Stricture of the ureteric-intestinal anastomosis occurs in 2.4%⁴ to 5.4%¹³ of cases (3% from our data). Thus, its incidence is rather low and comparable to that seen with open surgery. Leakage due to an insufficient ureteric-ileal anastomosis is reported in up to 4.3% of cases [27]. As anti-reflux ureteric implantation seems to offer little benefit in terms of preservation of renal function and prevention of urinary tract infections, refluxing techniques have become the standard for both open and robotic surgery [8]. Nevertheless, as a mechanism to reduce reflux, we would suggest routinely using an isoperistaltic afferent limb for ureteric implantation, as first described by Studer [28].

Many surgeons prefer the Wallace implantation technique over the Bricker technique [13] as it was traditionally reported to have lower stricture rates; however, this is still under debate [29]. With the Wallace technique, retrograde access to the kidneys is certainly easier, but the disadvantage is that a potential stricture frequently blocks both kidneys. In essence, the type of anastomosis should be chosen according to the surgeon’s preference and experience. Implantation follows the principles of open surgery: the ureter should be tension-free and kinks should be avoided. We recommend careful handling of the tissue during ureteric anastomosis, and we avoid any stripping of the adventitial tissue around the ureter in order to maintain good blood supply.

After the cystectomy, we transpose the left ureter under the sigmoid, though a generous window. The key to this sometimes-daunting step is to have completed an adequate pelvic lymph node dissection. This clearly demonstrates the retroperitoneal and pelvic blood supply and allows safe passage of the ureter avoiding damage to the large vessels but also the inferior mesenteric artery. The patient’s own anatomy will frequently guide the surgeon, with the window through being deeper than initially though. The ureters are closed off with a purple clip (Weck Hem-o-lok; Teleflex; Limerick, PA), onto which a 2–0 polyglactin 910 (Vicryl”) (Ethicon Inc., Somerville, NJ, USA) suture is tied, to aid ureteric handling. To keep the ureters safe and to correctly identify them at a later stage, they are then clipped to the right lower quadrant of the abdominal wall. This essential step protects the ureters from accidentally getting caught within the staple-line during bowel isolation. The ureters are shortened as far as possible to remove redundant tissue and optimize blood supply, which is easily achievable with an intra-corporeal approach.

Stenting of the ureteric anastomosis has been shown to prevent urinary leakage, upper tract dilatation and associated complications [30]. We use two 7.0F single J stents (Bander Ureteral Diversion Stent Set, Cook Medical, Spencer, IN), which are fixed to the neobladder with a fast resolving 3–0 polyglactin 910 suture (Vicryl rapid) (Ethicon Inc., Somerville, NJ, USA) to prevent accidental removal. We externalize the stents through the neobladder wall and the abdominal wall, while some others tie them to the catheter for easy extraction when the catheter is removed [26].

The majority of post-op complications following radical cystectomy are linked to the reconstructive part of the procedure [31]. A recent review found a complication rate of 17.2%. There were 31.4% Clavien I, 1% Clavien II, 62.9% Clavien III and 0% Clavien IV and V [13]. This seems to be comparable to the rates reported in a large open series [31]. Another study by the International Robotic Cystectomy Consortium, which did not distinguish between neobladder and conduit construction, found a major complication rate of 20% for RARC in patients with intra-corporeal diversion. In the group with extra-corporeal diversion, a 32% complication rate was seen [6]. Our own data demonstrate a reduction in overall complications from 48 to 31% in favour of robotic-assisted surgery, with a 5% significant (Grade 3/4) complication rate [7].

The first case of an RARC with intra-abdominal formation of an orthotopic ileal neobladder  – a Hautmann neobladder  – was described in 2003 [5]. Since then, several different techniques have been described; the most commonly used technique being a modified Studer Pouch [13]. A U-shaped without cross folding [32], a Y-shaped pouch [33] and a pyramid-shaped neobladder [34] have been described as well. Our preferred approach has previously been described by M. Annerstedt et al. Post-operative urodynamic evaluation has proven this technique provides a safe low-pressure system which is achievable without prolonged operative times.

Stone formation in the reservoir is rare, and it has been described in 1.4–2.8% of cases [13, 27]. It is associated with infection, residual urine and foreign bodies in contact with urine. To prevent later stone formation (for example, on staples), nearly all authors use absorbable sutures in a running fashion [13]. To prevent slipping and to guarantee water tightness, we would suggest a barbed suture (V-lock 2–0; Covidien Inc.; New Haven, CT) [35]. However, it is interesting to note that there is no clear proof that staples act as nucleus, around which stones may form [36], and a partially stapled neobladder has been described, which yielded few problems with stone formation and had the advantage of a reduced surgical time [37]. Furthermore, it is routine practice to use stapling techniques to close the proximal end of the ileal conduit and yet this does not translate into problems with stone formation. The most challenging part of the neobladder closure involves the posterior and anterior walls close to the urethral-enteric anastomoses. It requires a careful sero-submuscosal closure around this particularly fragile portion of the neobladder. Another helpful approach is to use a few interrupted sutures to oppose the edges along the neobladder walls; this aids with the inevitable movement of the neobladder as closure proceeds.

After neobladder formation, a leak test is mandatory, and residual openings can be closed off with extra interrupted sutures. We routinely place a Robinson drain in the pelvis, located close to the anastomosis.

Post-operative care of these patients is dictated by our enhanced-recovery after surgery (ERAS) protocol. Our protocol focuses on pre-operative counselling, nutrition, standard analgesic and anaesthetic regimens and early mobilization, and has continued to develop over several years. ERAS protocols modify the physiological and psychological responses to major surgery; however, limiting the initial surgical insult, for example, with a robotic-assisted approach has become one of the key principles [7].