Radical cystectomy (RC) with pelvic lymph node dissection (pLND) represents the standard of care for muscle-invasive and refractory nonmuscle-invasive bladder cancer. Growing interest in minimally invasive approaches, especially robot-assisted radical cystectomy (RARC), has been spurred aiming to decrease perioperative morbidity . RARC has been shown to be equivalent to the open approach in terms of oncologic and functional outcomes but superior in terms of blood loss, transfusion, hospital stay, and convalescence [1].

However, irrespective of the surgical approach, RC remains a morbid procedure with significant complications [2, 3]. It remains a complex and demanding procedure that involves simultaneous procedures performed in the urinary and gastrointestinal tracts, in addition to the retroperitoneum. Adding to this, bladder cancer is a disease of the elderly, and given that smoking is the main contributor to bladder cancer, patients usually suffer other comorbid conditions, especially cardiac and pulmonary, that pose additional anesthetic and surgical risks [4]. All of the aforementioned factors contribute to the high morbidity associated with RC.

Complications can be broadly divided into two main categories : general complications that may occur with any major surgery, e.g., thromboembolic events, cardiac and pulmonary complications; and procedure-specific (those related to RC, pLND, and urinary diversion). Perhaps, most of the latter groups are diversion-related [5]. Such complications vary according to the type (ileal conduit vs continent diversion) and technique of diversion (intracorporeal vs extracorporeal). They may respond to conservative, endoscopic, and percutaneous measures, but many will require reoperations during convalescence or even years later [5, 6].

While complications following RARC have been reported using standardized approaches, mainly within 30 or 90 days after RARC, there have been paucity of data on management of complications and their outcomes, especially those requiring surgical intervention. In this chapter, we describe postoperative complications related to RC and urinary diversion that may require reoperations, their causes, means of prevention, and treatment including operative management.

Uretero-enteric anastomotic complications represent the main cause of renal dysfunction after urinary diversion. They include obstruction, reflux, and urinary leakage. Obstruction may occur as a result of malignancy (local recurrence or pelvic adenopathy), or due to edema or hematomas in the early postoperative period, or from inadvertent twisting of the ureters when replacing the new reservoir in the abdomen after extracorporeal diversion during RARC [7]. Strictures may result from ischemia due to previous radiation or compromised ureteral vascularity during dissection or due to technical errors during anastomosis [8]. It is controversial if the type of uretero-enteric anastomosis (Bricker vs Wallace) affects the stricture rates [6, 9, 10]. Antireflux (tunneling) techniques have been associated with higher rates of strictures [11]. There is wide discrepancy in reporting the incidence of uretero-enteric complications, which may be attributed to the variability in reporting (in terms of patients or renal units), the frequency and type of imaging used, surgical technique and the follow up durations [12, 13]. Strictures were reported in 12% of patients after RARC after a median of 5 months. The cumulative incidence was at a rate of 12%, 16%, and 19% at 1, 3, and 5 years following RARC, respectively [6]. After open RC and neobladders, strictures occurred in 11% of patients at a rate of 8%, 11%, and 14% of renal units at 5, 10, and 15 years, respectively [5].

Usually patients are asymptomatic and there is often a long latency period before diagnosis (5–18 months) [14]. Therefore, follow-up is crucial especially during the first 2 years after surgery for early detection and prompt management [14–16]. Delayed management of urinary obstruction may compromise renal function and adversely impact long-term outcomes [14]. Any findings suggestive of obstruction, infection, or deterioration of kidney function should prompt further investigation.

In our experience, few technical points can prevent such complications: (1) Avoidance of excessive dissection and skeletonization of the ureters and therefore, having a good vascularity of the distal ureteric end; (2) Placing the ureters in a retroperitoneal position; (3) Wide spatulation of the ureter, and anastomosing it to a wide enterotomy in the conduit or a new bladder. We recommend removing a “button-hole” part of the bowel mucosa to serve this purpose; (4) Choosing the proper length of the ureter avoiding short ureters that will put the anastomosis under tension, or longer redundant ureters that may hinder drainage.

Initial management of uretero-enteric complications usually involves early endoscopic or percutaneous techniques, which provide initial relief of obstruction without exposing patients to significant risks. However, they lack durable long-term patency rates [17]. When conservative management fails, the gold standard is open revision with a success rate of up to 92% [17]. Despite the higher success rate, the associated morbidity and technical complexity may render the procedure challenging. We have recently reported our initial experience with robot-assisted revision of uretero-enteric anastomosis. We found that the initial results are promising and are comparable to the open approach [6]. Few other small case series reported similar outcomes and concluded that with increased comfort with the robotic platform, satisfactory outcomes can be achieved [18, 19].

Paralytic ileus and bowel obstruction can occur in up to 11% of patients undergoing RC [6, 20, 21]. Type of preoperative bowel preparation, prolonged fasting before surgery, pain control, long-term nasogastric intubation, excessive fluid administration, and delaying oral feeding after surgery are well established risk factors for paralytic ileus [22]. Bowel obstruction may occur as soon as few days following surgery or many years after. Possible causes include excessive bowel manipulation during surgery, presence of retroperitoneal collections resulting from urinary leakage or infections, electrolyte imbalance (e.g., hypokalemia), stenosis of the ileo-ileal anastomosis, and intraperitoneal adhesions. Nevertheless, most patients usually respond to conservative measures (Drip and Suck—IV fluids and nasogastric tube drainage). Less commonly internal bowel herniation and peritoneal carcinomatosis (<5%) may also cause bowel obstruction [6, 23].

Bowel-related complications may be avoided by gentle bowel handling during surgery, electrolyte replacement, adequate anastomosis, and adopting the fast-track principles (avoid prolonged fasting preoperative, carbohydrate loading few hours prior to surgery, early removal of the nasogastric tube, early institution of oral diet postoperative, early mobilization, and gum chewing) [24]. Some medications may also be helpful as Alvimopan [24].

The intervention rate after failure of conservative measures has been less than 3%, in both open and robotic series [5, 6, 25]. Intervention usually involves adhesiolysis and evaluation of bowel integrity. If bowel viability is a concern, bowel resection and diversion or primary anastomosis may be required. We have recently reported our experience in the robot-assisted management of bowel-related complication and found comparable results with open exploration [6].

Fistulae following RARC and open RC occur in less than 4% of cases [5, 25]. Fistulae may develop between the intestine and the reconstructed urinary tract or from any of these to the skin or even the other organs. Symptoms vary with type and size of the fistulous tract. Patients can present with total incontinence (neobladder-vagina), pneumaturia or fecaluria (neobladder-bowel) or with recurrent urinary tract infections.

Technical modifications may decrease the incidence of fistula, including preservation of female genital organs (when oncologically feasible), closing the vaginal stump meticulously with embedding of the mucosa, covering the vaginal stump with peritoneum in front of the anterior rectal wall and interposing a generously pedicled omental flap between the closed vaginal stump and the urethra-enteric anastomosis, or placing it in front of neobladders [26].

We reported our initial experience with robot-assisted repair of different types of fistula following RARC. Although the operative time was significantly longer, none of the patients required reoperation [6]. Similar results have been reported by a recent study, that described successful RA repair of 10 iatrogenic vesico-vaginal fistulas after gynecologic procedures [27].