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# A Systematic Review and Meta-analysis on Perioperative Stenting/Dwell Time and Postoperative Outcomes in Patients Undergoing Radical Cystectomy and Urinary Diversion for Bladder Cancer

Mithun Kailavasan, Alberto Martini, Max Bruins, Albert Carrion, Richard Cathomas, Eva Compérat, Jason a Efstathiou, Rainer Fietkau, Anna Lorch, Laura S Mertens, et al.

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Mithun Kailavasan, Alberto Martini, Max Bruins, Albert Carrion, Richard Cathomas, et al. A Systematic Review and Meta-analysis on Perioperative Stenting/Dwell Time and Postoperative Outcomes in Patients Undergoing Radical Cystectomy and Urinary Diversion for Bladder Cancer. European Urology Focus, 2025, 10.1016/j.euf.2025.05.024. hal-05299902

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https://hal.science/hal-05299902v1

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Review – Bladder Cancer

# A Systematic Review and Meta-analysis on Perioperative Stenting/
Dwell Time and Postoperative Outcomes in Patients Undergoing
Radical Cystectomy and Urinary Diversion for Bladder Cancer

Mithun Kailavasan<sup>a,*</sup>, Alberto Martini<sup>b</sup>, Max Bruins<sup>c</sup>, Albert Carrion<sup>d</sup>, Richard Cathomas<sup>e</sup>, Eva Compérat<sup>f</sup>, Jason A. Efstathiou<sup>g</sup>, Rainer Fietkau<sup>h</sup>, Anna Lorch<sup>i</sup>, Laura S. Mertens<sup>j</sup>, Richard P. Meijer<sup>k</sup>, Paramananthan Mariappan<sup>l</sup>, Mathew I. Milowsky<sup>m</sup>, Yann Neuzillet<sup>n</sup>, Valeria Panebianco<sup>o</sup>, Michael Rink<sup>p</sup>, George N. Thalmann<sup>q</sup>, S. Sæbjørnsen<sup>r</sup>, Antoine G. van der Heijden<sup>s</sup>

Article info

Article history:

Accepted May 27, 2025

Keywords:

Systematic review
Evidence synthesis
Bladder cancer
Complications
Ureteric stent

Abstract

**Background and objective:** Ureteral stents are used to protect the ureteroenteric anastomosis during radical cystectomy and urinary diversion (RCUD); however, complications can occur from its use. The objective of this study was to perform a systematic review of perioperative stenting strategies and postoperative outcomes in patients undergoing RCUD for bladder cancer.

**Methods:** This review was published via PROSPERO (CRD42024558468) and conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. Prospective comparative (randomised and nonrandomised) studies published until June 2024 were included. All outcomes were included in the analysis. Risk of bias assessments were undertaken.

**Key findings and limitations:** The search yielded 1516 abstracts. Six prospective comparative studies (740 patients) were included. Although there was some evidence of reduced postoperative complications (urinary leak, ureteroileal stricture, postoperative obstruction, length of stay, and readmission within 30 d) with the omission of stents

<footnote><sup>a</sup> Department of Urology, Victoria Hospital, London, Ontario, Canada; <sup>b</sup> Department of Urology, University of Cincinnati, Cincinnati, OH, USA; <sup>c</sup> Department of Urology, Zuyderland Medisch Centrum, Sittard/Heerlen, The Netherlands; <sup>d</sup> Department of Urology, Vall Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain; <sup>e</sup> Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland; <sup>f</sup> Department of Pathology, Medical University Vienna, General Hospital, Vienna, Austria; <sup>g</sup> Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA; <sup>h</sup> Department of Radiation Therapy, University of Erlangen, Erlangen, Germany; <sup>i</sup> Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland; <sup>j</sup> Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands; <sup>k</sup> Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands; <sup>l</sup> Edinburgh Bladder Cancer Surgery (EBCS), Western General Hospital, University of Edinburgh, Edinburgh, UK; <sup>m</sup> Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; <sup>n</sup> Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France; <sup>o</sup> Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy; <sup>p</sup> Department of Urology, Marienkrankenhaus Hamburg, Hamburg, Germany; <sup>q</sup> Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland; <sup>r</sup> Patient Representative, European Association of Urology Guidelines Office, Arnhem, The Netherlands; <sup>s</sup> Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands</footnote>

<footnote>* Corresponding author. Victoria Hospital & Children's Hospital, London, Ontario, Canada. Tel. +1 416 473 3249.
E-mail address: mithunk@hotmail.co.uk (M. Kailavasan).</footnote>
during RCUD, this did not reach statistical significance (n = 3). No differences in postop-
erative complications were identified between internal and external stenting (n = 2).
Early stent removal (5 d) was associated with reduced urinary tract infections and hos-
pital readmission (n = 1). There was a high/serious risk of bias with all studies.

**Conclusions and clinical implications:** The role of perioperative stenting during RCUD in preventing ureteroenteric complications remains equivocal and does not favour one approach over another. Until further results from on-going randomised controlled trials become available, urologists should carefully consider the indications to place a ureteric stent and its retention time after RCUD.

© 2025 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

ADVANCING PRACTICE

What does this study add?

The role of perioperative ureteric stenting during radical cystectomy and urinary diversion (RCUD) remains equivocal and does not favour one approach over another. Whilst there was some evidence suggesting fewer postoperative complications when stents were omitted and reduced stent retention time following RCUD, the differences between groups did not reach statistical significance. Another stent strategy (internal vs external) was explored, which revealed no differences in postoperative complications, although this was at the expense of longer stent duration and shorter length of stay in the internal stent group. Therefore, until further results from on-going randomised controlled trials (RCTs; NO-STENT and STENT-OPT) become available, urologists should carefully consider the indications for placing a ureteric stent and its retention time after RCUD. This systematic review also highlights the need for standardised outcome measures and composite endpoints to ensure that future RCTs are conducted effectively.

Clinical Relevance

Ureteral stents are commonly used during radical cystectomy and urinary diversion (RCUD). The present systematic review and metaanalysis analyzed ureteralenteric anastomosis complications as well as other complications within one year after surgery. The authors did not find any statistical significant difference between patients who did and did not undergo ureteral stenting. As there are currently RCTs ongoing on the topic, further data seem required to provide meaningful data as to whether stenting at RCUD should be omitted or not. Associate Editor: Malte Rieken, M.D.

Patient Summary

Ureteral stents are commonly used during radical cystectomy and urinary diversion surgeries, performed to remove the bladder and establish a new method for urine drainage in patients with advanced bladder cancer. We reviewed the existing studies to assess the impact of using or omitting stents during this procedure, and to determine the optimal duration for their use. Our review revealed limited evidence to support any specific approach to stenting in this context.

1. Introduction

Bladder cancer is the sixth most common cancer in men and the tenth most common when both genders are considered [1]. At diagnosis, over 75% of cases are classified as those with non-muscle invasive bladder cancer (NMIBC), and with appropriate treatment, most of these patients achieve positive outcomes [2,3]. The progression rate of NMIBC to muscle-invasive bladder cancer (MIBC) varies between 5% and 50% at 5 yr depending on histopathological features such as grade, stage, and presence of carcinoma in situ [4,5].

The optimal surgical management of MIBC consists of neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy and urinary diversion (RCUD) [6–9]. In the last couple of decades, RCUD has also gained attention

for treating patients with high-risk NMIBC [10]. Whilst data for Europe are unavailable, it is estimated that around 10 000–12 000 RCUD procedures are performed annually in the USA alone [11]. Despite advancements in perioperative care and surgical techniques (such as minimally invasive surgery), complications remain frequent, with morbidity rates of approximately 50% [12–15].

Several uncertainties persist in surgical practice, includ-
ing the role of perioperative ureteric stenting during RCUD.
Perioperative ureteric stenting is intended to minimise uri-
nary leakage and reduce ureteroenteric anastomotic (UEA)
complications, which account for approximately 30% of post-
operative morbidity [15-17]. However, stenting or pro-
longed stent retention may increase the risk of urinary tract
infections (UTIs) and the need for antibiotics (treatment or
prophylaxis), and may require additional follow-up for
removal, all of which place further strain on health care sys-
tems [18].

Peng et al [19] conducted a systematic review (SR) in
2021, demonstrating that ureteral stents in RCUD were
linked to higher rates of anastomotic strictures without
evidence supporting their efficacy in preventing postdi-
version urinary leakage. Similarly, Veccia et al [20] per-
formed an SR highlighting an increased risk of
complications related to perioperative stenting during
RCUD. However, neither SR evaluated the literature on
other stent management strategies or retention times.
This study, therefore, aims to systematically appraise the
literature for perioperative stenting strategies with RCUD
and postoperative outcomes.

## 2. Methods

This review was commissioned and undertaken by the
European Association of Urology (EAU) Muscle Invasive
Bladder Cancer Panel. The protocol was registered in the
International Prospective Register of Systematic Reviews
database (https://www.crd.york.ac.uk/PROSPERO;
CRD42024558468).

2.1. *Search strategy*

The review was performed as per the Preferred Report-
ing Items for Systematic Reviews and Meta-analyses
(PRISMA) and Cochrane guidelines. Databases including
MEDLINE, Embase, and Cochrane Central Register of
Controlled Trials (CENTRAL, via Ovid) were systemati-
cally searched for prospective comparative articles (ran-
domised and nonrandomised) published in English until
June 20, 2024.

## 2.2. Inclusion and exclusion criteria

The study population included adult patients with localised
or locally advanced bladder cancer (T1-T4, N1-3, and M0)
who underwent RCUD (including ileal conduit, continent
pouch, and neobladder). The index intervention was the
presence of an (external) stent. The comparator interven-
tion included the absence of a stent or an internal stent.
For studies that included the presence of perioperative ure-
teric stents only, comparative studies evaluating retention
time were also included.

The primary outcome was UEA complications (eg, uri-
nary leak, ureteroenteric stricture, sepsis, UTIs, and
hydronephrosis/ureteral obstruction) within 1 yr. The diag-
nostic method used to identify UEA complications was not
specified.

The secondary outcomes included other postoperative
infections (eg, gastrointestinal, respiratory, and wound),
intra-abdominal abscess, change in renal function, renal
failure, ileus, ureteral injury, need for secondary interven-
tional procedure (Clavien-Dindo IIIa and IIIb), life-
threatening complications requiring intensive care
(Clavien-Dindo IV), death (Clavien-Dindo V), length of stay,
readmission to hospital, need for additional outpatient hos-
pital visits, need for antibiotic prophylaxis, and other com-
plications reported in studies within 1 yr.

The exclusion criteria included noncomparative studies,
retrospective studies, studies published in a language other

than English, conference proceedings, studies reporting
complications but in a nonextractable way, studies with
fewer than ten patients, and studies on palliative or salvage
cystectomy.

2.3. Data extraction

Abstract and full-text screening, data extraction, risk of bias (RoB), and confounding assessments were performed independently by two authors (M.K. and A.M.), and disagreement was resolved by discussion or reference to an independent third party. The assessment of study quality and RoB was performed following the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool and the Risk of Bias (RoB version 2) tool, referring to the Cochrane Handbook for Systematic Reviews of Interventions [21,22].

2.4. Statistical analysis

Owing to the expected clinical and methodological hetero-
geneity of the included studies, a qualitative synthesis
was planned. A meta-analysis was performed when two
or more studies were reporting the same outcomes. The
incidences of complications were pooled using the
Cochran-Mantel-Haenszel method with the random-effect
model (decided a priori). Odds ratios (ORs) and 95% confi-
dence intervals (CI) were calculated to summarise dichoto-
mous outcome data (eg, complications); the mean
difference (MD) and 95% CI were used to summarise contin-
uous outcome data (eg, length of stay). Since only means
and standard deviations (SDs) can be used for a meta-
analysis of continuous data, the formula "SD = IQR/1.35"
was applied to convert the median and interquartile range
(IQR) of the study data when applicable, in accordance with
the Cochrane guidelines.

3. Results

3.1. Study selection and characteristics

The PRISMA flow diagram (Fig. 1) details the study selection
process. Our initial search yielded 1516 references. After
removing duplicates, we screened 1432 studies based on the
titles and abstracts, which identified nine articles for a full-
text review. Three studies were excluded due to incorrect
study design (n = 2) and inappropriate setting (n = 1). Ulti-
mately, we included six prospective studies (n = 740 patients)
that met the inclusion criteria for the SR. Of these studies,
three compared the presence of a stent with its absence
(two randomised parallel and one nonrandomised), two stud-
ies compared internal versus external ureteric stents (one ran-
domised and one nonrandomised), and one study assessed
stent dwell time (nonrandomised). The characteristics of the
included studies are summarised in Table 1 [18,23–27].

3.2. RoB and confounding assessment

Figs. 2 and 3 summarise the results of the RoB assess-
ment. Despite the inclusion of prospective studies, the
overall RoB was high (in randomised parallel arm trials)
and serious (in nonrandomised or randomised nonparal-
lel trials).
<figure><img src="image_3.png" /><figcaption>Fig. 1 - PRISMA flow diagram. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-analyses.</figcaption></figure>

### 3.3. Stent versus stent-less RCUD

Three studies compared the use or omission of ureteric stents during RCUD [23,25,27]. A total of 465 patients were included, with 402 and 63 patients undergoing open and robotic RCUD, respectively. Table 1 provides an overview of the included studies, including the type of urinary diversion and the proportion of patients who received neoadjuvant chemotherapy. Lambertini et al [25] and Mattei et al [23] reported outcomes with follow-up for 1 yr, whilst Donat et al [27] reported outcomes up to 30

d. These outcomes were pooled to facilitate meta-analyses.

#### 3.3.1. Primary outcome (ureteroenteric complications)

There was some evidence of reduced UEA complications (urinary leak-OR: 2.97, 95% CI: 0.57-15.6; ureteroenteric stricture-OR: 3.28, 95% CI: 0.82-13.1; UTIs-OR: 1.92, 95% CI: 0.92-4.02; and ureteral obstruction-OR: 2.50, 95% CI: 0.72-8.75) with the omission of stents during RCUD; however, differences between the groups did not meet statistical significance (Table 2) [23,25,27].
<table><caption>Table 1 - Characteristics of included studies</caption><thead><tr><th rowspan="2">Reference</th><th rowspan="2">Country</th><th rowspan="2">Recruitment</th><th rowspan="2">Study design</th><th rowspan="2">Type of surgery</th><th rowspan="2">Type of urinary diversion (number)</th><th colspan="2">Number of patients</th><th colspan="2">Age</th><th colspan="2">BMI</th><th colspan="2">Neoadjuvant chemotherapy</th><th colspan="2">Pathological stage</th></tr><tr><th>Arm A</th><th>Arm B</th><th>Arm A</th><th>Arm B</th><th>Arm A</th><th>Arm B</th><th>Arm A</th><th>Arm B</th><th>Arm A</th><th>Arm B</th></tr></thead><tbody><tr><td colspan="16">Presence vs absence of stent</td></tr><tr><td>Mattei et al<br>[23]</td><td>Switzerland</td><td>NI</td><td>RCT</td><td>Open</td><td>Ileal conduit (17)<br>Orthoptic<br>neobladder (37)</td><td>Stent<br>(29)</td><td>Stentless<br>(25)</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td></tr><tr><td>Donat et al<br>[27]</td><td>USA</td><td>2014-2018</td><td>Prospective<br>nonrandomised</td><td>Open</td><td>Ileal conduits<br>(180)<br>Continent<br>diversions (103)</td><td>Stent<br>(206)</td><td>Stentless<br>(77)</td><td>Mean: 69<br>(SD: 61.7,<br>75.0)</td><td>Mean: 72<br>(SD: 65.0, 77.7)</td><td>Median: 29<br>(IQR: 25-32.2)</td><td>Median: 28 (IQR:<br>24.6-30.7)</td><td>Median: 27 (IQR:<br>24-31)</td><td>8/31</td><td>12/32</td><td>≤T2 28/31<br>≥T3 3/31</td><td>≤T2 27/32<br>≥T3 5/32</td></tr><tr><td>Lambertini<br>et al<br>[25]</td><td>Italy</td><td>2021-2022</td><td>RCT</td><td>Robotic</td><td>Intracorporeal<br>Orthoptic<br>neobladder (63)</td><td>Stent<br>(31)</td><td>Stentless<br>(32)</td><td>Median:<br>65 (IQR:<br>55-76)</td><td>Median: 67<br>(IQR: 58-78)</td><td>Median: 25<br>(IQR: 24-29)</td><td>Median: 27 (IQR:<br>24-31)</td><td>NI</td><td>NI</td><td>NI</td><td>T0-T2: 26/36<br>T3-T4: 10/36</td><td>T0-T2: 22/33<br>T3-T4: 11/33</td></tr><tr><td>Internal vs external stent</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Abdel<br>Hakim<br>et al<br>[26]</td><td>Egypt</td><td>2010-2012</td><td>Prospective<br>nonrandomised</td><td>Open</td><td>Orthoptic<br>neobladder (69)</td><td>Internal<br>(33)</td><td>External<br>(36)</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td><td>NI</td></tr><tr><td>Osman<br>et al<br>[18]</td><td>Egypt</td><td>NI</td><td>RCT</td><td>Open</td><td>Orthoptic<br>neobladder (93)</td><td>Internal<br>(45)</td><td>External<br>(48)</td><td>Mean: 56<br>(SD: 7.4)</td><td>Mean: 56 (SD: 8.9)</td><td>BMI >30: 16/48</td><td>BMI >30: 19/45</td><td>NI</td><td>NI</td><td>NI</td><td>T0-T2: 39/45<br>T3-T4: 6/45</td><td>T0-T2: 38/48<br>T3-T4: 10/48</td></tr><tr><td>Stent dwell time</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Reano et al<br>[24]</td><td>USA</td><td>2013-2018</td><td>Retrospective<br>(2013-2014)<br>Prospective<br>nonrandomised<br>(2014-2018)</td><td>Open/<br>robotic</td><td>Open ileal<br>conduit (36)<br>Robotic<br>extracorporeal<br>ideal conduit<br>(115)<br>Robotic<br>intracorporeal<br>ideal conduit (27)</td><td>ESR: 5 d<br>(104)</td><td>LSR: >14<br>d (74)</td><td>Median:<br>71 (IQR:<br>63.5-77)</td><td>Median: 69<br>(IQR: 60-75)</td><td>NI</td><td>NI</td><td>55/104</td><td>46/74</td><td>Stage 0-1: 59/<br>104<br>Stage II-IV: 45/<br>104</td><td>Stage 0-1: 41/74<br>Stage II-IV: 33/<br>74</td></tr></tbody><tfoot><tr><td colspan="16">BMI = body mass index; ESR = early stent removal; IQR = interquartile range; LSR = late stent removal; NI = no information; RCT = randomised controlled trial; SD = standard deviation.</td></tr></tfoot></table>
Postoperative sepsis was reported only in the study of Donat et al [27], which demonstrated no significant differences at 30 d between the stent (27/206) and stentless (3/77) treatment groups ($p = 0.085$).

### 3.3.2. Secondary outcomes

There was no statistically significant difference between both arms regarding the length of stay (mean difference: 1.7 d; 95% CI: -1.5 to 4.9), readmission within 30 d (OR: 1.85, 95% CI: 0.98-3.47), ureteral endoscopic dilatation (OR: 2.93, 95% CI: 0.30-29), or ureteroenteric open reimplantation (OR: 2.89, 95% CI: 0.42-19.6).

Delta creatinine was reported only in the study of Lambertini et al [25], and no significant differences was only at 3 mo ($p = 0.13$) or 6 mo ($p = 0.14$).

## 3.4. Internal versus external stents in RCUD

Two studies evaluated internal versus external (extracorporeal) stent drainage following radical cystectomy (RC) and orthotopic neobladder formation (Table 1) [18,26]. An internal stent was defined as a ureteric stent placed within the ureter without externalisation through the neobladder and abdominal wall. Abdel Hakim et al [26] reported from a prospective comparative study, whereas Osman et al [18] conducted a prospective randomised trial on internal versus

external stents. Owing to statistical heterogeneity, an SR was performed.

### 3.4.1. Primary outcome (ureteroenteric complications)

Two studies (those by Abdel Hakim et al [26] and Osman et al [18]) reported comparable rates of UEA complications between internal and external stents, with no significant differences between both arms. Table 3 provides an overview of the outcomes in studies evaluating internal versus external stents following RCUD [18,26].

### 3.4.2. Secondary outcomes

Both studies reported a shorter average length of stay with internal stenting following RCUD (the study by Abdel Hakim et al [26], median, 6 vs 14 d, $p < 0.001$; and the study by Osman et al [18], mean, 14 vs 18 d, $p < 0.001$).

Abdel Hakim et al [26] demonstrated that 6-mo creatinine levels were similar between the internal and external groups (1.2 and 1.1 mg/dl, respectively, $p = 0.17$). Osman et al [18] found similar results in terms of postoperative creatinine (1.1 vs 1.2 mg/dl, $p = 0.8$); yet, the time of creatinine measurement was not specified.

Osman et al [18] showed no difference in readmission rates between the internal and external stent arms (7% and 8%, respectively, $p = 0.8$). Abdel Hakim et al [26] did not report readmission rates following RCUD.

<figure><img src="image_4.png" /><figcaption>Fig. 2 – Risk-of-bias (ROB version 2) assessments for randomised parallel group studies (n = 3) [18,23,25].</figcaption></figure>
<figure><img src="image_5.png" /></figure>

D1 Bias due to confounding

D2 Bias in selection of participants into the study

D3 Bias in classification of interventions

D4 Bias due to deviations from intended interventions

D5 Bias due to missing data

D6 Bias in the measurement of outcomes

D7 Bias in the selection of the reported result

<figure><img src="image_6.png" /><figcaption>Fig. 3 - Risk of bias assessments for nonrandomised prospective studies (n = 3) [24,26,27].</figcaption></figure>

### 3.5. Timing of stent removal following RCUD

Beano et al [24] analysed the safety of decreasing ureteral stent duration following open or robot-assisted RCUD using retrospective (2013–2014) and prospective (2014–2018) data at a tertiary centre. Patients with continent diversions and previous abdominal/pelvic radiotherapy were excluded [24]. Patients with late stent removal (LSR: >14 d) and early stent removal (ESR: 5 d) were those operated on before and after April 2015, respectively [24]. Stent duration was also extended at the discretion of the primary surgeon [24].

In total, 178 patients were included in the final analysis (LSR = 74, ESR = 104) [24]. Baseline preoperative characteristics were similar in both arms except for the surgical approach (eg, open vs robotic) [24]. The median follow-up was approximately 10 mo [24]. The LSR arm had significantly higher 90-d overall readmission rates (OR: 2.57, 95% CI: 1.19–5.53) and total UTIs (OR: 2.36, 95% CI: 1.11–5.04) [24]. No significant difference was identified between the cohorts in the incidence of ureteral stricture rate (OR: 2.07, 95% CI: 0.63–6.83) or inpatient complications (OR: 0.68, 95% CI: 0.34–1.35) [24].

## 4. Discussion

### 4.1. Principal findings

This study assesses the outcomes of an SR and meta-analysis on perioperative stenting strategies during RCUD. Our principal finding in 740 patients was that there were no significant differences in postoperative complications following the use

or omission of perioperative stents in RCUD. Furthermore, the use of internal JJ stents following RC and neobladder formation remains a valid alternative to external stents. Two SRs have published their findings on perioperative stenting in RCUD in the last 5 yr, demonstrating an increased interest in the subject [19,20]. Both studies reported no significant differences in the stent and stentless arms following RCUD [19,20]. Peng et al [19] reported both retrospective and prospective data in their meta-analysis and focused only on UEA leak and stricture as outcomes of interest. However, the inclusion of retrospective trials has a significant bias, and some prospective studies were excluded from their meta-analysis due to the nonreporting of their primary outcomes. Recently, Veccia et al [20] published their SR and meta-analysis and identified a significantly higher rate of Clavien-Dindo III complications in the stented arm. We were not able to draw the same conclusions from these studies as we could not identify the data from the published literature. Additionally, they used the RoB tool for assessing the bias in the nonrandomised trial (by Donat et al [27]), which is not recommended by the Cochrane methods. As such, this SR offers notable advancements. Specifically, it provides a comprehensive review of the literature, covering all perioperative stent strategies (omission vs use, internal vs external stents, and retention time) and includes prospective studies only, which is prone to less bias.

Perioperative stenting during RCUD has been performed since the 1980s to primarily prevent the incidence of UEA complications despite the paucity of randomised data supporting its benefits [27]. Although ureteric stents aim to
<table><caption>Table 2 – A meta-analysis of outcomes comparing stent versus stentless radical cystectomy and urinary diversion [23,25,27]</caption><thead><tr><th rowspan="2">Outcome</th><th colspan="2">Presence of stent</th><th colspan="2">Absence of stent</th><th rowspan="2">Weight (%)</th><th rowspan="2">Odds ratio, M-H, random (95% CI)</th><th rowspan="2">Composite odds ratio (95% CI)</th><th rowspan="2">Heterogeneity of studies included for meta-analyses (p value)</th></tr><tr><th>Events</th><th>Total</th><th>Events</th><th>Total</th></tr></thead><tbody><tr><td colspan="9"><strong>Primary outcomes—UEA complications</strong></td></tr><tr><td><strong>Urinary leak</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Donat [27]</td><td>13</td><td>206</td><td>1</td><td>77</td><td>65</td><td>5.12 (0.66, 39.8)</td><td></td><td></td></tr><tr><td>Lambertini [25]</td><td>1</td><td>31</td><td>1</td><td>33</td><td>35</td><td>1.07 (0.06, 17.8)</td><td>2.97 (0.57, 15.6)</td><td>p = 0.4</td></tr><tr><td>Mattei [23]</td><td>0</td><td>29</td><td>0</td><td>25</td><td></td><td>Not estimable</td><td></td><td></td></tr><tr><td><strong>Ureteroileal stricture</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Donat [27]</td><td>11</td><td>206</td><td>0</td><td>77</td><td>24</td><td>9.12 (0.53, 160)</td><td></td><td></td></tr><tr><td>Lambertini [25]</td><td>3</td><td>31</td><td>2</td><td>33</td><td>55</td><td>1.61 (0.25, 10.3)</td><td>3.28 (0.82, 13.1)</td><td>p = 0.3</td></tr><tr><td>Mattei [23]</td><td>3</td><td>29</td><td>0</td><td>25</td><td>21</td><td>6.74 (0.33, 140)</td><td></td><td></td></tr><tr><td><strong>Postoperative obstruction</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Donat [27]</td><td>11</td><td>206</td><td>0</td><td>77</td><td>18</td><td>9.12 (0.53, 160)</td><td></td><td></td></tr><tr><td>Lambertini [25]</td><td>5</td><td>31</td><td>4</td><td>33</td><td>65</td><td>1.35 (0.33, 5.56)</td><td>2.50 (0.72, 8.75)</td><td>p = 0.3</td></tr><tr><td>Mattei [23]</td><td>3</td><td>29</td><td>0</td><td>25</td><td>17</td><td>6.74 (0.33, 140)</td><td></td><td></td></tr><tr><td><strong>Postoperative UTI</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Donat [27]</td><td>42</td><td>206</td><td>9</td><td>77</td><td>91</td><td>1.93 (0.89, 4.19)</td><td></td><td></td></tr><tr><td>Lambertini [25]</td><td>NR</td><td>-</td><td>NR</td><td>-</td><td>-</td><td>NR</td><td>1.92 (0.92, 4.02)</td><td>p > 0.9</td></tr><tr><td>Mattei [23]</td><td>2</td><td>29</td><td>1</td><td>25</td><td>9</td><td>1.78 (0.15, 21)</td><td></td><td></td></tr><tr><td><strong>Postoperative sepsis</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Donat [27]</td><td>27</td><td>206</td><td>3</td><td>77</td><td>100</td><td>3.72 (1.09, 12.6)</td><td></td><td></td></tr><tr><td>Lambertini [25]</td><td>NR</td><td>-</td><td>NR</td><td>-</td><td>-</td><td>NR</td><td>Not appropriate</td><td>Not appropriate</td></tr><tr><td>Mattei [23]</td><td>NR</td><td>-</td><td>NR</td><td>-</td><td>-</td><td>NR</td><td></td><td></td></tr><tr><td colspan="9"><strong>Secondary outcomes</strong></td></tr><tr><td><strong>Readmission within 30 d</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Donat [27]</td><td>57</td><td>206</td><td>13</td><td>77</td><td>89</td><td>1.88 (0.96, 3.68)</td><td></td><td></td></tr><tr><td>Lambertini [25]</td><td>3</td><td>31</td><td>2</td><td>32</td><td>11</td><td>1.61 (0.25, 10.3)</td><td>1.85 (0.98, 3.47)</td><td>p = 0.9</td></tr><tr><td>Mattei [23]</td><td>NR</td><td>-</td><td>NR</td><td>-</td><td>-</td><td>NR</td><td></td><td></td></tr><tr><td><strong>Ureteral open reimplantation</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Donat [27]</td><td>NR</td><td>-</td><td>NR</td><td>-</td><td>-</td><td>NR</td><td></td><td></td></tr><tr><td>Lambertini [25]</td><td>2</td><td>31</td><td>1</td><td>32</td><td>61</td><td>2.14 (0.18, 25)</td><td>2.89 (0.42, 19.6)</td><td>p = 0.7</td></tr><tr><td>Mattei [23]</td><td>2</td><td>29</td><td>0</td><td>25</td><td>39</td><td>4.64 (0.21, 100)</td><td></td><td></td></tr><tr><td><strong>Ureteral endoscopic dilatation</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Donat [27]</td><td>NR</td><td>-</td><td>NR</td><td>-</td><td>-</td><td>NR</td><td></td><td></td></tr><tr><td>Lambertini [25]</td><td>1</td><td>31</td><td>0</td><td>32</td><td>50</td><td>3.20 (0.13, 82)</td><td>2.93 (0.30, 29)</td><td>p = 0.9</td></tr><tr><td>Mattei [23]</td><td>1</td><td>29</td><td>0</td><td>25</td><td>50</td><td>2.68 (0.10, 69)</td><td></td><td></td></tr></tbody></table>

CI = confidence interval; M-H = Mantel-Haenszel; NR = not reported; OR = odds ratio; UEA = ureteroenteric anastomotic; UTI = urinary tract infection.

OR >1 favours stentless radical cystectomy and urinary diversion.

All percentages and ORs are represented up to two significant figures.

improve urinary flow, these can cause periureteric inflammation, leading to UEA complications. Prolonged stent retention times may also result in biofilm colonisation, increasing the risk of ascending UTIs [28,29]. This SR demonstrates no significant differences between the use and omission of a stent, although there was some evidence of higher UEA complications after ureteric stenting. These findings are shared by the two previous SRs [19,20]. The meta-analysis included two randomised controlled trials (RCTs) that included a small number of patients in each arm (approximately n = 30), which lacks significant power to detect differences in complications. Furthermore, the remaining study by Donat et al [27] utilised prospectively collected data from an RCT (ClinicalTrials.gov NCT02145871) evaluating the association of perioperative goal-directed fluid therapy versus standard fluid therapy with postoperative ileus in patients undergoing RCUD. Predictably, this resulted in significant differences in baseline demographics, with an uneven distribution of patients with ureteric stents in the urinary diversion group and higher comorbidity (age, Charlson comorbidity index, American Society of Anesthesiologists status, and renal insufficiency) in the nonstent group [27]. Additionally, the studies had varying follow-up periods, with the longest follow-up period being 1 yr. Although benign ureteric strictures typically occur within the 1st year, these can occur later [30].

In our SR, Only one study evaluated stent retention time [24]. This study was subject to several biases, including the inclusion of a limited amount of retrospective data, differences in patient cohorts due to the adoption of robotic surgery and enhanced recovery protocols, and shorter follow-up periods for the ESR group. Despite these limitations, ESR was associated with reduced UTIs and 90-d readmissions. The on-going feasibility randomised trial evaluating ESR (5–7 d) versus LSR (4–6 wk) following RC and ileal conduit formation for bladder cancer (STENT-OPT, NCT06595446) may provide additional insights.

Internal ureteric stents are an alternative to external drainage during neobladder formation. Internal stents require no drainage bags, potentially enabling earlier ambulation. The two studies on this domain demonstrated a significant difference in the length of stay (approximately 4–7 d), which may be attributed to this benefit. However, external stents have the advantage of not requiring additional outpatient procedures for removal after discharge, which can reduce costs and avoid extended stent retention. Additionally, external stents can be assessed easily in cases of stent blockages. In the studies, external stents were typically removed after 3 wk following RC, whilst internal stents were removed between 5 and 6 wk. Despite these differences, no significant variations in complication rates or renal function outcomes were observed between the two approaches.
<table><caption>**Table 3** – An overview of primary outcomes in studies evaluating internal versus external (extracorporeal) stents following RCUD [18,26]</caption><thead><tr><th></th><th>Internal</th><th>External</th><th>Significance</th></tr></thead><tbody><tr><td>Number of patients</td><td></td><td></td><td></td></tr><tr><td>Abdel Hakim et al [26]</td><td>36</td><td>33</td><td></td></tr><tr><td>Osman et al [18]</td><td>45</td><td>48</td><td></td></tr><tr><td>Stent Dwell time (da)</td><td></td><td></td><td></td></tr><tr><td>Abdel Hakim et al [26], mean (SD)</td><td>42 (5)</td><td>13 (3)</td><td>NR</td></tr><tr><td>Osman et al [18] (per protocol)</td><td>34</td><td>11–12</td><td>NR</td></tr><tr><td>Length of stay</td><td></td><td></td><td></td></tr><tr><td>Abdel Hakim et al [26], mean (SD)</td><td>7 (3.0)</td><td>14 (3.7)</td><td>p < 0.001</td></tr><tr><td>Osman et al [18], median (range)</td><td>14 (10–42)</td><td>18 (14–32)</td><td>p < 0.001</td></tr><tr><td>Primary outcome</td><td></td><td></td><td></td></tr><tr><td>Urinary leak (%)</td><td></td><td></td><td></td></tr><tr><td>Abdel Hakim et al [26]</td><td>8.3</td><td>6.1</td><td>p > 0.9</td></tr><tr><td>Osman et al [18]</td><td>4.4</td><td>4.2</td><td>p = 0.9</td></tr><tr><td>Ureteroenteric stricture rate (%)</td><td></td><td></td><td></td></tr><tr><td>Abdel Hakim et al [26]</td><td>0</td><td>6.1</td><td>p = 0.2</td></tr><tr><td>Osman et al [18]</td><td>2.2</td><td>0</td><td>p = 0.3</td></tr><tr><td>UTI (%)</td><td></td><td></td><td></td></tr><tr><td>Abdel Hakim et al [26]</td><td>NR</td><td>NR</td><td>NR</td></tr><tr><td>Osman et al [18]</td><td>6.7</td><td>2.1</td><td>p = 0.3</td></tr><tr><td>Sepsis (%)</td><td></td><td></td><td></td></tr><tr><td>Abdel Hakim et al [26]</td><td>NR</td><td>NR</td><td>NR</td></tr><tr><td>Osman et al [18]</td><td>NR</td><td>NR</td><td>NR</td></tr><tr><td>Hydronephrosis (%)</td><td></td><td></td><td></td></tr><tr><td>Abdel Hakim et al [26]</td><td>0</td><td>0</td><td>NR</td></tr><tr><td>Osman et al [18]</td><td>2.2</td><td>0</td><td>p = 0.3</td></tr></tbody></table>

NR = not reported; RCUD = radical cystectomy and urinary diversion; SD = standard deviation; UTI = urinary tract infection.

Two studies in this SR included robotic RCUD [24,25]. The use of robotic RCUD has been well documented to reduce blood transfusions and length of stay without significant differences in oncological control compared with open surgery [14]. However, two SRs have demonstrated higher UEA stricture rates than open surgery [14,15]. Whilst there was no subgroup analysis of robotic outcomes in the study by Beano et al [24], Lambertini et al [25] demonstrated in their feasibility study a postoperative hydronephrosis rate of 10%, independent of stent use. With the growing adoption of robotic RCUD, it is crucial to address stent use and duration to minimise the risk of upper tract complications.

## 4.2. Strength and limitations

One of the main strengths of this SR is that it has been developed and conducted by a multidisciplinary panel of experts (EAU Muscle Invasive Bladder Cancer Guidelines Panel) supported by a strong methodology team. By adhering to a rigorous methodology and synthesising results from multiple studies, we ensure the highest level of evidence, even when the overall evidence base is limited.

There are some limitations to be recognised in this SR. First, the outcome data from the meta-analyses show wide CIs, which reflect the small sample size and uncertainty around the effect size. This is partly due to the rarity of certain complications in the included studies (with crude incidence rates being 4% for UEA leak, 5% for UEA stricture, and 6% for postoperative UEA obstruction). Therefore, future studies should use composite endpoints to reduce the sample size required to conduct surgical trials with sufficient power. Second, there was both low heterogeneity for UEA

complications (n = 3, I² = 0%) and high heterogeneity for length of stay (n = 3, I² = 87%) when comparing the use or omission of stents in RCUD. We favoured an approach to report in a meta-analysis as per previous studies using a random-effect model. The heterogeneity is likely to have been contributed by the small number of patients in two trials (those by Lambertini et al [25] and Mattei et al [23]), unequal treatment arms (due to data obtained from a separate RCT investigating goal-directed fluid therapy in RCUD patients) in the study by Donat et al [27], and a low event rate. Third, the follow-up period is short for the included studies, with the majority reporting follow-up periods up to 12 mo. Fourth, relevant outcome parameters remain unaddressed, such as the rate of percutaneous nephrosotomy, which was not reported in four of six studies, or the duration of postoperative antibiotic regimes, which may affect UTIs and sepsis rates (0/6). Therefore, core outcome sets need to be established to allow effective comparisons between surgical trials. Lastly, there was a high/serious RoB among all the included studies, and therefore these results must be interpreted with caution.

## 5. Conclusions

This SR highlights a well-known issue within surgery in which some surgical interventions/techniques have been widely adopted without rigorous evaluation. To strengthen this point, only three RCTs were identified in this SR. Whilst some evidence suggested fewer postoperative complications when stents were omitted and reduced stent retention following RCUD, the differences between groups did not reach conventional statistical significance. Until further results from on-going RCTs (NO-STENT and STENT-OPT) become available, urologists should consider carefully the indications for placing a ureteric stent and its retention time after RCUD.

**Author contributions:** Mithun Kailavasan had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

**Study concept and design:** Kailavasan, van der Heijden.

**Acquisition of data:** Kailavasan, Martini.

**Analysis and interpretation of data:** Kailavasan, Martini.

**Drafting of the manuscript:** Kailavasan, Martini.

**Critical revision of the manuscript for important intellectual content:** Kailavasan, Martini, Bruins, Carrion, Cathomas, Compérat, Efstathiou, Efstathiou, Lorch, Lorch, Meijer, Mariappan, Milowsky, Neuzillet, Panebianco, Rink, Thalmann, Sæbjørnsen, van der Heijden.

**Statistical analysis:** Kailavasan.

**Obtaining funding:** None.

**Administrative, technical, or material support:** EAU Methodology Office.

**Supervision:** van der Heijden.

**Other:** None.

**Financial disclosures:** Mithun Kailavasan certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
**Funding/Support and role of the sponsor:** None.

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