How to Minimize Hyper-Continence After Intracorporeal Robotic Neobladder Configuration in Women? The Three-Layer...

Background: Orthotopic neobladder in women presents functional challenges, notably hyper-continence requiring intermittent self-catheterization. Here, we describe a three-layer urethro-ileal anastomosis incorporating a peritoneal flap and evaluate its impact on functional outcomes at the time of robot-assisted radical cystectomy (RARC) and Florence Robotic Intracorporeal Neobladder (FloRIN) reconfiguration. Methods: Clinical data from consecutive patients treated with non-sexual-sparing RARC and FloRIN were prospectively collected between March 2016 and January 2024. Hyper-continence was defined as intermittent self-catheterization or postvoid residual > 200 cc at last follow-up. A three-layer anastomosis was performed incorporating a peritoneal flap and utilizing a three-step barbed suture technique for posterior reconstruction: (1) the peritoneum of the rectouterine pouch was sutured to the paraurethral ligaments, (2) the external ileal layer was approximated to the paraurethral ligaments, and (3) the ileal mucosa was anastomosed to the urethra. Urodynamic evaluation was performed 6 months postoperatively. Results: Overall, 32 patients entered the study. Median age was 72 (IQR 67-75) years, and median BMI was 24 (IQR 22-27) kg/m². Preoperative incontinence was reported in 10% of cases, while no hyper-continence was recorded preoperatively. Median console time was 334 (IQR 305-363) minutes. Early major complications (<30 days) occurred in three (9.4%) patients, while delayed major complications (>30 days) were observed in four (12.5%) cases. After a median follow-up of 36 (IQR 30-42) months, hyper-continence was observed in 7.2% of patients with a median self-catheterization number of 3 (IQR 2-5) per day. Multivariable analysis confirmed BMI > 25 kg/m² (OR: 1.24, p = 0.03) and age > 70 years (OR: 1.18, p = 0.04) as independent predictors of hyper-continence after FloRIN. Conclusions: Robot-assisted three-layer posterior reconstruction during FloRIN configuration in female patients demonstrated low rates of hyper-continence and no cases of permanent catheterization in long-term follow-up.