# Robot-assisted tubeless radical cystectomy: Is the absence of ureteral drainage a mistake?

Anne Mauger de Varennes, Marie Mermier, Zine-Eddine Khene, Anis Gasmi, Etienne Courboin, Romain Mathieu, Benoît Peyronnet, Juliette Hascoet, Quentin Vesval, Karim Bensalah, et al.

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Anne Mauger de Varennes, Marie Mermier, Zine-Eddine Khene, Anis Gasmi, Etienne Courboin, et al. Robot-assisted tubeless radical cystectomy: Is the absence of ureteral drainage a mistake?. Deleted Journal, 2025, 35 (6-7), pp.102899. 10.1016/j.fjurol.2025.102899. hal-05068061

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<figure><img src="image_1.png" /></figure>
Original Article

# Robot-assisted tubeless radical cystectomy: Is the absence of ureteral drainage a mistake?

<figure><img src="image_2.png" /></figure>

## La cystectomie radicale robot-assistée sans drain : l'absence de drainage urétéral est-elle une erreur ?

Anne Mauger de Varennes *, Marie Mermier, Zine Eddine Khene, Anis Gasmi, Etienne Courboin, Romain Mathieu, Benoit Peyronnet, Juliette Hascoet, Quentin Vesval, Karim Bensalah, Grégory Verhoest

University of Rennes, Department of Urology, CHU de Rennes, Rennes, France

ARTICLE INFO

Keywords:
Bladder cancer
Cystectomy
Ureteral drainage

ABSTRACT

**Objective:** Radical cystectomy is the gold standard technique for muscle-invasive bladder cancer and resistant non muscle-invasive bladder cancer. This surgery presents a high rate of complications despite the advance of robotic surgery. The aim of this study is to compare the complications according to the presence of ureteral stents or not.

**Methods:** Two hundred consecutive patients who underwent robotic radical cystectomy for bladder cancer at our center between 2012 and 2022 were included in this retrospective study. Cessation of upper tract drainage was introduced prospectively in February 2021, without any selection bias. Patients were divided into 2 groups: ureteral stents (US) or no ureteral stents (NUS). All complications were analyzed during 3 postoperative months. Urinary diversion-specific complications were analyzed during 12 postoperative months.

**Results:** Over the 200 included patients, 58 did not have any ureteral stents (29%). The overall postoperative complication rate was nearly identical between the NUS group at 48% and the US group at 53% (P = 0.56). The rate of severe complications ≥ Claviena seemed lower in the NUS group at 15% versus 24% in the US group (Chi²: 1.73, P = 0.19), as were the rates of infectious complications: NUS 29% versus US 38% (Chi²: 1.20, P = 0.27). These results were the same in subgroup analyses. Complications on the urinary diversion at 12 months were 12% for the NUS group and 20% for the US group (Chi²: 1.67, P = 0.196).

**Conclusion:** Going against all dogmas, the absence of upper urinary tract drainage for cystectomy does not increase the risk of early and late complications, and even seems to limit infectious and late complications such as stenosis.

**Level of evidence:** 3.

© 2025 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Mots clés:
Cancer de vesse
Cystectomie
Drainage urétéral

RÉSUMÉ

**Objectif:** La cystectomie radicale est le traitement de référence du cancer de vesse infiltrant le muscle détrusor ou non infiltrant mais résistant. Cette chirurgie est associée à une morbidité importante malgré l'essor de la chirurgie robotique. L'objectif de cette étude est de comparer les complications en fonction du drainage urétéral ou non.

**Méthodes:** Deux cent patients consécutifs ayant eu une cystectomie radicale robot-assistée pour cancer dans notre centre entre 2012 et 2022 ont été inclus dans cette étude. L'arrêt du drainage du haut appareil est apparu de façon prospective en février 2021, sans biais de sélection. Les patients ont été séparés dans 2 groupes : sondes urétérales

<footnote>* Corresponding author. CHU Pontchaillou, 2, rue Henri-le-Guilloux, 35000 Rennes, France.
E-mail address: anne.mauger.de.varennes@chu-rennes.fr (A. Mauger de Varennes).</footnote>
(SU) ou sans sondes urétérales (SSU). Toutes les complications ont été analysées pendant 3 mois. Les complications spécifiques à la dérivation urinaire ont été analysées pendant 12 mois.

**Résultats:** Sur les 200 patients inclus, 58 n'ont pas eu de sondes urétérales (29 %). Les dérivations urinaires étaient de : 64 patients avec néo-ressors dont 20 SSU (32 %), 136 patients avec dérivation iléale Bricker dont 38 SSU (28 %). Le taux de complications postopératoires était identique entre le groupe SSU 48 % et SU 53 % (p = 0,56). Le taux de complications graves ≥ Clavien3a semblait inférieur dans le groupe SSU 15 % vs SU 24 % (Chi² : 1,73, p = 0,19), de même pour les complications infectieuses : SSU 29 % vs SU 38 % (Chi² : 1,20, p = 0,27). Ces résultats sont identiques dans les analyses en sous-groupe. Les complications sur la dérivation urinaire à 12 mois étaient de 12 % SSU et 20 % SU (Chi² : 1,67, p = 0,196).

**Conclusion:** L'absence de drainage urétéral des cystectomies n'augmente pas les risques de complications précoces ou tardives, et semble limiter les complications infectieuses et tardives comme la sténose.

**Niveau de preuve:** 3.

© 2025 Les Auteurs. Published by Elsevier Masson SAS. This article is published in Open Access sous licence CC BY (http://creativecommons.org/licenses/by/4.0/).

# 1. Introduction

Bladder cancer ranks 4th in incidence and 7th in deaths among all cancers, with 13,070 estimated new cases and 5330 deaths in France in 2018, with 80% occurring in men. It is the second most common urologic cancer after prostate cancer, and its incidence is increasing every year [1].

Bladder tumors are classified based on the invasion of the muscular layer of the bladder during initial transurethral resection of the bladder (TURB). Radical treatment is necessary for muscle-invasive bladder cancer (MIBC) or high-risk non muscle-invasive bladder cancer (NMIBC) recurring after intravesical instillations [2].

Radical cystectomy with extended pelvic lymph node dissection remains the gold standard surgical technique. Despite successive improvements in the robotic era and better perioperative patient management, this surgery remains complex with a high rate of complications around 50%, and mortality from 3% to 7% [3-5]. Postoperative complications are correlated with age, comorbidities, history of radiotherapy, pelvic surgery, surgeon's and hospital volume, and type of urinary diversion [4-8]. Specific postoperative complications related to urinary reconstruction are linked to the risk of fistula and stenosis of the uretero-ileal anastomosis.

Since the development of silicone ureteral stents in the 80's, it has been admitted to temporarily use them in order to reduce these risks, without any scientific study demonstrating their real benefit. The European Association of Urology and the French Urology Association's recommendations do not describe the optimal drainage modalities or duration for urinary diversion [1,2,9,10].

The placement of this foreign body could not only be unnecessary but also create local inflammation, delayed healing, obstruction, and major infectious risks [11]. Few studies have compared complications based on the use of ureteral stents during open cystectomy, but the results of these retrospective studies with numerous biases were discordant [12,13].

In the era of robotic surgery and early recovery after mini invasive surgery, new studies are needed to evaluate the value of ureteral stents in preventing complications of robot-assisted radical cystectomy.

# 2. Materials and methods

## 2.1. Study design

Two hundred consecutive patients who underwent robot-assisted radical cystectomy for bladder cancer in our department between 2012 and 2022 were included in this retrospective study. All patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer (MIBC and high-risk or BCG refractory NMIBC) were included. Exclusion criteria were patients undergoing a partial cystectomy or a radical cystectomy for a non-oncologic indication.

Upper urinary tract drainage was systematically stopped in February 2021 for every patient having a RARC, without any exclusion criteria or selection bias. Datas were then collected prospectively.

Patients were divided into two groups: ureteral stents (US) or no ureteral stents (NUS). All complications were analyzed during the 3 postoperative months. Urinary diversion-specific complications (such as urinary strictures or fistulas) were analyzed during the 12 postoperative months.

## 2.2. Surgical technique and perioperative management

All patients were operated by the same experienced senior surgeon who performed all radical robotic-assisted cystectomy for bladder cancer at our university hospital center. The choice of urinary diversion was discussed between the patient and the surgeon based on age, stage of bladder cancer and comorbidities. All patients were included in an early rehabilitation protocol.

During the 10-year experience of RARC in our center, adjustments to the surgical technique of our lead surgeon have emerged to simplify the procedure. Starting in 2018, opioid-free anesthesia became the standard (144 patients in our study). In march 2019, we stopped placing abdominal cavity drainage at the end of the procedure. Since February 2021, no ureteral stents have been placed during RARC. Then, in July 2021, the ileal conduit was also performed intracorporeally. Previously, only neobladders were entirely done intracorporeally.

For all Bricker and neobladder technique, we use ileum mechanical stapling, crossing of the left ureter and direct et separated uretero-ileal anastomosis by continuous sutures. We do not use Indocyanine Green for oncological cystectomy.

Patients' characteristics, per- and postoperative parameters, complications, and final pathological examination were analyzed.

## 2.3. Study endpoints

The primary endpoint was to analyze all complications during the 90-days postoperative period.

The secondary endpoints were to study high grade complications Clavien ≥ 3, the rate of urinary tract infections, specific complications according to the type of urinary reconstruction, the rate of fistulas and strictures at 12 months after surgery, length of hospital stay, and readmission rate.

## 2.4. Statistical analysis

The demographic, clinical, and biological data of the US and NUS groups were compared using the Chi² test or Fisher's exact test for qualitative variables. The Student's t-test was used to compare means of continuous quantitative data with a normal distribution, and the Mann-Whitney test was used for non-normally distributed data.

All analyses were two-sided, and a P-value < 0.05 was considered significant.

All statistical analyses were performed using XLSTAT® software. Missing data were excluded from analysis.
<table><caption>**Table 1**
Preoperative clinical and pathological characteristics of population.</caption><thead><tr><th></th><th>Ureteral stent (US) (n = 142; 71%)</th><th>No ureteral stent (NUS) (n = 58; 29%)</th><th>Total cohort (n = 200)</th><th>P-value</th></tr></thead><tbody><tr><td>Gender (n, %)</td><td></td><td></td><td></td><td></td></tr><tr><td>Female</td><td>16 (11.3%)</td><td>6 (10.3%)</td><td>22 (11%)</td><td>0.8</td></tr><tr><td>Male</td><td>126 (88.7%)</td><td>52 (89.7%)</td><td>178 (89%)</td><td></td></tr><tr><td>Age at cystectomy (mean)</td><td>68.9 [39.1-93.4]</td><td>67.9 [40.8-83.5]</td><td>68.5 [39.1-93.4]</td><td>0.5</td></tr><tr><td>ASA score</td><td></td><td></td><td></td><td></td></tr><tr><td>ASA 1</td><td>19 (13.4%)</td><td>8 (13.8%)</td><td>27 (13.5%)</td><td>0.9</td></tr><tr><td>ASA 2</td><td>76 (53.5%)</td><td>37 (63.8%)</td><td>113 (56.5%)</td><td>0.18</td></tr><tr><td>ASA 3</td><td>45 (31.7%)</td><td>11 (19%)</td><td>56 (28%)</td><td>0.07</td></tr><tr><td>ASA 4</td><td>2 (1.4%)</td><td>2 (3.4%)</td><td>4 (2%)</td><td>0.58</td></tr><tr><td>ECOG PS</td><td></td><td></td><td></td><td></td></tr><tr><td>0</td><td>62 (43.7%)</td><td>32 (55.2%)</td><td>94 (47%)</td><td>0.14</td></tr><tr><td>1</td><td>76 (53.5%)</td><td>21 (36.2%)</td><td>97 (48.5%)</td><td>0.18</td></tr><tr><td>2</td><td>3 (2.1%)</td><td>2 (3.4%)</td><td>5 (2.5%)</td><td>0.63</td></tr><tr><td>3</td><td>0</td><td>2 (3.4%)</td><td>2 (1.1%)</td><td>0.08</td></tr><tr><td>4</td><td>1 (0.7%)</td><td>1 (1.8%)</td><td>2 (1%)</td><td>0.5</td></tr><tr><td>BMI (mean)</td><td>25.89 [18-44.96]</td><td>26.47 [16.70-45.01]</td><td>26.15 [16.70-45.01]</td><td>0.4</td></tr><tr><td>BMI > 30</td><td>19 (13.4%)</td><td>11 (19%)</td><td>30 (15%)</td><td>0.31</td></tr><tr><td>Smoking status (n, %)</td><td></td><td></td><td></td><td></td></tr><tr><td>Never</td><td>37 (26%)</td><td>11 (19%)</td><td>48 (24%)</td><td>0.29</td></tr><tr><td>Former or active smoker</td><td>105 (74%)</td><td>47 (81%)</td><td>152 (76%)</td><td></td></tr><tr><td>Preoperative renal clearance (CKD EPI)</td><td>68.45 [15-114]</td><td>72.86 [11-117]</td><td>69.98 [11-117]</td><td>0.21</td></tr><tr><td>Treatment (n, %)</td><td></td><td></td><td></td><td></td></tr><tr><td>Antiplatelet</td><td>36 (25.3%)</td><td>18 (31%)</td><td>54 (27%)</td><td>0.41</td></tr><tr><td>Anticoagulant</td><td>17 (12%)</td><td>8 (13.8%)</td><td>25 (12.5%)</td><td>0.72</td></tr><tr><td>Cancer data (n, %)</td><td></td><td></td><td></td><td></td></tr><tr><td>TVNIM before</td><td>42 (29.5%)</td><td>17 (29.3%)</td><td>59 (29.5%)</td><td>0.97</td></tr><tr><td>TVIM first</td><td>100 (70.5%)</td><td>41 (70.7%)</td><td>141 (70.5%)</td><td></td></tr><tr><td>cTNM before surgery</td><td></td><td></td><td></td><td></td></tr><tr><td>T1 and/or CIS</td><td>27 (19.0%)</td><td>12 (20.6%)</td><td>39 (19.5%)</td><td>0.95</td></tr><tr><td>T2</td><td>69 (48.6%)</td><td>28 (48.3%)</td><td>97 (48.5%)</td><td></td></tr><tr><td>T3</td><td>37 (26%)</td><td>14 (24.1%)</td><td>51 (25.5%)</td><td></td></tr><tr><td>T4</td><td>9 (6.3%)</td><td>4 (6.9%)</td><td>13 (6.5%)</td><td></td></tr><tr><td>N0</td><td>130 (91.5%)</td><td>51 (87.9%)</td><td>181 (90.5%)</td><td>0.43</td></tr><tr><td>N+</td><td>12 (8.5%)</td><td>7 (12.1%)</td><td>19 (9.5%)</td><td></td></tr><tr><td>M0</td><td>140 (98.6%)</td><td>57 (98.3%)</td><td>197 (98.5%)</td><td>0.88</td></tr><tr><td>M+</td><td>2 (1.4%)</td><td>1 (1.7%)</td><td>3 (1.5%)</td><td></td></tr><tr><td>Neoadjuvant chemotherapy (n, %)</td><td>66 (46.5%)</td><td>29 (50%)</td><td>95 (47.5%)</td><td>0.65</td></tr></tbody></table>

# 3. Results

## 3.1. Baseline characteristics of population

Demographic characteristics of the 200 patients are presented in Table 1. Patients in both groups were comparable, regarding age, sex ratio, performance status, ASA score, body mass index (BMI), smoking status and preoperative renal function.

Regarding oncological status, preoperative and postoperative TNM stages were equivalent in both groups. In the NUS group, 46% of the

patients and 50% in the US group underwent neoadjuvant chemotherapy (P = 0.650). Characteristics of the cohort are listed in Table 1.

## 3.2. Surgical data and perioperative outcomes

Over the 200 included patients, 58 did not have any ureteral stents (29%).

Urinary diversions were divided between 64 patients with continent neobladder, including 20 NUS (32%), and 136 patients with ileal conduit diversion, including 38 NUS (28%) (Table 2). Mean operative time was

<table><caption>**Table 2**
Surgical data and perioperative outcomes.</caption><thead><tr><th></th><th>Ureteral stent (US) (n = 142; 71%)</th><th>No ureteral stent (NUS) (n = 58; 29%)</th><th>Total cohort (n = 200)</th><th>P-value</th></tr></thead><tbody><tr><td>Type of urinary diversion (n, %)</td><td></td><td></td><td></td><td></td></tr><tr><td>Ileal conduit</td><td>98 (69%)</td><td>38 (65.5%)</td><td>136 (68%)</td><td>0.63</td></tr><tr><td>Neo bladder</td><td>44 (31%)</td><td>20 (34.5%)</td><td>64 (32%)</td><td></td></tr><tr><td>Median blood loss (mL) (median)</td><td>400 [50-3000]</td><td>300 [100-1300]</td><td>385 [50-3000]</td><td><b>P: 0.015</b></td></tr><tr><td>Mean operative time (min) (mean)</td><td>281 [140-585]</td><td>242 [165-350]</td><td>269 [140-585]</td><td><b>P: 0.0002</b></td></tr><tr><td>Median length of hospital stay (days), (median)</td><td>10.5 [5-73]</td><td>8 [5-47]</td><td>9[5-73]</td><td><b>P: 0.03</b></td></tr><tr><td>Readmission rate at least once (n, %)</td><td>52 (36.62%)</td><td>15 (25.86%)</td><td>67 (33.5%)</td><td><b>P: 0.14</b></td></tr><tr><td>Pathological examination (n, %)</td><td></td><td></td><td></td><td></td></tr><tr><td>pT0</td><td>45 (31.69%)</td><td>14 (24.14%)</td><td>59 (29.5%)</td><td><b>P: 0.29</b></td></tr><tr><td>pT1</td><td>23 (16.20%)</td><td>10 (17.24%)</td><td>33 (16.5%)</td><td><b>P: 0.85</b></td></tr><tr><td>pT2</td><td>23 (16.20%)</td><td>9 (15.52%)</td><td>32 (16%)</td><td><b>P: 0.98</b></td></tr><tr><td>pT3</td><td>27 (19.01%)</td><td>16 (27.59%)</td><td>43 (21.5%)</td><td><b>P: 0.18</b></td></tr><tr><td>pT4</td><td>24 (16.90%)</td><td>9 (15.52%)</td><td>33 (89.1%)</td><td><b>P: 0.81</b></td></tr><tr><td>pN0</td><td>116 (81.69%)</td><td>47 (81.03%)</td><td>163 (81.5%)</td><td><b>P: 0.91</b></td></tr><tr><td>pN+</td><td>26 (18.31%)</td><td>11 (18.97%)</td><td>37 (18.5%)</td><td></td></tr><tr><td>Median ureteral stents removal (days)</td><td>8.8 [0-30]</td><td>0</td><td></td><td></td></tr></tbody></table>

Characters in bold: significantly different P < 0.05.
<table><caption>**Table 3**
Postoperative complications.</caption><thead><tr><th></th><th>Ureteral stent (US) (n = 142; 71%)</th><th>No ureteral stent (NUS) (n = 58; 29%)</th><th>Total cohort (n = 200)</th><th>P-value</th></tr></thead><tbody><tr><td>Overall complications (n, %)</td><td>75 (52.8%)</td><td>28 (48.3%)</td><td>103 (51.5%)</td><td>Chi<sup>2</sup>: 0.34, P: 0.56</td></tr><tr><td>Major complications Clavien ≥ 3 (n, %)</td><td>34 (23.9%)</td><td>9 (15.5%)</td><td>43 (21.5%)</td><td>Chi<sup>2</sup>: 1.73, P: 0.19</td></tr><tr><td>Urinary diversion complications (n, %)</td><td>28 (19.7%)</td><td>7 (12%)</td><td>35 (17.5%)</td><td>Chi<sup>2</sup>: 1.67, P: 0.19</td></tr><tr><td>Stenosis</td><td>16 (11.3%)</td><td>4 (6.8%)</td><td>20 (10%)</td><td>OR: 1.71, CI [0.52; 7.36], P: 0.44</td></tr><tr><td>Leakage</td><td>10 (7%)</td><td>3 (5.1%)</td><td>13 (6.5%)</td><td>OR: 1.39, CI [0.34; 8.14], P: 0.76</td></tr><tr><td>All infections (n, %)</td><td>54 (38%)</td><td>17 (29.3%)</td><td>70 (35%)</td><td>Chi<sup>2</sup>: 1.37, P: 0.24</td></tr><tr><td>Urinary tract infections</td><td>48 (33.8%)</td><td>15 (25.9%)</td><td>62 (31%)</td><td>Chi<sup>2</sup>: 1.20, P: 0.27</td></tr><tr><td>Intra-abdominal abscess</td><td>6 (4.2%)</td><td>2 (3.4%)</td><td>8 (4%)</td><td>OR: 1.23, CI [0.21; 12.87]</td></tr></tbody></table>

significantly shorter in the NUS group (242 minutes) compared to the US group (281 minutes) (P < 0.001).

In the US group, ureteral stents were removed at 8.8 days. Length of hospital stay was significantly shorter in the NUS group (8 days) compared to the US group (10.5 days) (P = 0.03). Patients' readmission rate was 25.9% in the NUS group and 36.6% in the US group (P = 0.14). The shorter length of hospital stay in the NUS group is not associated with an increased rate of re-hospitalization.

### 3.3. Postoperative complications analysis

Overall complications rate during the first 90 postoperative days are presented in Table 3 and was similar between the NUS group at 48% and the US group at 53% (Chi² = 0.34, P = 0.56). Major complications ≥ Clavien 3a seemed to be lower in the NUS group at 15% compared to the US group at 24%, without reaching statistical significance (Chi² = 1.73, P = 0.19). The same finding was observed for infectious complications: NUS 29% vs. US 38% (Chi²: 1.37, P = 0.24).

Complication rate regarding the type of urinary diversion at 12 months was 12% in the NUS group and 20% in the US group (Chi²: 1.67, P = 0.19). The more specific analysis of anastomotic strictures in the NUS group was 7% vs. 11% in the US group (OR: 1.7, CI [0.52; 7.36]). Uretero-ileal fistulas accounted for 5% in the US group and 7% in the NUS group (OR: 1.39, CI [0.34; 8.14]).

These results are consistent in subgroup analyses according to the type of urinary diversion.

### 3.4. Ileal conduit diversion subgroup analyses

In Bricker-type ileal diversions, patients with at least one complication were 52% in the NUS group and 50% in the US group (Chi²: 0.08, P = 0.78). Major complications ≥ Clavien 3 seemed lower in the NUS group at 16% vs. 22% in the US group (Chi² = 0.74, P = 0.39), as well as infectious complications: SSU 24% vs. SU 31% (Chi²: 0.64, P = 0.42) (Fig. 1).

The complication rate of uretero-ileal anastomosis during the year after surgery was 5% in the NUS group and 11% in the US group for strictures (OR: 2.26, CI [0.46; 22.04]). Regarding the rate of fistulas 8% occurred in the NUS group and 3% in the US group (OR: 0.37, CI [0.048; 2.90]).

### 3.5. Neobladder subgroup analyses

Total complication rate was not significantly different, with 50% in the NUS group and 59% in the US group respectively (Chi²: 0.46, P = 0.49). Major complications ≥ Clavien 3 seemed to be lower in the NUS group at 15% compared to 27% in the US group (OR: 2.10, CI [0.48; 13.18]), as well as infectious complications: NUS 40% vs. US 55% (Chi²: 1.16, P = 0.28) (Fig. 2).

The complication rate of uretero-ileal anastomoses was similar in both groups at 10% for strictures (OR: 1.15, CI [0.17; 13.19]). Regarding fistulas specific to uretero-ileal anastomosis, no patients presented fistulas in the NUS group and 11% in the US group (P-value: 0.31). Fistulas concerning the neobladder itself were similar.

<figure><img src="image_3.png" /><figcaption>Fig. 1. Complications in the ileal conduit subgroup.</figcaption></figure>
<figure><img src="image_4.png" /><figcaption>Fig. 2. Complications in the neobladder subgroup.</figcaption></figure>

## 4. Discussion

Few studies have evaluated the benefit of ureteral stents. This study demonstrates that patients without ureteral stents during RARC for bladder cancer do not have more complications, and might be less invasive. It also allows faster recovery. Therefore, the imperative necessity to drain the upper tract raises questions.

We demonstrated in this study a significant reduction length of hospital stay between stented and non-stented patients (10.5 vs. 8 days, *P* = 0.03). Previous studies had already shown similar findings for open radical cystectomy [13]. This might be explained by a lower infection rate, as urinary tract infections are the most common post-cystectomy complications, and the leading cause of re-hospitalization according to several studies [14,15]. The absence of any drainage also allows early mobilization and recovery of patients.

Gayarre Abril et al. observed that 55% of re-hospitalizations were due to urinary tract infections, half of which occurred just after ureteral stent removal. This study did not find a prophylactic antibiotic protocol or stent duration that reduced these numerous infections. Another study has already shown that reducing the duration of ureteral stenting from 15 to 5 days decreased the infection risk and readmission rate with an identical stenosis rate [16].

The hypothesis is that ureteral stents quickly become coated with a bacterial biofilm that is difficult to access with antibiotics [17]. The bacterial mobilization during the stent removal in a recently operated and immunocompromised patient is believed to be responsible for the high infection's rate [18]. It has also been demonstrated that ureteral peristalsis is disrupted by this foreign body, altering urine flow and causing inflammation of the renal pelvis [19].

In uretero-ileal anastomosis, stents irritate the sutures, create fibrosis due to inflammation, and delay healing or even develop stenosis due to hyperplasia of fibrous tissue. In addition, another major risk of ureteral stents is their obstruction by mucus, stopping urine flow and causing renal insufficiency or urinary tract infection.

Our results are consistent with recent studies that have analyzed the ureteral drainage in radical cystectomy. Donat et al.'s study, conducted at Memorial Sloan Kettering Cancer Center and published in 2021, was the first to question the usefulness of ureteral stents in radical cystectomy [15]. Although this study has many biases (one group of surgeons used ureteral stents while the other did not, ureteral drainage was decided upon surgeon's appreciation during the procedure without any

randomization, the primary objective was the analysis of ileus after randomization on IV fluid administration during the surgery rather than the use or non-use of ureteral stents, and the study only examined complications at 30 days). The incidence of 30-day complications (including infection, ureteral leak or obstruction) was significantly different, with 14% in the non-stent group compared to 32% in the stent group (*P* = 0.003). The infectious related complications were 12% in the NUS group vs. 20% in the US group (*P* = 0.039).

The recent study by Vecchia et al. (2025), which conducted a systematic review and meta-analysis on radical cystectomy with urinary diversion without stents. This study is in accordance with our results by suggesting that the absence of stents could be a reasonable option, with no statistically significant difference in terms of major postoperative complications, strictures, or anastomotic leaks.

One major concern is the significant reduction of hospital stay. Several studies have shown different results between the costs of RARC and ORC [20–23]. Cost-efficiency of RARC with the absence of ureteral drainage could strengthen robotic surgery. RARC's costs have been analyzed in a multicentric European study. Nearly 84% of costs of RARC were due to hospital stay: urology department stay (42%), intensive care unit stay (3%) and operative time (39%), while 16% of costs were due to robotic (8%) and stapling (8%) instruments [24]. Mean total cost of RARC + ICUD averaged 11,947€ in France and 14,794€ in Europe.

In our study, we demonstrated a reduction of 2.5 days in hospital stay and 40 minutes in operative time in the NUS group. This would result in a calculated cost-sparing of 1958€ (calculated from the average cost of one day of hospitalization in France and the cost of one minute of operating room) [25]. Of course, this is only a premise and it should be further evaluated in a dedicated cost-efficiency study.

Although the absence of ureteral stents does not fully explain the differences between the two groups, the removal of these stents is the major surgical technique variation performed during these 10 years that explains the difference on complications on urinary diversion of 12% in the non-stent group and 20% in the stent group.

However, our study has several limitations. One of these limitations is a chronological bias. Indeed, patients were not randomized but retrospectively analyzed in the stent group and prospectively included in the no stent group.

The consequences of this bias are limited by the study of patient characteristics, which shows similar results in terms of demographics and comorbidities.
Our results should be interpreted with caution, considering the inherent limitations with the retrospective nature of this study and of the chronological bias. The evolution of surgical management and the increasing surgeon experience over the past decade should be evaluated by a large and multicenter study.

An important bias could have been having multiple operators, with different numbers of cystectomy/year, techniques, and choices of suture material. In our study, a single operator performed all 200 procedures, with a high experience of robotic surgery. We do not know if these results are generalizable to a less experienced surgeon or other centers. These results are only applicable to cystectomy for bladder carcinoma. Further studies could be conducted for robot-assisted cystectomy for neurogenic bladder.

Despite these limitations, this study confirms previous research on improving postoperative outcomes in radical cystectomy. It is the first study to show no more complications, reduced hospital stay, and lower rate of stenosis and fistula at 12 months for non-drained uretero-ileal anastomoses in RARC for cancer.

## 5. Conclusion

The absence of upper tract urinary drainage in RARC did not show any difference in all-stage or major complications at 90 days and urinary diversion complications at 12 months between US versus NUS, with reduced length of hospital stay. Prospective and multicentric studies are needed to provide a high level of evidence and to recommend the non-use of ureteral stents as a standard of care.

## Disclosure of interest

The authors declare that they have no competing interest.

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