Uretero-enteric strictures after cystectomy: revealing the modifiable risk factors

Uretero-enteric strictures are feared complications following cystectomy. Despite surgical advancements, particularly the rise of robot-assisted approaches, the risk factors associated with these strictures remain poorly defined. This study aimed to identify the risk factors associated with uretero-enteric anastomotic strictures after cystectomy, according to the surgical approach and type of urinary diversion (extracorporeal vs. intracorporeal).

We conducted a single-center retrospective study including 340 patients who underwent cystectomy between 2016 and 2024 at Tours University Hospital. Clinical, biological, perioperative, and postoperative data were analyzed. The occurrence of a uretero-ileal anastomotic stricture was defined radiologically by a uretero-hydronephrosis ≥20 mm. We constructed and analyzed a learning curve for robotic surgery with intracorporeal urinary diversion.

Strictures occurred in 60 patients (17.6%). On multivariable analysis, reduced preoperative glomerular filtration rate (odds ratio [OR] = 1.45 per 10 mL/min decrease, 95% CI [1.12-1.87], p = 0.004), elevated creatinine (OR = 1.30 per 10 µmol/L increase, 95% CI [1.05-1.61], p = 0.018), prior myocardial infarction (OR = 2.25, 95% CI [1.10-4.62], p = 0.027), and postoperative urinary tract infection (OR = 3.10, 95% CI [1.65-5.82], p < 0.001) were independent predictors. Most strictures were left-sided. Intracorporeal robotic diversion had a higher, though non-significant, stricture rate (21.5% vs. 15.2%, OR = 1.52, p = 0.12). Stricture rates fell markedly after 20 robotic cases per surgeon (23.8% vs. 12.1%).

Uretero-enteric strictures are multifactorial, strongly influenced by baseline renal function, cardiovascular comorbidity, and postoperative infection. Robotic intracorporeal diversion shows a learning curve effect, underlining the importance of surgical expertise and infection prevention in reducing risk.