# Robot-assisted supratrigonal cystectomy and augmentation cystoplasty for adult neurogenic lower urinary tract dysfunction: comparison of extracorporeal versus intracorporeal diversion

Neha Sihra, Pierre Lecoanet, Alexandre Dubois, Juan Penafiel, Camille Haudebert, Charles Mazeaud, Adil Mellouki, Juliette Hascoet, Younes Ahallal, Andréa Manunta, et al.

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Neha Sihra, Pierre Lecoanet, Alexandre Dubois, Juan Penafiel, Camille Haudebert, et al. Robot-assisted supratrigonal cystectomy and augmentation cystoplasty for adult neurogenic lower urinary tract dysfunction: comparison of extracorporeal versus intracorporeal diversion. Therapeutic Advances in Urology, 2025, 17, pp.17562872251359339. 10.1177/17562872251359339. hal-05248833

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# Robot-assisted supratrigonal cystectomy and augmentation cystoplasty for adult neurogenic lower urinary tract dysfunction: comparison of extracorporeal versus intracorporeal diversion

Neha Sihra<sup>ID</sup>, Pierre Lecoanet, Alexandre Dubois, Juan Penafiel, Camille Haudebert, Charles Mazeaud, Adil Mellouki, Juliette Hascoet, Younes Ahallal, Andrea Manunta, Imad Bentellis and Benoit Peyronnet<sup>ID</sup>

**Abstract:** We aim to explore the feasibility of robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RA-SCAC) for the management of adult neurogenic lower urinary tract dysfunction and to compare the functional and surgical outcomes of an intracorporeal and extracorporeal approach. A retrospective review of all patients who underwent robot-assisted supratrigonal cystectomy and augmentation cystoplasty was performed. Data was collected on age, body mass index, American Society of Anaesthesiologists (ASA) score, type and duration of neurological disease, previous abdominal surgery and renal function. Bladder diary, urodynamics and validated symptom score results were recorded at baseline and repeated postoperatively. Intraoperative details included type of diversion, concomitant surgery, duration of surgery, blood loss and conversion to open. Postoperative surgical recovery was also reviewed. The primary endpoint was the rate of major postoperative complications defined as any complication Clavien-Dindo grade ≥3 occurring within the first 90 days postoperatively. There were 26 patients in total; 7 performed extracorporeally and 19 intracorporeally. Mean age was 41.5, mean BMI 24.4 and majority were ASA score 2 (61.5%). Twelve (46.1%) patients had spinal cord injury and 6 (23.1%) spina bifida. Seven (26.9%) had a concomitant procedure including bladder neck artificial urinary sphincter (AUS) insertion, bladder neck fascial sling or creation of a continent catheterisable channel. The surgical outcomes were analysed separately for those that had RA-SCAC only versus RA-SCAC with a concomitant procedure. The operative time was shorter in the intracorporeal group, and the length of stay was similar in both groups. The total number of major postoperative complications was low (n = 3; 11.5%). All urodynamic parameters significantly improved at 6 months in the intracorporeal group. Median number of urinary incontinence episodes per 24 h decreased significantly in both groups at 3 months but the continence status and ICIQ-UI SF demonstrated statistical significance in the intracorporeal group only. In conclusion, robot-assisted supratrigonal cystectomy and augmentation cystoplasty is feasible in adult neurological patients, favouring an intracorporeal approach.

Ther Adv Urol

2025, Vol. 17: 1–11

DOI: 10.1177/
17562872251359339

© The Author(s), 2025.
Article reuse guidelines:
sagepub.com/journals-
permissions

Correspondence to:
**Neha Sihra**
The Royal London
Hospital, Barts Health
NHS Trust, Whitechapel
Road, London E1 1FR, UK

Department of Urology,
University of Rennes,
Rennes, France
nehasihra@gmail.com

Pierre Lecoanet
Charles Mazeaud
Department of Urology,
University of Nancy,
Nancy, France

Alexandre Dubois
Juan Penafiel
Camille Haudebert
Juliette Hascoet
Andrea Manunta
Benoit Peyronnet
Department of Urology,
University of Rennes,
Rennes, France

Adil Mellouki
Younes Ahallal
Imad Bentellis
Department of Urology,
University of Nice, Nice,
France

Current affiliation: The
Royal London Hospital,
Barts Health NHS Trust,
Whitechapel Road,
London, UK

<figure><img src="image_2.png" /></figure>
## Plain language summary

# Robot-assisted supratrigonal cystectomy and augmentation cystoplasty for adult neurogenic lower urinary tract dysfunction and a comparison of different surgical techniques

Neurological disease in the adult population can cause lower urinary tract dysfunction and may require surgical intervention when less invasive treatments have failed. Augmentation cystoplasty has traditionally been performed as an open operation and can be associated with significant peri-operative morbidity due to its surgical complexity. We reviewed the records of 26 patients who underwent this operation using a minimally invasive robot-assisted approach. We compared two different surgical techniques (intracorporeal versus extracorporeal diversion) and looked at both the functional and surgical outcomes to assess its feasibility in this patient group. Our findings suggest that a robot-assisted approach is safe and feasible and that when performed, an intracorporeal diversion is preferential.

**Keywords:** augmentation cystoplasty, neurogenic bladder, robotic, urinary diversion

Received: 18 November 2024; revised manuscript accepted: 16 June 2025.

## Introduction

Neurological disease can cause a spectrum of lower urinary tract dysfunction, including detrusor overactivity, detrusor sphincter dyssynergia, detrusor failure and stress urinary incontinence. Incontinence and infections are some of the common sequelae affecting quality of life but more importantly, there can be a risk of renal failure due to small capacity, poorly compliant bladders with high storage and/or voiding pressures. Examples of some of the common neurological diseases causing neurogenic lower urinary tract dysfunction (NLUTD) include multiple sclerosis, spina bifida and spinal cord injury. The mainstay of treatment is with oral pharmacotherapy using anti-cholinergics, clean intermittent catheterisation (CIC) and intra-detrusor Botulinum Toxin A injections.¹

In some cases, these treatment options may be insufficient to achieve or maintain continence as well as maintain safe bladder pressures, and so more invasive reconstructive options may be required.² These patients should be risk-stratified, and those with high risk neurogenic lower urinary tract dysfunction (NLUTD) must be identified early and appropriately managed to minimise morbidity and renal failure.³,⁴

Augmentation cystoplasty is an established surgical technique for the management of refractory NLUTD, intended to create a large storage reservoir with safe pressures. It has most commonly been performed as an open procedure and can be associated with significant perioperative complications, including cardiovascular and respiratory compromise, venous thromboembolism, infections and bowel dysfunction.⁵ Patients with neurological disease can often have an array of other medical issues and so the risk of perioperative complications may be even greater in this cohort.⁶,⁷ It is therefore imperative to explore options to minimise morbidity and improve peri-operative recovery in this patient group.

Minimally invasive surgery has been shown to improve perioperative outcomes and recovery and both laparoscopic and robot-assisted laparoscopic approaches have been used to perform supratrigonal cystectomy and augmentation cystoplasty; however, the numbers remain small and most of the existing series include only paediatric populations.

While there is increasing evidence that intracorporeal urinary diversion may have more favourable perioperative outcomes during radical cystectomy, no such data exists for augmentation cystoplasty.⁸,⁹
The aim of the present study was to explore the feasibility of this approach by reporting the surgical and functional outcomes of adult patients with neurological disorders who underwent robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RA-SCAC) and to compare the outcomes of intracorporeal versus extracorporeal RA-SCAC.

## Methods

### Study design

The medical records of all patients who underwent RA-SCAC for neurogenic lower urinary tract dysfunction between October 2015 and March 2024 (i.e. 8 years and 5 months) in three French centres were retrospectively reviewed.

Adult patients ≥18 years with neurological disease refractory to anticholinergics and intra-detrusor Botulinum Toxin A injections, performing self-catheterisation were eligible for a RA-SCAC.

Initially those who required concomitant procedures were not offered a robotic approach, but this changed with time (i.e. after 2022).

The following data was collected for each patient: age, body mass index (BMI), ASA score, type and duration of neurological disease, and previous abdominal surgery.

All patients completed a bladder diary, urodynamic and validated symptom score (USP, Urinary Symptom Profile and ICIQ-UI SF, International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form) at baseline and had their renal function tested using serum cystatin C.

All data was collected and analysed without any patient identifiable information. As a retrospective study there was a waiver of written consent, but patients were informed of the use of their data for research purposes and were given the option to request for the withdrawal of their data.

### Surgical techniques

The diversion was performed extracorporeally between 2015 and 2019 and intracorporeally thereafter. Until 2022, only patients who required augmentation cystoplasty alone were selected for the robotic approach, and those who required

augmentation cystoplasty and a concomitant procedure, such as creation of a catheterisable channel, had their surgery performed through an open abdominal incision. From 2022, all patients eligible for augmentation cystoplasty had this performed robotically including those requiring concomitant surgery. In cases of coexisting intrinsic sphincter deficiency requiring a concomitant anti-incontinence procedure, both bladder neck artificial urinary sphincter (AUS) and autologous slings were offered to men and women taking into consideration several factors including manual dexterity, need to perform clean intermittent catheterisation and patient preference.

All procedures were performed with an Intuitive Surgical® Da Vinci surgical robot, either Si (for the first few extracorporeal cases) or Xi.

**Operative steps.** After positioning the patient in a 23-degree Trendelenburg position with legs placed in Lithotomy, a 16 Fr urethral catheter is inserted.

A supraumbilical incision is made to facilitate camera port insertion using an open cut down (Hasson's) technique. The remaining ports are then inserted under direct vision (x3 8 mm robotic ports on both sides of the camera port and x2 12 mm ports in both the right and left flanks). The robot is then docked between the legs. The bladder is filled via the urethral catheter, and mobilised, starting anteriorly and progressing laterally.

The posterior aspect of the bladder is released from the peritoneum that is spared and utilised to extra-peritonealise the cystoplasty at the end of the procedure. The bladder is opened in a longitudinal plane using monopolar scissors. Both ureteric orifices are identified and bilateral ureteric stents are only inserted if there is concern about close proximity. A supratrigonal partial cystectomy is then performed, and the specimen is placed into an Endo Catch bag.

**Extracorporeal diversion.** The robot is undocked and the supraumbilical incision is extended to a 6 cm midline incision. An ileal segment 15 cm upstream from the ileo-caecal junction is extracted through the midline incision. A total of 30 cm of ileum is harvested, and intestinal continuity is restored as an end-to-end handsewn anastomosis. The ileal segment is reconfigured into a 'U'-shaped
ileo-cystoplasty and reinserted into the abdomen. The robot is redocked and the ileo-cystoplasty is sutured to the trigone with Quill and V-Loc sutures.

*Intracorporeal diversion.* Once the supratrigonal cystectomy is completed, the ileo-caecal junction is identified and 40 cm of ileum, 15 cm upstream from the ileo-caecal junction, is marked with Vicryl sutures. The two lower ends of the future 'W' are sutured to the posterior aspect of the bladder trigone facing each ureteral orifice to facilitate the harvesting and future reconfiguration.

A total of 2 ml of indocyanine green (ICG) is injected intravenously, and near-infrared fluorescence (Firefly) is used to help delineate the mesenteric vascular supply. The marked segment of ileum is harvested using a 60 mm Endo GIA ensuring good mesenteric blood supply. Intestinal continuity is restored as a side-to-side anastomosis with the 60 mm Endo GIA, and the mesenteric window is closed using 3/0 polysorb.

The ileal segment is brought into the pelvis and reconfigured into a 'W'-shape with V-Loc after having been detubularised on its anti-mesenteric border. The ileo-cystoplasty is then anastomosed to the bladder trigone with Quill and V-Loc sutures.

The anastomosis integrity is tested with 180 ml of diluted methylene blue, and additional stitches are placed if any leakage is observed. The peritoneum is closed with V-Loc sutures to extra-peritonealise the cystoplasty.

A surgical drain is not routinely placed. The bladder catheter is washed out three times per day until removal at 3 weeks. A cystogram is not routinely performed. Patients then recommence clean-intermittent catheterisation at this stage. If ureteric stents were inserted, these are removed at 4 weeks.

### Outcomes of interest

The primary endpoint was the rate of major post-operative complications defined as any complication Clavien-Dindo grade 3 or higher occurring within the first 90 days postoperatively. All complications were recorded using the Clavien-Dindo classification.¹⁰

The other outcomes of interest were the other main perioperative outcomes (operative time, estimated blood loss, length of stay, postoperative complications, time to return of bowel function, time to resumption of oral feeding). These were analysed separately for those undergoing RA-SCAC only versus RA-SCAC + concomitant procedure.

Functional outcomes were assessed at 3 and 12 months (bladder diary: maximum voided volume, number of CIC per 24 h; continence status categorised as unchanged versus improved versus complete continence; the USP stress urinary incontinence (SUI) subscore (/9) and overactive bladder (OAB) subscore (/21); the ICIQ-UI SF and the urodynamics outcomes (maximum cystometric capacity, maximum detrusor pressure during filling (Pdet max), compliance (ml/cmH2O) which was calculated manually from the traces; first desire to void (ml), strong desire to void (ml), detrusor overactivity (yes vs no)). The follow-up urodynamics were performed 6–12 months postoperatively.

### Statistical analyses

Means and standard deviations were reported for continuous variables, medians and ranges for categorical variables, and proportions for nominal variables. Comparisons between groups were performed using the $\chi^2$ test or Fisher's exact test for discrete variables, and the Mann-Whitney test for continuous variables as appropriate. Change of continuous variables over time was assessed using the paired student t-test. Statistical analyses were performed using JMP v.18.0 software (SAS Institute Inc., Cary, NC, USA). All tests were two-sided with $p<0.05$ as a threshold to define statistical significance.

## Results

### Patient characteristics

Twenty-six patients were included for analysis: 7 in the extracorporeal group and 19 in the intracorporeal group. The patient characteristics are summarised in Table 1.

There were significantly more female patients in the intracorporeal group (68.4% vs 14.3%; $p=0.03$).
<table><caption>**Table 1.** Patient characteristics.</caption><thead><tr><th>Characteristics</th><th>Whole cohort<br>N=26</th><th>RA-SCAC (extracorporeal)<br>N=7</th><th>RA-SCAC (intracorporeal)<br>N=19</th><th>p-Value*</th></tr></thead><tbody><tr><td>Mean age (years)</td><td>41.5 (±17.5)</td><td>31 (±8.2)</td><td>45.4 (±18.6)</td><td>0.10</td></tr><tr><td>Gender</td><td></td><td></td><td></td><td></td></tr><tr><td>Male</td><td>12 (46.1%)</td><td>6 (85.7%)</td><td>6 (31.6%)</td><td>0.03</td></tr><tr><td>Female</td><td>14 (53.8%)</td><td>1 (14.3%)</td><td>13 (68.4%)</td><td></td></tr><tr><td>ASA score</td><td></td><td></td><td></td><td></td></tr><tr><td>1</td><td>7 (26.9%)</td><td>3 (42.9%)</td><td>4 (21.1%)</td><td>0.47</td></tr><tr><td>2</td><td>16 (61.5%)</td><td>3 (42.9%)</td><td>13 (68.4%)</td><td></td></tr><tr><td>3</td><td>3 (11.5%)</td><td>1 (14.3%)</td><td>2 (10.5%)</td><td></td></tr><tr><td>Body Mass Index (kg/m²)</td><td>24.4 (±3.9)</td><td>25.4 (±3.4)</td><td>24.1 (±4.1)</td><td>0.49</td></tr><tr><td>Neurological conditions</td><td></td><td></td><td></td><td></td></tr><tr><td>Spinal Cord Injury</td><td>12 (46.1%)</td><td>4 (57.1%)</td><td>8 (42.1%)</td><td>0.31</td></tr><tr><td>Spina bifida</td><td>6 (23.1%)</td><td>3 (42.9%)</td><td>3 (15.8%)</td><td></td></tr><tr><td>Other</td><td>8 (30.8%)</td><td>0 (0%)</td><td>8 (42.1%)</td><td></td></tr><tr><td>Concomitant procedure</td><td>7 (26.9%)</td><td>1 (14.3%)</td><td>6 (31.6%)</td><td>0.36</td></tr><tr><td>Bladder neck AUS</td><td>2 (7.7%)</td><td>1 (14.3%)</td><td>1 (5.3%)</td><td></td></tr><tr><td>Bladder neck fascial sling</td><td>1 (3.8%)</td><td>0 (0%)</td><td>1 (5.3%)</td><td></td></tr><tr><td>Catheterisable channel<br>creation (Monti/Mitrofanoff)</td><td>4 (15.4%)</td><td>0 (0%)</td><td>4 (21.1%)</td><td></td></tr></tbody></table>

The mean age, BMI, neurological conditions and ASA score were similar in both groups.

Eight out of the twenty-six patients had a concomitant procedure, one in the extracorporeal group and seven in the intracorporeal group.

There were more concomitant procedures in the intracorporeal group (36.8% vs 14.3%), especially catheterisable channel creation (n=5; 26.3%), although the difference was not statistically significant (p=0.36).

## Perioperative outcomes

The perioperative outcomes are presented in Table 2.

When looking at those that underwent RA-SCAC only, the operative time was shorter in the intracorporeal group (305.4 vs 428.3 min) with a lower rate of conversion to an open approach (0% vs 33%).

The mean length of stay for the whole cohort was 8.8 days and was similar in both groups. The overall rate of postoperative complications was high (72%) and was greater in the extracorporeal group (83% vs 67%); however, the rate of major postoperative complications was relatively small (n=1; 6%), which occurred in the intracorporeal group.

Only one patient who had a concomitant procedure had this performed using an extracorporeal

<footnote>*Comparison for intracorporeal versus extracorporeal.
AUS, artificial urinary sphincter.</footnote>
<table><caption>**Table 2.** Perioperative outcomes.</caption><thead><tr><th>Outcomes</th><th>Whole cohort<br>N=18</th><th>Extracorporeal<br>N=6</th><th>Intracorporeal<br>N=12</th></tr></thead><tbody><tr><td colspan="4"><strong>RA-SCAC only</strong></td></tr><tr><td>Mean operative time (min)</td><td>346.3 (±106.5)</td><td>428.3 (±120.9)</td><td>305.4 (±73.4)</td></tr><tr><td>Mean estimated blood loss (ml)</td><td>86.1 (±67.7)</td><td>55 (±48.1)</td><td>101.6 (±72.3)</td></tr><tr><td>Length of hospital stay (days)</td><td>8.8 (±5.0)</td><td>9 (±5.3)</td><td>8.75 (±5.1)</td></tr><tr><td>Conversion to an open approach</td><td>2 (11%)</td><td>2 (33%)</td><td>0</td></tr><tr><td>Postoperative complications</td><td>13 (72%)</td><td>5 (83%)</td><td>8 (67%)</td></tr><tr><td>Major postoperative complications</td><td>1 (6%)</td><td>0</td><td>1 (8%)</td></tr><tr><td>Time to oral feeding (days)</td><td>4.4 (±3.7)</td><td>4.3 (±1.8)</td><td>4.5 (±4.5)</td></tr><tr><td>Time to return of bowel function (days)</td><td>4.1 (±3.7)</td><td>3.5 (±1.5)</td><td>4.3 (±4.4)</td></tr><tr><td>Readmission rate</td><td>4 (22%)</td><td>2 (33%)</td><td>2 (17%)</td></tr><tr><td colspan="4"><strong>RA-SCAC + concomitant procedure</strong></td></tr><tr><td>Mean operative time (min)</td><td>358.8 (±115.9)</td><td>460 (±0)</td><td>344.2 (±117.1)</td></tr><tr><td>Mean estimated blood loss (ml)</td><td>66.3 (±Extracorporeal<br>Extracorporeal<br>45.0)</td><td>20 (±0)</td><td>72.9 (±44.2)</td></tr><tr><td>Length of hospital stay (days)</td><td>11.4 (±5.9)</td><td>12.3 (±0)</td><td>5 (±5.7)</td></tr><tr><td>Conversion to an open approach</td><td>0</td><td>0</td><td>0</td></tr><tr><td>Postoperative complications</td><td>7 (88%)</td><td>1 (100%)</td><td>6 (86%)</td></tr><tr><td>Major postoperative complications</td><td>2 (25%)</td><td>1 (100%)</td><td>1 (14%)</td></tr><tr><td>Time to oral feeding (days)</td><td>4.8 (±5.0)</td><td>3 (±0)</td><td>5 (±5.4)</td></tr><tr><td>Time to return of bowel function (days)</td><td>4.5 (±2.6)</td><td>3 (±0)</td><td>4.7 (±2.8)</td></tr><tr><td>Readmission rate</td><td>4</td><td>1</td><td>3</td></tr><tr><td colspan="4">RA-SCAC, robot-assisted supratrigonal cystectomy and augmentation cystoplasty.</td></tr></tbody></table>
approach. The operative time was longer in this
group (460 vs 344.2 min) as was the length of stay
(12.3 vs 5 days). No patients who had a RA-SCAC
with a concomitant procedure required a conver-
sion to open.

The overall number of complications was 88%
but of these only two patients had a major
complication.

In the extracorporeal group, there was one
Clavien ≥3 complication: a case of a concomitant
bladder neck artificial urinary sphincter insertion
where the implant subsequently became infected
and required explantation on day 10.

In the intracorporeal group, there were two
Clavien ≥ 3 complications.

One mechanical small bowel obstruction requiring an emergency laparotomy and adhesiolysis on day 10, re-presenting 4 months later with an enterovesical fistula requiring surgical repair.

One case of a concomitant autologous fascial
sling insertion with a resultant vesicosymphyseal
fistula requiring prolonged antibiotics, urinary
diversion with percutaneous nephrostomies and
subsequent removal of the extruded fascia lata
sling.

The time to oral feeding, time to return of bowel function and readmission rates did not differ significantly between the two groups undergoing RA-SCAC only, but the readmission rate was higher in the intracorporeal group who underwent an additional procedure alongside their RA-SCAC but the overall number in this group was much higher.

Functional outcomes

At baseline, there was no statistically significant
difference between the intracorporeal and extra-
corporeal groups in terms of number of CIC per
24h, number of leakages per 24h, ICIQ-UI SF
and urodynamic parameters (see Table 3).

All urodynamic parameters significantly improved
between baseline and 6 months postoperatively in
the intracorporeal group, while none demon-
strated statistically significant improvement in the
extracorporeal group. The median number of uri-
nary incontinence episodes per 24 h decreased
significantly in both groups at 3 months, but the

continence status and ICIQ-UI SF at 3 months
demonstrated statistically significant at 3 months
only in the intracorporeal group. The only statis-
tically significant difference between the two
groups in terms of functional outcomes was the
ICIQ-UI SF at 3 months favouring the intracor-
poreal group (2.4 vs 9; *p*=0.01). After a median
follow-up of 17 months, there was no incisional
hernia in any of the two groups.

Discussion

Augmentation cystoplasty is an established surgical technique for refractory neurogenic lower urinary tract dysfunction whereby the main goal is to preserve renal function and achieve continence. It should be considered once pharmacotherapy and intra-detrusor Botulinum Toxin A injections have failed to achieve a safe and continent urinary reservoir.¹¹

Recognised complications of open augmentation
cystoplasty include metabolic disturbance, bowel
dysfunction, urinary tract infections, urolithiasis,
perforation, the need for clean intermittent cath-
eterisation and malignancy. ¹² Some of these com-
plications, such as bowel dysfunction, may be
more pronounced in this patient group with neu-
rological disease, as there may already be a signifi-
cant degree of bowel dysfunction at baseline.

The surgical and functional outcomes of open
augmentation cystoplasty are well reported; how-
ever, the benefits of a minimally invasive approach
are yet to be demonstrated.¹³

Minimally invasive surgery and robotic surgery
have been widely adopted in urological oncology
for their recognised benefits of reduced blood
loss, enhanced recovery with less pain and
reduced length of stay. ¹⁴ It therefore seems logical
to try to apply these approaches to benign recon-
structive surgery to promote enhanced recovery
in this surgically complex patient group. ¹⁵

The first laparoscopic cystoplasty was reported by
Elliot et al.¹⁶ in 2002. Subsequently, Al-Othman
et al.¹⁷ reported the first robot-assisted laparo-
scopic augmentation cystoplasty in 2008 with the
aim to achieve the advantages provided by a mini-
mally invasive laparoscopic technique as well as
the added benefit of a reduction in the length of
surgery due to quicker suturing with more preci-
sion. A small series of complete intracorporeal
robot-assisted laparoscopic cystoplasty showed a
<table><caption>**Table 3.** Functional outcomes.</caption><thead><tr><th></th><th>Whole cohort<br>N=26</th><th>Robotic extracorporeal<br>augmentation cystoplasty<br>N=7</th><th>Robotic intracorporeal<br>augmentation cystoplasty<br>N=19</th><th>p-Value<sup>a</sup></th></tr></thead><tbody><tr><td>Median number of urinary leakage/24 h</td><td></td><td></td><td></td><td></td></tr><tr><td>Preoperatively</td><td>8 (0-20)</td><td>10 (0-20)</td><td>6 (0-20)</td><td>0.67</td></tr><tr><td>3 months postoperatively</td><td>0 (0-20)*</td><td>0 (0-20)*</td><td>0 (0-4)*</td><td>0.26</td></tr><tr><td>Median number of CIC/24 h</td><td></td><td></td><td></td><td></td></tr><tr><td>Preoperatively</td><td>8 (5-20)</td><td>6 (5-10)</td><td>8 (5-20)</td><td>0.07</td></tr><tr><td>3 months postoperatively</td><td>7 (4-16)</td><td>7 (5-8)</td><td>7 (4-16)</td><td>0.57</td></tr><tr><td>Mean maximum voided volume on bladder diary (ml)</td><td></td><td></td><td></td><td></td></tr><tr><td>Preoperatively</td><td>309.7 (±119.6)</td><td>274.8 (±129.1)</td><td>323.1 (±118.3)</td><td>0.50</td></tr><tr><td>3 months postoperatively</td><td>405.8 (±126.6)*</td><td>318 (±152.1)</td><td>429.6 (±113.8)*</td><td>0.27</td></tr><tr><td>Change</td><td>+96.1</td><td>+33.2</td><td>+103.5</td><td>0.25</td></tr><tr><td>Mean maximum cystometric capacity (ml)</td><td></td><td></td><td></td><td></td></tr><tr><td>Preoperatively</td><td>265.9 (±127.1)</td><td>294.2 (±160.9)</td><td>247.1 (±116.9)</td><td>0.99</td></tr><tr><td>6 months postoperatively</td><td>403.2 (±111.9)*</td><td>336.7 (±136.3)</td><td>447.6 (±68.7)*</td><td>0.11</td></tr><tr><td>Change</td><td>+137.3</td><td>+42.5</td><td>+200.5</td><td>0.19</td></tr><tr><td>Mean maximum detrusor pressure during filling (cmH2O)</td><td></td><td></td><td></td><td></td></tr><tr><td>Preoperatively</td><td>33.2 (±37.8)</td><td>35 (±16.8)</td><td>29.7 (±44.1)</td><td>0.66</td></tr><tr><td>6 months postoperatively</td><td>20.3 (±11.2)*</td><td>23.6 (±2.5)</td><td>13.7 (±15.9)*</td><td>0.54</td></tr><tr><td>Change</td><td>-10.9</td><td>-11.4</td><td>-16</td><td>0.79</td></tr><tr><td>Detrusor overactivity</td><td></td><td></td><td></td><td></td></tr><tr><td>Preoperatively</td><td>17 (68%)</td><td>5 (71.4%)</td><td>12 (66.7%)</td><td>0.82</td></tr><tr><td>6 months postoperatively</td><td>6 (26.1%)*</td><td>3 (42.9%)</td><td>3 (18.8%)*</td><td>0.23</td></tr><tr><td>Continence status</td><td></td><td></td><td></td><td></td></tr><tr><td>Incontinence preoperatively</td><td>22 (84.6%)</td><td>5 (71.4%)</td><td>17 (89.5%)</td><td>0.26</td></tr><tr><td>Incontinence at 3 months</td><td>6 (23%)*</td><td>2 (28.6%)</td><td>2 (10.5%)*</td><td>0.26</td></tr><tr><td>ICIQ-SF (/21)</td><td></td><td></td><td></td><td></td></tr><tr><td>Preoperatively</td><td>17.3 (±37.8)</td><td>16 (±5.3)</td><td>17.8 (±4.3)</td><td>0.94</td></tr><tr><td>3 months postoperatively</td><td>4.3 (±11.2)*</td><td>9 (±8.1)</td><td>2.4 (±3.5)*</td><td>0.01</td></tr><tr><td>Change</td><td>-10.9</td><td>-7</td><td>-15.4</td><td>0.24</td></tr></tbody><tfoot><tr><td colspan="5"><sup>a</sup>Intracorporeal versus extracorporeal.</td></tr><tr><td colspan="5"><sup>*</sup>p < 0.05 for change versus baseline.</td></tr><tr><td colspan="5">CIC, clean intermittent catheterisation.</td></tr></tfoot></table>
median operative time 250 min (210–268),
median length of stay of 13 (10–14) days and
median time to restart CIC of 12 (10.5–13)
days.¹⁸

Trying to minimise the length of surgery should
be a priority as there can be potential conse-
quences of a prolonged Trendelenburg position
combined with prolonged pneumoperitoneum
resulting in raised intra-ocular pressures, cogni-
tive impairment and respiratory compromise,
particularly in those who may already have hydro-
cephalus or an element of cognitive dysfunction
at baseline.¹⁹

In addition to the already well-recognised advan-
tages of minimally invasive surgery, there may be
other benefits in the neurogenic population such
as a lower risk of abdominal wall hernia owing to
smaller incisions when compared with a large
midline laparotomy or Pfannenstiel incision in a
cohort in whom abdominal wall muscles are
weaker when compared with the non-neurogenic
population. In our series, we did not have any
postoperative incisional hernias.

Several surgical techniques have been reported
for augmentation cystoplasty including the type
of bowel segment utilised, the configuration pat-
tern, whether a clam cystoplasty versus supratrig-
onal cystectomy is performed and whether the
reconstruction is performed intracorporeally ver-
sus extracorporeally.²⁰

In our series, we performed a supratrigonal cyst-
tectomy. In the extracorporeal group a ‘U’-shaped
cystoplasty with 30 cm of ileum was performed,
and in the intracorporeal group a ‘W’-shaped cys-
toplasty using 40 cm of ileum, as originally
described by Hautmann, was performed.²¹ The
slight differences observed in terms of functional
outcomes may be more attributable to this differ-
ence in the cystoplasty configuration rather than
the surgical approach.²² Two patients in the intra-
corporeal group had a concomitant anti-stress
urinary incontinence procedure (×1 AUS
replacement and ×1 fascial sling insertion), and
one patient in the extracorporeal group had an
AUS insertion. It is unlikely that this influenced
the functional outcomes at 3 months postopera-
tively as both the AUS and the fascial sling were
removed prior to the first follow-up due to surgi-
cal complications.

In some cases, a concomitant continent catheter-
isable channel (Mitrofanoff or Monti) was
required.

In our early experience, only cases which did not
require concomitant procedures were selected for
the robotic approach while the others were still
performed open. With time we were able to offer
a robotic approach even when a concomitant pro-
cedure was needed which could explains why the
rate of concomitant procedure is higher in the
intracorporeal group. This higher overall com-
plexity of cases in this group may have com-
pounded the possible benefits of the intracorporeal
approach in terms of perioperative outcomes
which is why we analysed the two subgroups
separately.

In both groups (RA-SCAC alone vs
RA-SCAC + concomitant procedure), we found
that the operative time was shorter in the intra-
corporeal group, which could be explained by
the time required to undock and redock the
robot with the extracorporeal diversion tech-
nique, as well as the progression of the surgeon's
learning curve. The latter is a subject which has
been extensively researched with evidence to
suggest that surgical outcomes improve as case
volume increases.²³ Our findings are also in
keeping with the results from a systematic review
comparing the operative time for ileal conduit
urinary diversion using an intracorporeal versus
extracorporeal approach.²⁴

To our knowledge, the present series is the largest
so far to report the outcomes of robot-assisted
supratrigonal cystectomy and augmentation cys-
toplasty in adult neurological patients and the
first to compare intracorporeal with extracorpor-
eal urinary diversion.

Our experience demonstrates that RA-SCAC is a
safe and feasible option for this patient group.

We recognise the limitations of our case series
which includes a small sample size, retrospective
reporting, short follow-up duration and some
incomplete follow-up data. The relatively long
time span and the fact that the two cohorts (extra-
corporeal and intracorporeal) were consecutive
may be regarded as a drawback as the overall sur-
geons' experience was greater in the intracorpor-
eal group.
## Conclusion

Robot-assisted supratrigonal cystectomy and augmentation cystoplasty appears to be technically feasible in adult neurological patients. The perioperative outcomes are mostly comparable in the intracorporeal and extracorporeal groups except for a shorter operative time in the intracorporeal group. The functional outcomes are overall satisfactory and are better in the intracorporeal group, which may be related to the ‘W’-shaped versus ‘U’-shaped cystoplasty configuration rather than to the surgical approach.

More data and longer term follow-up are needed to validate its role in the armamentarium of benign lower urinary tract reconstruction.

## Declarations

### Ethics approval and consent to participate

This retrospective study was conducted following the principles of the Declaration of Helsinki and approved by our local ethics committee; CNIL (Commission Nationale Informatique et Libertés) ref number: 2236448 v0. Formal written consent was not obtained due to the retrospective nature of the study but verbal consent was obtained. No patient identifiable information has been included in the manuscript.

### Consent for publication

Not applicable.

### Author contributions

**Neha Sihra:** Data curation; Formal analysis; Writing – original draft; Writing – review & editing.

**Pierre Lecoanet:** Data curation.

**Alexandre Dubois:** Data curation.

**Juan Penafiel:** Data curation.

**Camille Haudebert:** Data curation.

**Charles Mazeaud:** Data curation.

**Adil Mellouki:** Data curation.

**Juliette Hascoet:** Data curation; Writing – review & editing.

**Younes Ahallal:** Data curation.

**Andrea Manunta:** Supervision.

**Imad Bentellis:** Data curation.

**Benoît Peyronnet:** Conceptualisation; Supervision; Writing – review & editing.

## Acknowledgements

None.

## Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

## Competing interests

Benoît Peryronnet is a consultant for Boston scientific, Intuitive, Medtronic, Pierre Fabre, Ibsa, Coloplast, Schwa medico, Hollister, Ipsen and AbbVie.

## Availability of data and materials

Not applicable.

## ORCID iDs

**Neha Sihra** https://orcid.org/0000-0002-7396-0956

**Benoit Peyronnet** https://orcid.org/0009-0003-7374-7922

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