Comprehensive 90-Day Morbidity Assessment Following Robot-Assisted Radical Cystectomy With Intracorporeal Diversion

To evaluate perioperative morbidity following robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) during the transition from open surgery at a single academic center, and to provide detailed complication profiles to guide surgical teams and patient counseling.

We retrospectively analyzed 111 consecutive patients undergoing iRARC between 2017 and 2023. Perioperative outcomes and complications were assessed at 30 and 90 days, using the Clavien-Dindo (CD) classification. Complications were further categorized by etiology and severity. Detailed incidence rates and management strategies were recorded per patient.

A total of 163 complications occurred within 90 days, with 129 (79%) recorded within 30 days. Early complications were predominantly low-grade (n = 96, 74%), while 33 (26%) were high-grade. Systemic complications 108 (84%) outnumbered primary surgical events 21 (16%). Among early high-grade complications, cardiovascular and respiratory events were the most common (n = 9, 27%), followed by infectious (n = 7, 21%) and genitourinary complications (n = 7, 21%). Incidence rates for events were calculated on a per-patient basis: acute coronary syndrome 1.2%, pneumonia 2.7%, arrhythmias 2.7%, thrombosis 1.8%, pulmonary embolism 0.9%, insufficiency of the ileal anastomosis 0.9%, urinary tract infections 32.4%, and infected lymphoceles 8.1%. Genitourinary complications, including ureteral strictures (6.3%) and urinary leakage (3.6%), required frequent endourological interventions. Despite minimally invasive surgery and strict ERAS protocol implementation, paralytic ileus occurred in 19.8% of patients but was managed conservatively in all cases. Thirty-four additional complications occurred between days 30 and 90, including 16 high-grade events. The 90-day mortality rate was 1.8%. In the multivariable analysis, no independent predictors of high-grade complications were identified. Variables including BMI, clinical stage ≥ cT2, age, sex, and neoadjuvant chemotherapy showed no significant association (all p ≥ 0.20).

iRARC is feasible and associated with an acceptable safety profile during the learning curve. Most complications were systemic and not directly related to the surgical technique, underscoring the need for multidisciplinary perioperative management. Detailed incidence data of specific complications provide valuable insights for realistic patient counseling and heightened awareness among care teams.