Sage Journals: Discover world-class research

Abstract

We aim to explore the feasibility of robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RA-SCAC) for the management of adult neurogenic lower urinary tract dysfunction and to compare the functional and surgical outcomes of an intracorporeal and extracorporeal approach. A retrospective review of all patients who underwent robot-assisted supratrigonal cystectomy and augmentation cystoplasty was performed. Data was collected on age, body mass index, American Society of Anaesthesiologists (ASA) score, type and duration of neurological disease, previous abdominal surgery and renal function. Bladder diary, urodynamics and validated symptom score results were recorded at baseline and repeated postoperatively. Intraoperative details included type of diversion, concomitant surgery, duration of surgery, blood loss and conversion to open. Postoperative surgical recovery was also reviewed. The primary endpoint was the rate of major postoperative complications defined as any complication Clavien-Dindo grade ≥3 occurring within the first 90 days postoperatively. There were 26 patients in total; 7 performed extracorporeally and 19 intracorporeally. Mean age was 41.5, mean BMI 24.4 and majority were ASA score 2 (61.5%). Twelve (46.1%) patients had spinal cord injury and 6 (23.1%) spina bifida. Seven (26.9%) had a concomitant procedure including bladder neck artificial urinary sphincter (AUS) insertion, bladder neck fascial sling or creation of a continent catheterisable channel. The surgical outcomes were analysed separately for those that had RA-SCAC only versus RA-SCAC with a concomitant procedure. The operative time was shorter in the intracorporeal group, and the length of stay was similar in both groups. The total number of major postoperative complications was low (n = 3; 11.5%). All urodynamic parameters significantly improved at 6 months in the intracorporeal group. Median number of urinary incontinence episodes per 24 h decreased significantly in both groups at 3 months but the continence status and ICIQ-UI SF demonstrated statistical significance in the intracorporeal group only. In conclusion, robot-assisted supratrigonal cystectomy and augmentation cystoplasty is feasible in adult neurological patients, favouring an intracorporeal approach.

Plain language summary

Robot-assisted supratrigonal cystectomy and augmentation cystoplasty for adult neurogenic lower urinary tract dysfunction and a comparison of different surgical techniques

Neurological disease in the adult population can cause lower urinary tract dysfunction and may require surgical intervention when less invasive treatments have failed. Augmentation cystoplasty has traditionally been performed as an open operation and can be associated with significant peri-operative morbidity due to its surgical complexity. We reviewed the records of 26 patients who underwent this operation using a minimally invasive robot-assisted approach. We compared two different surgical techniques (intracorporeal versus extracorporeal diversion) and looked at both the functional and surgical outcomes to assess its feasibility in this patient group. Our findings suggest that a robot-assisted approach is safe and feasible and that when performed, an intracorporeal diversion is preferential.

Keywords

augmentation cystoplasty neurogenic bladder robotic urinary diversion

Introduction

Neurological disease can cause a spectrum of lower urinary tract dysfunction, including detrusor overactivity, detrusor sphincter dyssynergia, detrusor failure and stress urinary incontinence. Incontinence and infections are some of the common sequalae affecting quality of life but more importantly, there can be a risk of renal failure due to small capacity, poorly compliant bladders with high storage and/or voiding pressures. Examples of some of the common neurological diseases causing neurogenic lower urinary tract dysfunction (NLUTD) include multiple sclerosis, spina bifida and spinal cord injury. The mainstay of treatment is with oral pharmacotherapy using anticholinergics, clean intermittent catheterisation (CIC) and intra-detrusor Botulinum Toxin A injections.¹

In some cases, these treatment options may be insufficient to achieve or maintain continence as well as maintain safe bladder pressures, and so more invasive reconstructive options may be required.² These patients should be risk-stratified, and those with high risk neurogenic lower urinary tract dysfunction (NLUTD) must be identified early and appropriately managed to minimise morbidity and renal failure.^3,4

Augmentation cystoplasty is an established surgical technique for the management of refractory NLUTD, intended to create a large storage reservoir with safe pressures. It has most commonly been performed as an open procedure and can be associated with significant perioperative complications, including cardiovascular and respiratory compromise, venous thromboembolism, infections and bowel dysfunction.⁵ Patients with neurological disease can often have an array of other medical issues and so the risk of perioperative complications may be even greater in this cohort.^6,7 It is therefore imperative to explore options to minimise morbidity and improve perioperative recovery in this patient group.

Minimally invasive surgery has been shown to improve perioperative outcomes and recovery and both laparoscopic and robot-assisted laparoscopic approaches have been used to perform supratrigonal cystectomy and augmentation cystoplasty; however, the numbers remain small and most of the existing series include only paediatric populations.

While there is increasing evidence that intracorporeal urinary diversion may have more favourable perioperative outcomes during radical cystectomy, no such data exists for augmentation cystoplasty.^8,9

The aim of the present study was to explore the feasibility of this approach by reporting the surgical and functional outcomes of adult patients with neurological disorders who underwent robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RA-SCAC) and to compare the outcomes of intracorporeal versus extracorporeal RA-SCAC.

Methods

Study design

The medical records of all patients who underwent RA-SCAC for neurogenic lower urinary tract dysfunction between October 2015 and March 2024 (i.e. 8 years and 5 months) in three French centres were retrospectively reviewed.

Adult patients ⩾18 years with neurological disease refractory to anticholinergics and intra-detrusor Botulinum Toxin A injections, performing self-catheterisation were eligible for a RA-SCAC.

Initially those who required concomitant procedures were not offered a robotic approach, but this changed with time (i.e. after 2022).

The following data was collected for each patient: age, body mass index (BMI), ASA score, type and duration of neurological disease, and previous abdominal surgery.

All patients completed a bladder diary, urodynamics and validated symptom score (USP, Urinary Symptom Profile and ICIQ-UI SF, International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form) at baseline and had their renal function tested using serum cystatin C.

All data was collected and analysed without any patient identifiable information. As a retrospective study there was a waiver of written consent, but patients were informed of the use of their data for research purposes and were given the option to request for the withdrawal of their data.

Surgical techniques

The diversion was performed extracorporeally between 2015 and 2019 and intracorporeally thereafter. Until 2022, only patients who required augmentation cystoplasty alone were selected for the robotic approach, and those who required augmentation cystoplasty and a concomitant procedure, such as creation of a catheterisable channel, had their surgery performed through an open abdominal incision. From 2022, all patients eligible for augmentation cystoplasty had this performed robotically including those requiring concomitant surgery. In cases of coexisting intrinsic sphincter deficiency requiring a concomitant anti-incontinence procedure, both bladder neck artificial urinary sphincter (AUS) and autologous slings were offered to men and women taking into consideration several factors including manual dexterity, need to perform clean intermittent catheterisation and patient preference.

All procedures were performed with an Intuitive Surgical^® Da Vinci surgical robot, either Si (for the first few extracorporeal cases) or Xi.

Operative steps

After positioning the patient in a 23-degree Trendelenburg position with legs placed in Lithotomy, a 16 Fr urethral catheter is inserted.

A supraumbilical incision is made to facilitate camera port insertion using an open cut down (Hasson’s) technique. The remaining ports are then inserted under direct vision (x3 8 mm robotic ports on both sides of the camera port and x2 12 mm ports in both the right and left flanks). The robot is then docked between the legs. The bladder is filled via the urethral catheter, and mobilised, starting anteriorly and progressing laterally.

The posterior aspect of the bladder is released from the peritoneum that is spared and utilised to extra-peritonealise the cystoplasty at the end of the procedure. The bladder is opened in a longitudinal plane using monopolar scissors. Both ureteric orifices are identified and bilateral ureteric stents are only inserted if there is concern about close proximity. A supratrigonal partial cystectomy is then performed, and the specimen is placed into an Endo Catch bag.

Extracorporeal diversion

The robot is undocked and the supraumbilical incision is extended to a 6 cm midline incision. An ileal segment 15 cm upstream from the ileo-caecal junction is extracted through the midline incision. A total of 30 cm of ileum is harvested, and intestinal continuity is restored as an end-to-end handsewn anastomosis. The ileal segment is reconfigured into a ‘U’-shaped ileo-cystoplasty and reinserted into the abdomen. The robot is redocked and the ileo-cystoplasty is sutured to the trigone with Quill and V-Loc sutures.

Intracorporeal diversion

Once the supratrigonal cystectomy is completed, the ileo-caecal junction is identified and 40 cm of ileum, 15 cm upstream from the ileo-caecal junction, is marked with Vicryl sutures. The two lower ends of the future ‘W’ are sutured to the posterior aspect of the bladder trigone facing each ureteral orifice to facilitate the harvesting and future reconfiguration.

A total of 2 ml of indocyanine green (ICG) is injected intravenously, and near-infrared fluorescence (Firefly) is used to help delineate the mesenteric vascular supply. The marked segment of ileum is harvested using a 60 mm Endo GIA ensuring good mesenteric blood supply. Intestinal continuity is restored as a side-to-side anastomosis with the 60 mm Endo GIA, and the mesenteric window is closed using 3/0 polysorb.

The ileal segment is brought into the pelvis and reconfigured into a ‘W’-shape with V-Loc after having been detubularised on its anti-mesenteric border. The ileo-cystoplasty is then anastomosed to the bladder trigone with Quill and V-Loc sutures.

The anastomosis integrity is tested with 180 ml of diluted methylene blue, and additional stitches are placed if any leakage is observed. The peritoneum is closed with V-Loc sutures to extra-peritonealise the cystoplasty.

A surgical drain is not routinely placed. The bladder catheter is washed out three times per day until removal at 3 weeks. A cystogram is not routinely performed. Patients then recommence clean-intermittent catheterisation at this stage. If ureteric stents were inserted, these are removed at 4 weeks.

Outcomes of interest

The primary endpoint was the rate of major postoperative complications defined as any complication Clavien-Dindo grade 3 or higher occurring within the first 90 days postoperatively. All complications were recorded using the Clavien-Dindo classification.¹⁰

The other outcomes of interest were the other main perioperative outcomes (operative time, estimated blood loss, length of stay, postoperative complications, time to return of bowel function, time to resumption of oral feeding). These were analysed separately for those undergoing RA-SCAC only versus RA-SCAC + concomitant procedure.

Functional outcomes were assessed at 3 and 12 months (bladder diary: maximum voided volume, number of CIC per 24 h; continence status categorised as unchanged versus improved versus complete continence; the USP stress urinary incontinence (SUI) subscore (/9) and overactive bladder (OAB) subscore (/21); the ICIQ-UI SF and the urodynamics outcomes (maximum cystometric capacity, maximum detrusor pressure during filling (Pdet max), compliance (ml/cmH2O) which was calculated manually from the traces; first desire to void (ml), strong desire to void (ml), detrusor overactivity (yes vs no)). The follow-up urodynamics were performed 6–12 months postoperatively.

Statistical analyses

Means and standard deviations were reported for continuous variables, medians and ranges for categorical variables, and proportions for nominal variables. Comparisons between groups were performed using the χ² test or Fisher’s exact test for discrete variables, and the Mann–Whitney test for continuous variables as appropriate. Change of continuous variables over time was assessed using the paired student t-test. Statistical analyses were performed using JMP v.18.0 software (SAS Institute Inc., Cary, NC, USA). All tests were two-sided with p < 0.05 as a threshold to define statistical significance.

Results

Patient characteristics

Twenty-six patients were included for analysis: 7 in the extracorporeal group and 19 in the intracorporeal group. The patient characteristics are summarised in Table 1.

Table 1.

Patient characteristics.

Characteristics	Whole cohortN = 26	RA-SCAC (extracorporeal)N = 7	RA-SCAC (intracorporeal)N = 19	p-Value*
Mean age (years)	41.5 (±17.5)	31 (±8.2)	45.4 (±18.6)	0.10
Gender
Male	12 (46.1%)	6 (85.7%)	6 (31.6%)	0.03
Female	14 (53.8%)	1 (14.3%)	13 (68.4%)
ASA score
1	7 (26.9%)	3 (42.9%)	4 (21.1%)	0.47
2	16 (61.5%)	3 (42.9%)	13 (68.4%)
3	3 (11.5%)	1 (14.3%)	2 (10.5%)
Body Mass Index (kg/m²)	24.4 (±3.9)	25.4 (±3.4)	24.1 (±4.1)	0.49
Neurological conditions
Spinal Cord Injury	12 (46.1%)	4 (57.1%)	8 (42.1%)	0.31
Spina bifida	6 (23.1%)	3 (42.9%)	3 (15.8%)
Other	8 (30.8%)	0 (0%)	8 (42.1%)
Concomitant procedure	7 (26.9%)	1 (14.3%)	6 (31.6%)	0.36
Bladder neck AUS	2 (7.7%)	1 (14.3%)	1 (5.3%)
Bladder neck fascial sling	1 (3.8%)	0 (0%)	1 (5.3%)
Catheterisable channel creation (Monti/Mitrofanoff)	4 (15.4%)	0 (0%)	4 (21.1%)

Comparison for intracorporeal versus extracorporeal.

AUS, artificial urinary sphincter.

There were significantly more female patients in the intracorporeal group (68.4% vs 14.3%; p = 0.03).

The mean age, BMI, neurological conditions and ASA score were similar in both groups.

Eight out of the twenty-six patients had a concomitant procedure, one in the extracorporeal group and seven in the intracorporeal group.

There were more concomitant procedures in the intracorporeal group (36.8% vs 14.3%), especially catheterisable channel creation (n = 5; 26.3%), although the difference was not statistically significant (p = 0.36).

Perioperative outcomes

The perioperative outcomes are presented in Table 2.

Table 2.

Perioperative outcomes.

Outcomes	Whole cohortN = 18	ExtracorporealN = 6	IntracorporealN = 12
RA-SCAC only
Mean operative time (min)	346.3 (±106.5)	428.3 (±120.9)	305.4 (±73.4)
Mean estimated blood loss (ml)	86.1 (±67.7)	55 (±48.1)	101.6 (±72.3)
Length of hospital stay (days)	8.8 (±5.0)	9 (±5.3)	8.75 (±5.1)
Conversion to an open approach	2 (11%)	2 (33%)	0
Postoperative complications	13 (72%)	5 (83%)	8 (67%)
Major postoperative complications	1 (6%)	0	1 (8%)
Time to oral feeding (days)	4.4 (±3.7)	4.3 (±1.8)	4.5 (±4.5)
Time to return of bowel function (days)	4.1 (±3.7)	3.5 (±1.5)	4.3 (±4.4)
Readmission rate	4 (22%)	2 (33%)	2 (17%)
Outcomes	Whole cohortN = 8	ExtracorporealN = 1	IntracorporealN = 7
RA-SCAC + concomitant procedure
Mean operative time (min)	358.8 (±115.9)	460 (±0)	344.2 (±117.1)
Mean estimated blood loss (ml)	66.3 (±Extracorporeal Extracorporeal 45.0)	20 (±0)	72.9 (±44.2)
Length of hospital stay (days)	11.4 (±5.9)	12.3 (±0)	5 (±5.7)
Conversion to an open approach	0	0	0
Postoperative complications	7 (88%)	1 (100%)	6 (86%)
Major postoperative complications	2 (25%)	1 (100%)	1 (14%)
Time to oral feeding (days)	4.8 (±5.0)	3 (±0)	5 (±5.4)
Time to return of bowel function (days)	4.5 (±2.6)	3 (±0)	4.7 (±2.8)
Readmission rate	4	1	3

RA-SCAC, robot-assisted supratrigonal cystectomy and augmentation cystoplasty.

When looking at those that underwent RA-SCAC only, the operative time was shorter in the intracorporeal group (305.4 vs 428.3 min) with a lower rate of conversion to an open approach (0% vs 33%).

The mean length of stay for the whole cohort was 8.8 days and was similar in both groups. The overall rate of postoperative complications was high (72%) and was greater in the extracorporeal group (83% vs 67%); however, the rate of major postoperative complications was relatively small (n = 1; 6%), which occurred in the intracorporeal group.

Only one patient who had a concomitant procedure had this performed using an extracorporeal approach. The operative time was longer in this group (460 vs 344.2 min) as was the length of stay (12.3 vs 5 days). No patients who had a RA-SCAC with a concomitant procedure required a conversion to open.

The overall number of complications was 88% but of these only two patients had a major complication.

In the extracorporeal group, there was one Clavien ⩾ 3 complication: a case of a concomitant bladder neck artificial urinary sphincter insertion where the implant subsequently became infected and required explantation on day 10.

In the intracorporeal group, there were two Clavien ⩾ 3 complications.

One mechanical small bowel obstruction requiring an emergency laparotomy and adhesiolysis on day 10, re-presenting 4 months later with an enterovesical fistula requiring surgical repair.

One case of a concomitant autologous fascial sling insertion with a resultant vesicosymphyseal fistula requiring prolonged antibiotics, urinary diversion with percutaneous nephrostomies and subsequent removal of the extruded fascia lata sling.

The time to oral feeding, time to return of bowel function and readmission rates did not differ significantly between the two groups undergoing RA-SCAC only, but the readmission rate was higher in the intracorporeal group who underwent an additional procedure alongside their RA-SCAC but the overall number in this group was much higher.

Functional outcomes

At baseline, there was no statistically significant difference between the intracorporeal and extracorporeal groups in terms of number of CIC per 24 h, number of leakages per 24 h, ICIQ-UI SF and urodynamic parameters (see Table 3).

Table 3.

Functional outcomes.

	Whole cohortN = 26	Robotic extracorporeal augmentation cystoplastyN = 7	Robotic intracorporeal augmentation cystoplastyN = 19	p-Value^a
Median number of urinary leakage/24 h
Preoperatively	8 (0–20)	10 (0–20)	6 (0–20)	0.67
3 months postoperatively	0 (0–20)*	0 (0–20)*	0 (0–4)*	0.26
Median number of CIC/24 h
Preoperatively	8 (5–20)	6 (5–10)	8 (5–20)	0.07
3 months postoperatively	7 (4–16)	7 (5–8)	7 (4–16)	0.57
Mean maximum voided volume on bladder diary (ml)
Preoperatively	309.7 (±119.6)	274.8 (±129.1)	323.1 (±118.3)	0.50
3 months postoperatively	405.8 (±126.6)*	318 (±152.1)	429.6 (±113.8)*	0.27
Change	+96.1	+ 33.2	+ 103.5	0.25
Mean maximum cystometric capacity (ml)
Preoperatively	265.9 (±127.1)	294.2 (±160.9)	247.1 (±116.9)	0.99
6 months postoperatively	403.2 (±111.9)*	336.7 (±136.3)	447.6 (±68.7)*	0.11
Change	+137.3	+ 42.5	+200.5	0.19
Mean maximum detrusor pressure during filling (cmH2O)
Preoperatively	33.2 (±37.8)	35 (±16.8)	29.7 (±44.1)	0.66
6 months postoperatively	20.3 (±11.2)*	23.6 (±2.5)	13.7 (±15.9)*	0.54
Change	−10.9	−11.4	−16	0.79
Detrusor overactivity
Preoperatively	17 (68%)	5 (71.4%)	12 (66.7%)	0.82
6 months postoperatively	6 (26.1%)*	3 (42.9%)	3 (18.8%)*	0.23
Continence status
Incontinence preoperatively	22 (84.6%)	5 (71.4%)	17 (89.5%)	0.26
Incontinence at 3 months	6 (23%)*	2 (28.6%)	2 (10.5%)*	0.26
ICIQ-SF (/21)
Preoperatively	17.3 (±37.8)	16 (±5.3)	17.8 (±4.3)	0.94
3 months postoperatively	4.3 (±11.2)*	9 (±8.1)	2.4 (±3.5)*	0.01
Change	−10.9	−7	−15.4	0.24

Intracorporeal versus extracorporeal.

p < 0.05 for change versus baseline.

CIC, clean intermittent catheterisation.

All urodynamic parameters significantly improved between baseline and 6 months postoperatively in the intracorporeal group, while none demonstrated statistically significant improvement in the extracorporeal group. The median number of urinary incontinence episodes per 24 h decreased significantly in both groups at 3 months, but the continence status and ICIQ-UI SF at 3 months demonstrated statistically significant at 3 months only in the intracorporeal group. The only statistically significant difference between the two groups in terms of functional outcomes was the ICIQ-UI SF at 3 months favouring the intracorporeal group (2.4 vs 9; p = 0.01). After a median follow–up of 17 months, there was no incisional hernia in any of the two groups.

Discussion

Augmentation cystoplasty is an established surgical technique for refractory neurogenic lower urinary tract dysfunction whereby the main goal is to preserve renal function and achieve continence. It should be considered once pharmacotherapy and intra-detrusor Botulinum Toxin A injections have failed to achieve a safe and continent urinary reservoir.¹¹

Recognised complications of open augmentation cystoplasty include metabolic disturbance, bowel dysfunction, urinary tract infections, urolithiasis, perforation, the need for clean intermittent catheterisation and malignancy.¹² Some of these complications, such as bowel dysfunction, may be more pronounced in this patient group with neurological disease, as there may already be a significant degree of bowel dysfunction at baseline.

The surgical and functional outcomes of open augmentation cystoplasty are well reported; however, the benefits of a minimally invasive approach are yet to be demonstrated.¹³

Minimally invasive surgery and robotic surgery have been widely adopted in urological oncology for their recognised benefits of reduced blood loss, enhanced recovery with less pain and reduced length of stay.¹⁴ It therefore seems logical to try to apply these approaches to benign reconstructive surgery to promote enhanced recovery in this surgically complex patient group.¹⁵

The first laparoscopic cystoplasty was reported by Elliot et al.¹⁶ in 2002. Subsequently, Al-Othman et al.¹⁷ reported the first robot-assisted laparoscopic augmentation cystoplasty in 2008 with the aim to achieve the advantages provided by a minimally invasive laparoscopic technique as well as the added benefit of a reduction in the length of surgery due to quicker suturing with more precision. A small series of complete intracorporeal robot-assisted laparoscopic cystoplasty showed a median operative time 250 min (210–268), median length of stay of 13 (10–14) days and median time to restart CIC of 12 (10.5–13) days.¹⁸

Trying to minimise the length of surgery should be a priority as there can be potential consequences of a prolonged Trendelenburg position combined with prolonged pneumoperitoneum resulting in raised intra-ocular pressures, cognitive impairment and respiratory compromise, particularly in those who may already have hydrocephalus or an element of cognitive dysfunction at baseline.¹⁹

In addition to the already well-recognised advantages of minimally invasive surgery, there may be other benefits in the neurogenic population such as a lower risk of abdominal wall hernia owing to smaller incisions when compared with a large midline laparotomy or Pfannenstiel incision in a cohort in whom abdominal wall muscles are weaker when compared with the non-neurogenic population. In our series, we did not have any postoperative incisional hernias.

Several surgical techniques have been reported for augmentation cystoplasty including the type of bowel segment utilised, the configuration pattern, whether a clam cystoplasty versus supratrigonal cystectomy is performed and whether the reconstruction is performed intracorporeally versus extracorporeally.²⁰

In our series, we performed a supratrigonal cystectomy. In the extracorporeal group a ‘U’-shaped cystoplasty with 30 cm of ileum was performed, and in the intracorporeal group a ‘W’-shaped cystoplasty using 40 cm of ileum, as originally described by Hautmann, was performed.²¹ The slight differences observed in terms of functional outcomes may be more attributable to this difference in the cystoplasty configuration rather than the surgical approach.²² Two patients in the intracorporeal group had a concomitant anti-stress urinary incontinence procedure (×1 AUS replacement and ×1 fascial sling insertion), and one patient in the extracorporeal group had an AUS insertion. It is unlikely that this influenced the functional outcomes at 3 months postoperatively as both the AUS and the fascial sling were removed prior to the first follow-up due to surgical complications.

In some cases, a concomitant continent catheterisable channel (Mitrofanoff or Monti) was required.

In our early experience, only cases which did not require concomitant procedures were selected for the robotic approach while the others were still performed open. With time we were able to offer a robotic approach even when a concomitant procedure was needed which could explains why the rate of concomitant procedure is higher in the intracorporeal group. This higher overall complexity of cases in this group may have compounded the possible benefits of the intracorporeal approach in terms of perioperative outcomes which is why we analysed the two subgroups separately.

In both groups (RA-SCAC alone vs RA-SCAC + concomitant procedure), we found that the operative time was shorter in the intracorporeal group, which could be explained by the time required to undock and redock the robot with the extracorporeal diversion technique, as well as the progression of the surgeon’s learning curve. The latter is a subject which has been extensively researched with evidence to suggest that surgical outcomes improve as case volume increases.²³ Our findings are also in keeping with the results from a systematic review comparing the operative time for ileal conduit urinary diversion using an intracorporeal versus extracorporeal approach.²⁴

To our knowledge, the present series is the largest so far to report the outcomes of robot-assisted supratrigonal cystectomy and augmentation cystoplasty in adult neurological patients and the first to compare intracorporeal with extracorporeal urinary diversion.

Our experience demonstrates that RA-SCAC is a safe and feasible option for this patient group.

We recognise the limitations of our case series which includes a small sample size, retrospective reporting, short follow-up duration and some incomplete follow-up data. The relatively long time span and the fact that the two cohorts (extracorporeal and intracorporeal) were consecutive may be regarded as a drawback as the overall surgeons’ experience was greater in the intracorporeal group.

Conclusion

Robot-assisted supratrigonal cystectomy and augmentation cystoplasty appears to be technically feasible in adult neurological patients. The perioperative outcomes are mostly comparable in the intracorporeal and extracorporeal groups except for a shorter operative time in the intracorporeal group. The functional outcomes are overall satisfactory and are better in the intracorporeal group, which may be related to the ‘W’-shaped versus ‘U’-shaped cystoplasty configuration rather than to the surgical approach.

More data and longer term follow-up are needed to validate its role in the armamentarium of benign lower urinary tract reconstruction.

Footnotes

Acknowledgements

None.

Declarations

ORCID iDs

Neha Sihra

Benoit Peyronnet

References

Ginsberg

Boone

Cameron

, et al. The AUA/SUFU guideline on adult neurogenic lower urinary tract dysfunction: treatment and follow-up. J Urol 2021; 206(5): 1106–1113.

Truzzi

Gonçalves de Almeida

Sacomani

, et al. Neurogenic bladder - concepts and treatment recommendations. Int Braz J Urol 2022; 48(2): 220–243.

Sinha

Follow-up for the upper urinary tract in patients with high-risk neurogenic lower urinary tract dysfunction. World J Urol 2023; 41(11): 3309–3316.

Chen

Kuo

HC.

Interventional management and surgery of neurogenic lower urinary tract dysfunction in patients with chronic spinal cord injury: a urologist’s perspective. Low Urin Tract Symp 2022; 14(3): 132–139.

Greenwell

Venn

Mundy

AR.

Augmentation cystoplasty. BJU Int 2001; 88(6): 511–525.

Dhallu

Baiomi

Biyyam

, et al. Perioperative management of neurological conditions. Health Serv Insights 2017: 10: 1178632917711942.

Di Bello

Siech

Angelis , et al. Perioperative complications and in-hospital mortality in paraplegic radical cystectomy patients. Ann Surg Oncol 2025; 32(1): 583–588.

Katayama

Mori

Pradere

, et al. Intracorporeal versus extracorporeal urinary diversion in robot-assisted radical cystectomy: a systematic review and meta-analysis. Int J Clin Oncol 2021; 26(9): 1587–1599.

Mastroianni

Tuderti

Ferriero

, et al. Robot-assisted radical cystectomy with totally intracorporeal urinary diversion versus open radical cystectomy: 3-Year outcomes from a randomised controlled trial. Eur Urol 2024; 85(5): 422–430.

10.

Clavien

Barkun

de Oliveira

, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009; 250(2): 187–196.

11.

Myers

Lenherr

Stoffel

, et al. The effects of augmentation cystoplasty and botulinum toxin injection on patient-reported bladder function and quality of life among individuals with spinal cord injury performing clean intermittent catheterization. Neurourol Urodyn 2019; 38(1): 285–294.

12.

Veeratterapillay

Thorpe

Harding

Augmentation cystoplasty: contemporary indications, techniques and complications. Indian J Urol 2013; 29(4): 322–327.

13.

Çetinel

Kocjancic

Demirdağ

Ç.

Augmentation cystoplasty in neurogenic bladder. Investig Clin Urol 2016; 57(5): 316–323.

14.

Jain

Gautam

Robotics in urologic oncology. J Minim Access Surg 2015; 11(1): 40–44.

15.

Cohen

Brodie

Murthy

, et al. Comparative outcomes and perioperative complications of robotic vs open cystoplasty and complex reconstructions. Urology 2016; 97: 172–178.

16.

Elliott

Meng

Anwar

, et al. Complete laparoscopic ileal cystoplasty. Urology 2002; 59(6): 939–943.

17.

Al-Othman

Al-Hellow

Al-Zahrani

, et al. Robotic augmentation enterocystoplasty. J Endourol 2008; 22(4): 597–600; discussion 600.

18.

Grilo

Chartier-Kastler

Grande

, et al. Robot-assisted supratrigonal cystectomy and augmentation cystoplasty with totally intracorporeal reconstruction in neurourological patients: technique description and preliminary results. Eur Urol 2021; 79(6): 858–865.

19.

Vitish-Sharma

Maxwell-Armstrong

Guo

, et al. The trendelenburg position and cognitive decline: a case-control interventional study involving healthy volunteers. JMIR Perioper Med 2019; 2(1): e11219.

20.

Khastgir

Hamid

Arya

, et al. Surgical and patient reported outcomes of “clam” augmentation ileocystoplasty in spinal cord injured patients. Eur Urol 2003; 43(3): 263–269.

21.

Hautmann

Egghart

Frohneberg

, et al. The ileal neobladder. J Urol 1988; 139(1): 39–42.

22.

Sidi

Reinberg

Gonzalez

Influence of intestinal segment and configuration on the outcome of augmentation enterocystoplasty. J Urol 1986; 136(6): 1201–1204.

23.

Wijburg

Hannink

Michels

CTJ

, et al. Learning curve analysis for intracorporeal robot-assisted radical cystectomy: results from the EAU robotic urology section scientific working group. Eur Urol Open Sci 2022; 39: 55–61.

24.

Tanneru

Behzad Jazayeri

Kumar

, et al. Intracorporeal versus extracorporeal urinary diversion following robot-assisted radical cystectomy: a meta-analysis, cumulative analysis, and systematic review. J Robot Surg 2021; 15(3): 321–333.

Robot-assisted supratrigonal cystectomy and augmentation cystoplasty for adult neurogenic lower urinary tract dysfunction: comparison of extracorporeal versus intracorporeal diversion