Hand-sewn versus stapled ileo-ileal anastomosis following radical cystectomy: A systematic review and meta-analysis

Radical cystectomy (RC) with urinary diversion is the standard treatment for muscle-invasive bladder cancer. Intestinal continuity may be restored using either hand-sewn or stapled ileo-ileal anastomosis, yet contemporary evidence comparing their clinical and economic outcomes is limited. This study aims to evaluate and compare perioperative outcomes, postoperative complications, and hospital parameters between these 2 techniques. PubMed, Scopus, Web of Science, and Cochrane Library were searched for studies published up to August 2025. Eligible studies compared stapled vs. hand-sewn ileo-ileal anastomosis following RC and reported at least 1 relevant perioperative or postoperative outcome. Data were extracted independently, and risk of bias was assessed using the Newcastle-Ottawa Scale. Pooled analyses were performed using Review Manager software, with mean differences (MDs) and odds ratios (ORs) calculated under random- or fixed-effects models based on heterogeneity (I² statistic). Four studies encompassing 529 patients were included. There were no significant differences between techniques in estimated blood loss (MD = -17.39 [-61.26, 26.48]; P = 0.44), time to drain removal (MD = -1.00 [-2.24, 0.24]; P = 0.11), or gastrointestinal complications (OR = 1.13 [0.66, 1.93]; P = 0.66). Stapled anastomosis was associated with faster time to oral intake (MD = 0.31 [0.12, 0.50]; P = 0.001), whereas hand-sewn anastomosis demonstrated a modest advantage in time to flatus (MD = -0.25 [-0.49, -0.02]; P = 0.04). These differences were less than 1 day and of uncertain clinical relevance. Cost estimates reported in 2 contemporary robotic series suggested higher institutional costs for stapled techniques; however, these were not standardized across healthcare systems. Available retrospective evidence suggests broadly comparable safety profiles between hand-sewn and stapled ileo-ileal anastomoses following radical cystectomy. Observed differences in recovery metrics were statistically significant but small in magnitude and may not meaningfully alter postoperative recovery pathways. Given reported institutional cost differences, hand-sewn anastomosis may represent a resource-conscious alternative in selected settings. Prospective studies are needed to define clinically meaningful differences.