The International Consultative Committee on Urological Diseases (ICUD-EAU) conducted a meta-analysis of 16,000 postoperative urinary diversion patients with bladder cancer from 11 medical centers. The results demonstrated that ileal outflow tract accounted for 42.2%, in situ cystectomy accounted for 38%, and ureteral dermatostomy accounted for 10.4%.
In situ ileal neobladder and ileal outflow tract procedures need exquisite surgical techniques and long operative time [13–14]. The concept of rapid rehabilitation in surgical procedures is well established, aiming to facilitate quicker recovery. However, this approach is limited by the condition of the intestinal tract and the patient's overall fitness. It involves the use of various complications associated with intestinal tubes, thus, the tubes selected for the reconstruction of the neobladder and ileal outflow tract must be in a normal condition. Therefore, patients with conditions such as short bowel syndrome, inflammatory diseases of the small intestine, and extensive radiation exposure of the ileum are not considered suitable candidates for these procedures.
Cutaneous ureterostomy is a relatively simple procedure with a short learning curve and operative time. It does not interfere with intestinal function and allows for quick postoperative recovery. This surgical approach is particularly suitable for cases with a short life expectancy, palliative total cystectomy, severe medical comorbidities, combined with intestinal diseases, or when patients refuse bowel-related operations.
However, CU comes with certain drawbacks, including the potential for ureteral strictures [15], necrosis, and the often necessary implementation of bilateral ureterostomy, which can complicate postoperative care. Excessive or insufficient dissociation of the ureter during the procedure may lead to high ureteral tension, resulting in impaired blood supply to the ureter. To enhance surgical quality and mitigate these challenges, it is crucial to adhere to some basic principles: ensure the blood supply of the ureter (appropriate length of ureteral dissociating, reduce the tension of the ureteral outflow tract), try to achieve unilateral ureterostomy and so on.
In order to realize the above basic principles, the Department of Urology in Zhejiang Provincial People's Hospital has leveraged previous reports and experience of laparoscopic and Da Vinci robotic laparoscopic surgery, explored the whole endoscopy operation, fine ureteral dissociating technology assisted by robots, successfully released the Robot-assisted "Y-shaped" end-to-side ureteral anastomosis technique under whole endoscopy for radical cystectomy, with no serious complications observed during the perioperative period and postoperative follow-up.
We believe that the technical points and advantages of this procedure assisted by Da Vinci robot include: 1. Robotic operation provides high-definition operation view. 2. Minimize the length of ureteral dissociation, appropriately preserving distal ureteral length and blood supply, and avoiding ineffective excursions that may lead to impaired ureteral blood supply. Taking strategies, for example, pulling the left ureter from the mesenteric non-avascular zone to the right side. We found that releasing the left ureter about 1 cm lateral to the cephalad of the iliac vessels was generally adequate. Similarly, the anastomotic position of the right ureter was often chosen to be 1 cm lateral to the cephalad of the right iliac vessel. 3. To safeguard the blood supply of the ureter, the approach involves avoiding torsion and dissecting along the longitudinal axis of the ureter on the nonmembranous side. 4. The diameter of the "Y-shaped" end-to-side ureteral anastomosis should be adequate, and 4 − 0 or 5 − 0 single strand absorbable line is recommended for accurately anastomosis. 5. The use of peritoneal coverage of the ureter (peritoneal exteriorization) is helpful in anastomotic regional healing to minimize the risk of leakage of anastomotic fluid into the peritoneal cavity, and circumventing internal hernia at the same time. 6. Whole endoscopy operation of urinary diversion reduces the exposure time of the bowel.
Furthermore, manual dilatation of the ureteral diameter by using hem-o-lock to temporarily clamp the ureter prior to anastomosis. While this facilitates the anastomosis, it is crucial to monitor postoperative renal function to avoid potential complications. Creta et al. [16] proposed that elderly patients with bladder cancer may experience deterioration of renal function due to acute kidney injury, after RC + UD. Considering the stoma habitus, all patients in this study had a right-sided stoma through pulling the left ureter to the right side with an end-to-side anastomosis. However, conversely, pulling the right ureter to the left side can also be considered. Depend on our previously study, using the greater omentum to wrap the ureter or anastomotic region to provide additional blood supply is also a question that needs further demonstration analysis.
The disposal strategy of the single J tube in this procedure requires further exploration, considering factors such as the number of tubes, their retention time, replacement or removal postoperatively, and the appropriate diameter. In this study, individualized placement of one or two single J-tubes was based on the diameter of the right ureter. Recognizing that ureteral stenosis is a common complication, routine postoperative changes of single J tubes were performed under the guidance of ultra-smooth guidewire during postoperative period. Accidental dislodgement of the single J tube for reinsertion could potentially lead to uncontrollable stent tube placement. However, adequate patient education on stoma care and proper fixation of the stent tube, this did not occur in this study.
To enhance surgical safety and minimize operation time, routine or extended node dissection was not performed, and only two patients underwent obturator lymphatic biopsy. Considering the potential for uroepithelial carcinoma to present multisource lesions and the possibility of upper tract urothelial carcinoma (UTUC), in addition to preoperative imaging evaluation, we routinely perform intraoperative frozen section diagnosis of ureteral stump to eliminate the risk of uroepithelial carcinoma in the ureteral stump.
Thus, choose the appropriate mode of urinary diversion individually is crucial. We summarized the target population or indications for performing "Y-shaped" end-to-side ureteral anastomosis: emphasis on preoperative prognosis and assessment, including the degree of obesity [17] and/or pelvic adiposity, economic ability, bowel conditions, objective quantitative indicators such as preoperative BMI, CT abdominal wall fat thickness, ureteral diameter can further evaluate. Our study suggests that obese patients with a body mass index > 24 kg/m2 may be passively subjected to this procedure.