A Population-based Study of Ureteroenteric Strictures After Open and Robot-assisted Radical Cystectomy

Published:October 13, 2019DOI:



      To evaluate differences in the incidence of benign ureteroenteric stricture, we compared stricture rates of robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) using Surveillance, Epidemiology, and End Results-Medicare data.


      We identified 332 RARC and 1449 ORC performed between 2009 and 2014 to determine stricture rates at 6, 12, and 24 months following surgery. We defined ureteroenteric stricture as the need for procedural intervention. Additionally, we compared the incidence of stricture diagnosis. Multivariable proportional hazards regression was performed to determine factors associated with stricture development.


      The incidence of ureteroenteric stricture at 6 and 12 months was higher for RARC vs ORC at 12.1% vs 7.0% (P < .01) and 15.0% vs 9.5% (P = .01), respectively. RARC vs ORC stricture incidence at 2 years did not differ significantly at 14.6% vs 11.4% (P = .29). Similarly, the stricture diagnosis rates were significantly lower following ORC at 6, 12, and 24 months (P < .05). In adjusted analysis, RARC (HR 1.64, 95%CI 1.23-2.19) and preoperative hydronephrosis (HR 1.51, 95% CI 1.17-1.94) were associated with the development of stricture. Higher hospital volume was associated with a lower risk of stricture (HR 0.40, 95%CI 0.26-0.63).


      RARC is associated with a higher rate of ureteroenteric stricture diagnosis and intervention on a population-based level that is mitigated by higher hospital volume. A significant study limitation is inability to differentiate extracorporeal vs intracorporeal diversion. However, a stricture complication compounds the financial burden of care and efforts must be pursued to improve this surgical outcome.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Yu H
        • Hevelone ND
        • Lipsitz SR
        • et al.
        Comparative analysis of outcomes and costs following open radical cystectomy versus robot-assisted laparoscopic radical cystectomy: results from the US Nationwide Inpatient Sample.
        Eur Urol. 2012; 61: 1239-1244
        • Bochner BH
        • Dalbagni G
        • Marzouk KH
        • et al.
        Randomized trial comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: oncologic outcomes.
        Eur Urol. 2018; 74: 465-471
        • Raza SJ
        • Wilson T
        • Peabody JO
        • et al.
        Long-term oncologic outcomes following robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.
        Eur Urol. 2015; 68: 721-728
        • Novara G
        • Catto JWF
        • Wilson T
        • et al.
        Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy.
        Eur Urol. 2015; 67: 376-401
        • Shah SH
        • Movassaghi K
        • Skinner D
        • et al.
        Ureteroenteric strictures after open radical cystectomy and urinary diversion: the university of southern california experience.
        Urology. 2015; 86: 87-91
        • Shimko MS
        • Tollefson MK
        • Umbreit EC
        • et al.
        Long-term complications of conduit urinary diversion.
        J Urol. 2011; 185: 562-567
        • Lobo N
        • Dupré S
        • Sahai A
        • et al.
        Getting out of a tight spot: an overview of ureteroenteric anastomotic strictures.
        Nat Rev Urol. 2016; 13: 447-455
        • Warren JL
        • Klabunde CN
        • Schrag D
        • et al.
        Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population.
        Med Care. 2002; 40 (IV–3)
        • Elixhauser A
        • Steiner C
        • Harris DR
        • et al.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Shaw NM
        • Lobo JM
        • Zee R
        • et al.
        Management of ureteroenteric stricture: predictive modeling to compare cost.
        J Endourol. 2016; 30: 1244-1251
        • Hanna N
        • Leow JJ
        • Sun M
        • et al.
        Comparative effectiveness of robot-assisted vs. open radical cystectomy.
        Urol Oncol. 2018; 36: 88.e1-88.e9
        • Parekh DJ
        • Reis IM
        • Castle EP
        • et al.
        Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial.
        Lancet. 2018; 391: 2525-2536
        • Bochner BH
        • Dalbagni G
        • Sjoberg DD
        • et al.
        Comparing open radical cystectomy and Robot-assisted laparoscopic radical cystectomy: a randomized clinical trial.
        Eur Urol. 2015; 67: 1042-1050
        • Wittig K
        • Ruel N
        • Barlog J
        • et al.
        Critical analysis of hospital readmission and cost burden after Robot-assisted radical cystectomy.
        J Endourol. 2016; 30: 83-91
        • Large MC
        • Cohn JA
        • Kiriluk KJ
        • et al.
        The impact of running versus interrupted anastomosis on ureterointestinal stricture rate after radical cystectomy.
        J Urol. 2013; 190: 923-927
        • Anderson CB
        • Morgan TM
        • Kappa S
        • et al.
        Ureteroenteric anastomotic strictures after radical cystectomy-does operative approach matter?.
        J Urol. 2013; 189: 541-547
        • Mullins JK
        • Guzzo TJ
        • Ball MW
        • et al.
        Ureteral stents placed at the time of urinary diversion decreases postoperative morbidity.
        Urol Int. 2012; 88: 66-70
        • Desai MM
        • Gill IS
        • de Castro Abreu AL
        • et al.
        Robotic intracorporeal orthotopic neobladder during radical cystectomy in 132 patients.
        J Urol. 2014; 192: 1734-1740
        • Hautmann RE
        • de Petriconi R
        • Kahlmeyer A
        • et al.
        Preoperatively dilated ureters are a specific risk factor for the development of ureteroenteric strictures after open radical cystectomy and Ileal neobladder.
        J Urol. 2017; 198: 1098-1106
        • Hussein Al Awamlh B Al
        • Wang LC
        • Nguyen DP
        • et al.
        Is continent cutaneous urinary diversion a suitable alternative to orthotopic bladder substitute and ileal conduit after cystectomy?.
        BJU Int. 2015; 116: 805-814
        • Ahmed YE
        • Hussein AA
        • May PR
        • et al.
        Natural history, predictors and management of ureteroenteric strictures after Robot assisted radical cystectomy.
        J Urol. 2017; 198: 567-574
        • Hayn MH
        • Hussain A
        • Mansour AM
        • et al.
        The learning curve of robot-assisted radical cystectomy: results from the International robotic cystectomy consortium.
        Eur Urol. 2010; 58: 197-202
        • Collins JW
        • Tyritzis S
        • Nyberg T
        • et al.
        Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder - what is the effect of the learning curve on outcomes?.
        BJU Int. 2014; 113: 100-107
        • Hussein AA
        • May PR
        • Jing Z
        • et al.
        Outcomes of intracorporeal urinary diversion after Robot-assisted radical cystectomy: results from the International robotic cystectomy consortium.
        J Urol. 2017; 188: 1302-1311
        • Wilson TG
        • Guru K
        • Rosen RC
        • et al.
        Best practices in robot-assisted radical cystectomy and urinary reconstruction: recommendations of the Pasadena Consensus Panel.
        Eur Urol. 2015; 67: 363-375
        • Goh AC
        • Gill IS
        • Lee DJ
        • et al.
        Robotic intracorporeal orthotopic ileal neobladder: replicating open surgical principles.
        Eur Urol. 2012; 62: 891-901
        • Dason S
        • Goh AC
        Updates on robotic intracorporeal urinary diversions.
        Curr Urol Rep. 2018; 19: 28
        • Ahmadi N
        • Ashrafi AN
        • Hartman N
        • et al.
        Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy.
        BJU Int. 2019; 124: 302-307