors including patient age, mental status, reservoir volume, and
[9]
urethral length. Tyritzis et al. had a cohort of 70 patients with an 88% daytime continence rate with an
orthotopic Studer neobladder performed intracorporeally. Of this group, 88.6% were men. At their one-year
follow-up, 46 men and 2 out of 3 females were defined as the continent with < 1 pad per day. One of the
females had hypercontinence requiring clean intermittent catheterization. Canda et al. reported daytime
[29]
continence in 11 out of 17 patients who underwent intracorporeal urinary diversion with an orthotopic
neobladder.

Obrecht et al. recently published their one-year data of intracorporeal orthotopic neobladder creation
[24]
looking primarily at functional outcomes. They had a 100% “social continence” rate, defined as < 1 pad per
day as well as post-void residual of 0 with a median pouch capacity of 404 cc . It is important to note,
[24]
however, that this is a small sample of 12 patients that were all male. It is difficult to be able to extrapolate
this data over larger, more diverse populations. In addition to this, continence definitions vary widely across
studies with terms such as “daytime continence” and “social continence” sometimes being used
interchangeably without having a consistent clear definition.