LAUSR

DOI: 10.1111/iju.13782 ICUD has the potential benefits of a smaller incision, reduced pain, decreased bowel exposure, reduced risk of fluid imbalance and early postoperative recovery. Indeed, ICUD is gaining popularity during RARC, but purely laparoscopic ICUD has seldom been reported because of the technical difficulty, particularly precise intracorporeal suturing. We herein describe our modified technique to facilitate ureteroenteric anastomosis during pure laparoscopic intracorporeal IC after LRC and evaluate perioperative outcomes. From 2007 to 2017, 66 patients underwent LRC with pelvic lymphadenectomy with IC diversion at three institutions (35 intracorporeal IC, 31 extracorporeal). Total intracorporeal IC began in May 2014. LRC started using a five-port, fan shaped, transperitoneal approach. After lymphadenectomy and radical cystectomy, the left ureter was delivered under the sigmoid mesocolon to the right side. A 15-cm ileal segment of the bowel was harvested as previously described during RARC. The schema of ureteroenteric anastomosis and intraoperative findings are shown in Figure 1 and Video S1. After inserting a guidewire from a 3-mm port placed just superior to the pubic symphysis, a 6-Fr single-J ureteral stent was placed in the ureter. A conduit was irrigated using a 22-Fr catheter to minimize spillage of bowel contents. A single-J ureteral stent attached to the ureter was passed through two enterotomies in the proximal conduit and 12-mm assistant port. Ureteroenteric anastomosis was carried out using a continuous running suture method comprising two running 4-0 synthetic absorbable polyglyconate sutures. The first stitch was placed on the tip of spatulation of the ureter and IC. The second stitch was placed on the end opposite to the first stitch, and both stitches were tied. Then, the short tails of the two stitches were pulled by two laparoscopic graspers inserted from the port above the pubis and assistant port. The traction of the short tails of the two sutures could adjust the suture line parallel to a laparoscopic needle holder in the surgeon’s right hand, which makes carrying out running suture easier. The long tail of the second stitch was used for the anterior part of ureteroenteric anastomosis with three or four stitches using the running suture method, and it was tied to the first stitch. The posterior part of anastomosis was inverted by pulling the short tail of both stitches, and running suture was carried out in the same manner. A 3–4-cm skin incision was made at the supraumbilical site, and the specimen was removed. As for extracorporeal IC, a 5–7-cm skin incision was made at the infraumbilical site. The isolated ileum for conduit was washed outside the incision, and ureteroenteric anastomosis was carried out using a continuous running suture method. Perioperative data were compared between the intracorporeal and extracorporeal IC groups using propensity score matching. The primary study end-point was postoperative early (within 90 days) complication rates. In total, 28 matched pairs were evaluated. No significant difference in preoperative data was found (Table S1). The operative time for intracorporeal IC diversion and ureteroenteric anastomosis was 187 31 and 74 17 min, respectively. The median total operative time in intracorporeal groups was significantly longer, but the total median blood loss significantly decreased compared with that in extracorporeal groups (560 vs 1165 mL, respectively, P < 0.001). Importantly, the postoperative early complication rate in the intracorporeal group was significantly lower than that in the extracorporeal group (39% vs 71%, P = 0.016; Table S2). Similarly, the postoperative early major complication rate (Clavien grade 3–5) tended to decrease in the intracorporeal group (7% vs 29%, respectively, P = 0.036). The details are summarized in Table S3. As for postoperative recovery of bowel function, the mean days to regular oral food intake were 4 and 7 days in the intracorporeal and extracorporeal groups, respectively (P < 0.001). The Kaplan–Meier method showed no significant difference in ureteroenteric strictures between both groups (P = 0.60; Fig. S1). Urological Notes