Posterior conduit fixation with retroperitonealization of uretero-ileal anastomosis after open radical cystectomy reduces the postoperative complication rate: a retrospective, matched-paired single-center analysis

Abstract

Background

Our study aimed to assess the efficacy of posterior conduit fixation with retroperitoneal ureteroileal anastomosis (UIA) in reducing perioperative complications after radical cystectomy (RC) with ileal conduit (IC) urinary diversion.

Methods

We conducted a retrospective case-control study, including 150 patients who underwent either modified IC technique (extraperitonealized anastomosis with posterior conduit fixation; n = 79) or the conventional IC technique (n = 71). The primary endpoints were the incidence of clinical parastomal hernia (PSH) and ileus. Secondary endpoints included operative time, postoperative complication rates, and length of hospital stay (LOS). Multivariate logistic regression was performed to identify predictors of early and late stoma- related complications.

Results

The modified group showed significantly lower incidence of both early and late postoperative complications, including ileus and PSH, compared to the conventional group (8.86% vs. 28.1%, p = 0.01 and 7.6% vs. 17%, p = 0.03, respectively) after a median follow-up of 34 months. Corresponding hazard ratios were 0.312 (95% CI: 0.047–0.798, p = 0.01) for early complications and 0.267 (95% CI: 0.105–0.611, p = 0.03) for late complications.

Conclusion

The results support our hypothesis that extraperitoneal ureteroileal anastomosis combined with posterior conduit fixation effectively reduces the risk of both early and late postoperative complications, including parastomal hernia and ileus.

Background

Radical cystectomy (RC) is one of the most challenging and morbid procedures in surgical urologic oncology [1]. Since the early 20th century, the surgical principles of RC have continuously evolved, with numerous modifications aimed at improving perioperative outcomes [2–4]. Despite promising results with robot-assisted RC, the open approach remains the preferred method in most European countries. Although continent urinary diversions and neobladder reconstructions are gaining popularity, RC with ileal conduit (IC) diversion remains the most effective curative approach for patients with invasive bladder cancer [3–5]. The Wallace technique of ureteroileal anastomosis (UIA) has been the standard urinary diversion method for more than half a century and remains the preferred technique at our center [3, 6]. However, given the numerous complications associated with IC, modified surgical techniques have been developed over time [3, 6–9]. Notably, nearly half of these complications relate to the stoma and the UIA [9]. Although risk factors for parastomal hernias (PSH) have been well characterized, limited data exist on the incidence and risk factors for postoperative ileus related to surgical techniques. Anterior IC fixation is a well-established but yields controversial outcomes [8, 9]. In contrast, posterior fascial or extraperitoneal conduit fixation has been less frequently described, yet appears to improve perioperative outcomes [7, 10, 11]. Additionally, reconstructing the peritoneum after RC and extended lymphadenectomy may reduce postoperative pain, promote early recovery of bowel function, and decrease early complication rates [12]. However, no studies have directly compared outcomes of posterior conduit fixation and UIA retroperitonealization to the standard technique. Understanding these differences could yield critical insights into reducing length of hospital stay (LOS), incidence of ileus, and parastomal hernias over long-term follow-up.

This study aims to compare perioperative outcomes, including the incidence of PSH, ileus, and LOS, in patients who underwent open RC with either the modified or traditional IC technique. We hypothesized that the modified IC technique would significantly reduce PSH and ileus incidence.

Methods

Study design

From a total of 220 patients who underwent RC at the Urology Clinic, Clinical Center of Montenegro, between January 2010 and January 2022, we retrospectively analyzed 160 consecutive patients who received IC urinary diversion. Patients were divided into two groups: 85 patients who underwent posterior conduit fixation with ureteroenteric extraperitonealization (study group) and 75 patients treated with conventional IC diversion (control group). Prior 2015, there were no specific selection criteria and all patients were treated using standard surgical technique, according to our surgical protocol. Due to a high incidence of postoperative ileus and PSH observed in earlier cases [3], we decided to develop a modified technique, addressing the importance of conduit fixation and retroperitonealization. Following this change, patient assignment to each technique was semi-random, based on the surgeon’s preference. To ensure comparability, patients who underwent the modified technique were matched to those in the conventional group on the basis of the following perioperative variables: age, sex, preoperative hemoglobin and albumin levels, and history of prior pelvic or abdominal surgery. Following this matching process, 79 patients from the modified technique group were matched to 71 patients from the control group.

Endpoints evaluated:

• Primary endpoints: Incidence of postoperative ileus and PSH.

• Secondary endpoints: Operative time, postoperative complication rates and LOS.

Inclusion criteria were: age ≥ 40 years, clinical stage T2-T3/N0-3/M0 bladder cancer, and patients who underwent IC urinary diversion. Exclusion criteria included prior pelvic radiation, clinical stage M1 disease, history of extensive abdominal surgery, or inability to comply with follow-up. The study was approved by the Ethical Committee of the Clinical Center of Montenegro (Nr 03/01-517-1) and conducted in accordance with the principles of the Declaration of Helsinki. All surgeries were performed at a single center by one surgeon, who had an annual RC volume of 30–40 cases.

Measurements

Collected data included patient demographics (age, sex, body mass index [BMI]), clinicopathologic characteristics (tumor and nodal stage, prior treatments), and preoperative and intraoperative variables (operative time, blood loss). Postoperative data included the LOS, time to bowel function recovery, and complication incidence, with an emphasis on postoperative ileus and PSH rates.

Complications were categorized using the modified Dindo‒Clavien classification system [13]. Patients underwent an identical follow-up protocol, with evaluations every 3–6 months, including. physical examination, imaging (chest, abdomen, and pelvis), urine cytology and complete blood work. Key outcomes included postoperative pain, anastomotic complications, ileus, PSH, and LOS [14]. Internal herniation was diagnosed via CT urography in symptomatic patients. Clinical PSH was defined as the protrusion of abdominal contents adjacent to the stoma site [15].

Surgical technique

Prior to surgery, a urologist and stoma therapist assessed each patient to determine and mark the optimal stoma site. Following open RC and standard pelvic lymph node dissection [16] an isolated ileal segment and Wallace UIA were created using a well-established technique [3]. In the study group (group I), the IC was brought directly to the anterior abdominal wall through a two-fingerbreadth opening, within the rectus muscle fibers [8]. The distal end was anchored to the anterior rectus sheath via two interrupted Vicryl 3 − 0 sutures and secured to the skin to create a stoma nipple. The proximal segment was fixated to the posterior peritoneum and abdominal wall using three to six interrupted Vicryl 3–0 sutures. Additionally, a peritoneal flap was placed over the UIA, and the peritoneal cavity was reconstructed to extraperitonealize the ileal conduit and anastomosis [3, 12]. The stoma was then reflected upon itself via 3–0 Vicryl sutures, and ureteral catheters were fixed for approximately 14 days postoperatively. The detailed intraoperative steps are illustrated in Figs. 1 and 2. Complete retroperitonealization was not required; coverage of the anastomotic end with proper fixation was deemed sufficient to prevent PSH and ileus.

Fig. 1.

Description of the modified technique of ileal conduit urinary diversion: A extraperitonealization of ureteroileal anastomosis: 1 -peritoneal flap covering the anastomosis; 2 - reconstructed peritoneum; 3 - ileal conduit segment; 4 - small bowel loop; B final shape of the ileal conduit: (a) parietal peritoneum covering the ureteroileal anastomosis and small part of the proximal conduit; (b) free conduit segment fixed for the peritoneum covering the posterior abdominal wall; (c) fixation points using 3–0 Vycryl sutures; C distal end of the conduit anchored to the anterior rectus sheath with two interrupted Vicryl 3–0 sutures and then to the skin-forming stoma nipple: thin arrow– two anchor sutures to the anterior rectus sheet; dicking arrow– stoma nipple fixed to the skin

Fig. 2.

Intraoperative view of the modified technique: A 1 - peritoneum; 2 - ureteral plate; 3 -conduit segment; B a-peritoneal flap extraperitonealizing the ileal conduit and the anastomotic site; b - conduit segment; c - fixation point for the periosteum covering the posterior abdominal wall; d - reconstructed peritoneal cavity

In the control group (group II), after the conduit was brought to the anterior abdominal wall, only anterior fixation was performed using two 2–0 Vicryl sutures between the anterior rectus sheath and the conduit, following the standard technique [3]. No posterior reinforcement was applied. In accordance with the local protocol, loopogram studies were conducted at 3, 6, and 12 months postoperatively and then annually thereafter to assess for UIA anastomotic strictures [3]. Both groups followed modified Enhanced Recovery After Surgery (ERAS) protocol, including preoperative patient counseling, fluid optimization, shortened postoperative fasting early oral nutrition, intraoperative warming and limited bowel manipulation [14],. Multimodal analgesia was prioritized, with opioids reserved for refractory pain. Prior to 2015, patients received mechanical bowel preparation and had delayed oral intake.Nasogastric tubes were removed on the second postoperative day. Post-2015, bowel prep was omitted, nasogastric tubes were removed intraoperatively, and clear liquids were started on the day of surgery.

Follow-up and complications

During follow-up, a patient was diagnosed with PSH if a palpable bulge was identified upon physical examination and was associated with a fascial defect at the ileal conduit stoma site [8]. Stoma-related complications included stenosis, retraction, and prolapse. If PSH was suspected, an abdominal CT scan was performed to confirm the diagnosis; however, radiological findings alone were insufficient for diagnosis.

Postoperative ileus was defined as the absence of flatus for > 72 h and classified as either mechanical (obstruction) or paralytic. Internal herniation,, was confirmed via CT imaging. UIA complications included urinary leakage and anastomotic obstruction. Early complications, defined as those occurring within 90 days of surgery, were categorized using the modified Clavien–Dindo grading system [13]. Late complications, defined as those occurring more than 90 days post-surgery, included anastomotic strictures and stoma-related complications.

A summary of patient and disease characteristics, is provided in Table 1. The postoperative complications observed between the two groups are detailed in Table 2.

Table 1.

Demographic and perioperative patient and tumor characteristics of 150 patients who received ileal conduit diversion

Patients’ characteristics	Group I (n=79)	Group II (n=71)	P
Gender	n (%)	n (%)
Female	24 (30.4)	20 (28.1)	0.56
Male	55 (69.6)	51 (71.9)	0.33

Preoperative data	Median ± SD	Median ± SD
Age, years,	69 ± 11	65±12	0.19
BMI, kg/m2,	22.9 ± 3.9	23.0 ± 3.1	0.31
Albumin (g/dl)	3.8 ± 0.6	3.7 ± 0.8	0.16
Hemoglobin (g/dl)	12.1 ± 1.3	11.9 ± 0.8	0.07
Hydronephrosis, n (%)	32 (40.5)	29 (40.8)	0.09
Prior pelvic or abdominal surgery, n (%)	10 (12.6)	8 (11.2)	0.33
CCI, n (%)
≤ 2	34 (43)	29 (40.9)	0.08
>2	45 (57)	42 (59.1)	0.1
ASA score, n (%)
≤ 2	45 (56.9)	40 (56.3)	0.4
>2	34 (43.1)	31 (43.7)	0.9
Pathological stage	n (%)	n (%)
T1	0	9 (12.6)	-
T2	31 (39.2)	20 (28.1)	0.03*
T3	44 (55.6)	40 (56.3)	0.11
T4	4 (5.1)	2 (2.81)	0.08
Lymph Node status	n (%)	n (%)
N0	58 (73.4)	52 (73.2)	0.92
N+	21 (26.6)	19 (26.8)	0.88
Estimated intraoperative bleeding (mL), median ± IQR	300 ± 200	225 ± 200	0.12
Operative duration (min), median ± IQR	360 ± 103.5	350 ± 83.3	0.06
Postoperative length of hospital stay (LOS), days, median ± IQR	10± 4.3	14 ± 5.3	0.04*
Neoadjuvant cht, n (%)	n (%)	n (%)	0.74
Yes	30 (37.9)	26 (36.6)	-
No	49 (62.1)	45 (63.4)	-
Adjuvant cht	n (%)	n (%)	0.57
Yes	20 (25.3)	18 (25.3)
No	59 (74.7)	53 (74.7)

IQR interquartile range, CCI Charlson comorbidity score, ASA American Society of Anesthesiology

asterisk (*) depicts statistical significance

Table 2.

Postoperative complications of patients in the two groups

Technique-related complications	Posterior conduit fixation group (group I)	Conventional group (group II)	P
Early complications (≤ 3 months), n	Total (≥ grade 3)†	Total (≥ grade 3)†
Total	7 (3)	20 (12)	0.01*
Intestinal leakage	0	0	-
Ileus	1	6 (4)	0.002*
Mechanical	0	4 (4)	-
Paralytic	1	2	-
Ureterointestinal anastomosis leakage	0	1 (1)	-
Lymphocele	3 (2)	4 (1)	-
Wound dehiscence	1 (1)	1 (1)	-
Incisional hernia	0	1 (1)	-
Postoperative infection	1	0	-
Incisional infection	0	1	-
Delayed complications (> 3 months), n
Total	6 (2)	12 (5)	0.03*
Ureterointestinal anastomosis stenosis	2 (1)	4 (2)	-
Stomal complications	4 (1)	8 (3)	0.04*
Parastomal hernia	0	4 (3)
Stomal retraction	2 (1)	0	-
Stomal prolapse	2	3	-
Stomal stenosis	0	1	-
Major complications, n (%)
Pyelonephritis	9 (11.3)	7 (9.8)	0.07
Pneumonia	3 (3.7)	2 (2.8)	0.3
Renal insufficiency	4 (5)	5 (7)	0.1
Renal calculosis	1 (1.2)	0	-
Thromboembolic events	3 (3.7)	2 (2.8)	0.6
Follow-up time, mean (SD)	28.5 (5.7)	38 (4.8)	0.04*

^†Clavien‒Dindo grading system

asterisk (*) depicts statistical significance

External validation of the pentafecta

Pentafecta validation required fulfillment of five criteria: removal of ≥ 16 lymph nodes, negative soft-tissue surgical margins, no major complications (Clavien-Dindo ≥ III) within 90 days, time from transurethral surgery to RC < 3 months and no local or distant recurrence within 12 months [17]. We controlled for confounders such as surgeon experience, comorbidities, and postoperative care variability to strengthen the validity of the findings.

Statistical analysis

Continuous variables were compared using Student’s t test or the Mann‒Whitney U test, depending on the data distribution. Categorical variables were analyzed via the Chi-Square or Fisher’s Exact test. Blood loss, operative time, and LOS were assessed as continuous variables and tested for normality via the Kolmogorov test. Multivariate Cox regression analysis was performed to identify independent predictors of early and late complications. Results are reported as hazard ratios (HRs) with 95% confidence intervals (CIs). Kaplan‒Meier analysis assessed complication-free survival. Statistical significance was set at p < 0.05. All analyses were performed using SPSS software version XX (SPSS Inc., Chicago, IL).

Results

Following the application of exclusion criteria and propensity score matching, 150 patients were deemed eligible for this study. Both groups are comparable in terms of age, sex, BMI, preoperative hemoglobin and albumin levels, and history of prior pelvic or abdominal surgery (Table 1). Fifty-six patients received neoadjuvant chemotherapy. Baseline characteristics reveal significant differences in the LOS and incidence of the T2 pathological stage (p = 0.04 and p = 0.03, respectively). Median follow-up was 34 months (28.5 months for the conventional group vs. 38 months for the modified group, p = 0.56). There were 12 local recurrences (8%), and five deaths three of which from bladder cancer (2%). Since the primary focus of the modified surgical technique is the prevention of stoma- and UIA-related complications, other complications are not analyzed in detail. Nevertheless, the most common technique, non-related complication is pyelonephritis, which occurrence is more common in the modified group (11.3 vs. 9.8), although statistical significance is not reached (Table 2). A total of 27 (18%) early complications related to the surgical technique and UIA are recorded across the 150 patients. Early postoperative complications were significantly lower in the modified group (8.86% vs. 28.1%, p = 0.01). Notably, no ureterointestinal anastomotic leak occurred in the modified group, compared to one in the conventional group. The incidence of late complications, including PSH and UIA stenosis, was also reduced in the modified group (7.6% vs. 17%, p = 0.03) (Table 2). During follow-up, the modified group demonstrated significantly lower PSH (0% vs. 5.6%) and ileus (1.26% vs. 8.4%, p = 0.002) rates. Stoma-related late complications occurred in 12 patients (8%), all PSH cases being from the conventional group. Kaplan-Meier analysis demonstrated superior complication-free survival in the modified group (Fig. 3). Multivariate Cox regression the modified surgical technique as an independent predictor of reduced early and late complications (HR 0.31, 95% CI 0.04–0.79, p = 0.02 and HR 0.21, 95% CI 0.06–0.71, p = 0.01, respectively). Additionally, advanced tumor stage is associated with an increased risk of late complications (HR 0.33, 95% CI 0.08–0.73; p = 0.02), while comorbidity index, previous abdominal surgery, and cystectomies performed before 2015 were associated with higher early complication rates (HR 0.21, 2.45 and 0.23; p = 0.02, 0.01 and 0.03, respectively) (Table 3).

Fig. 3.

Kaplan‒Meier diagram showing complication-free survival between the two groups

Table 3.

Multivariate logistic regression analysis for predictors of early and late complications related to stoma and ureteroileal anastomosis in bladder cancer patients after ileal conduit surgery

Variable	Early complications			Late complications
	HR	(95% CI)	P value	HR	(95% CI)	P value
Ileal conduit surgery (modified vs. conventional)	0.312	(0.047–0.798)	0.011*	0.267	(0.105–0.611)	0.030*
Age (> 65 vs. ≤ 65)	0.461	(0.211–3.561)	0.336	0.233	(0.112–3.697)	0.296
Gender (female vs. male)	3.246	(0.056–13.234)	0.431	1.223	(0.814–9.961)	0.332
Pathologic T stage
T2 vs. T1	2.122	(0.667–9.356)	0.812	2.626	(0.274–9.866)	0.441
T3 vs. T2	1.453	(0.165–8.442)	0.413	0.335	(0.083–0.732)	0.021*
T4 vs. T3	1.468	(0.426–6.612)	0.214	2.149	(0.896–8.432)	0.415
Pathologic N stage (N + vs. N0)	1.336	(0.521–11.224)	0.084	1.620	(0.134–10.341)	0.315
Neoadjuvant chemotherapy (yes vs. no)	1.315	(0.089–10.362)	0.327	1.472	(0.933–6.012)	0.212
Adjuvant chemotherapy (yes vs. no)	2.543	(1.351–8.116)	0.192	1.325	(0.096–11.357)	0.317
BMI (> 21.8 vs. ≤ 21.8)	2.687	(1.142–7.623)	0.112	2.321	(1.025–6.816)	0.286
CCI (> 2 vs.≤2)	0.211	(0.027–0.689)	0.020*	0.138	(0.008–3.499)	0.281
ASA score (> 2 vs.≤2)	2.594	(0.121–7.783)	0.067	1.973	(0.142–9.126)	0.259
Previous abdominal surgery	2.455	(1.132–5.791)	0.013*	1.884	(0.329–7.324)	0.061
Year of surgery (> 2017 vs.≤2017)	0.231	(0.029–0.667)	0.030*	0.602	(0.0127–1.933)	0.305

The asterisk (*) indicates statistical significance

BMI body mass index, CCI Charlson comorbidity score, ASA American Society of Anesthesiology

Overall 53.3% (n = 80) of patients fulfilled all five RC-pentafecta criteria.. The modified IC technique demonstrated significantly better results in two criteria (p = 0.03 and p = 0.02, respectively) (Table 4).

Table 4.

Percentage of RC pentafecta criteria and comparison between groups

Pentafecta criteria (%)	Posterior conduit fixation group (group I)	Conventional group (group II)	P
Free positive surgical margins	85	63	0.02*
Lymph node dissection of ≥ 16 lymph nodes removed during RC	75	80	0.4
No complication according to Clavien– Dindo grade 3–5 within 90 days after RC	81	80	0.1
Treatment-free time between TURBT with detection of muscle-invasive BC and RC < 3 months	85	65	0.03*
Absence of local BC-recurrence in the pelvis ≤ 12 months	79	70	0.07

RC radical cystectomy, TURBT transurethral resection of bladder tumor

The asterisk (*) indicates statistical significance

Discussion

This study demonstrates that posterior conduit fixation combined with retroperitonealization of the UIA significantly reduces both early and late postoperative complications following RC with IC urinary diversion. The modified technique was associated with lower rates of PSH and bowel obstruction, as well as improved overall complication-free survival - indicating a clear benefit over the conventional approach. Both surgical techniques utilized the Wallace method for UIA, where newly constructed ureteral plate was anastomosed to the proximal end of an open bowel segment, instead of separate UIA, as seen in the Bricker technique. A significant reduction in early complications was observed in the modified group compared to the conventional group (8.9% vs. 28.1%, p = 0.01), with no cases of UIA leaks reported in the modified cohort. Although some modern robotic approaches employ stentless UIAs and have shown feasibility, they are limited by small sample sizes and short follow-up periods [18]. Our stented Wallace UIA, reinforced by peritoneal covering, offers a reproducible and device-supported alternative in open surgery. Compared with robotic neobladder techniques, our approach provides a more accessible and consistent method for open surgeons, while achieving similar objectives: reduced anastomotic complications, minimized device burden, and optimized abdominal wall integration.

PSH remains a common complication following IC surgery, with reported incidence rates as high as 45% in some studies [15, 19]. Since most PSH cases require surgical intervention, which carries considerable morbidity,, it is essential to consider techniques that reduce hernia incidence. While the prophylactic use of mesh has shown promise in PSH prevention [20, 21], concerns remain regarding mesh erosion and subsequent stomal complications [22]. Our modified technique demonstrated significant improvements in stomal, outcomes, with no cases of PSH reported, compared to a 5.6% incidence in the conventional group over a median follow-up of 34 months. These findings suggest that modifying the standard RC technique may not only reduce the incidence of stomal complications but also prevent subsequent surgeries and their associated risks. One potential mechanism for this improvement is the enhanced support to the abdominal fascia via fixation sutures placed between the conduit and the posterior abdominal wall. This anchoring may substantially reduce intra-abdominal tension and pressure on the stoma, thereby lowering the risk of hernia formation.

Similar findings were reported by Li Z et al. [7], who demonstrated that modification of the IC technique significantly reduced the incidence of PSH, regardless of patients’ baseline hernia risk factors. Their study emphasized that complete extraperitonealization of the IC and ureters, combined with multiple anchoring sutures to the anterior abdominal wall, was a decisive factor in lowering PSH rates. In a recently published randomized controlled trial, the same authors reported a 22.7% reduction in PSH incidence at 36 months post-surgery (34.9% in the conventional group vs. 12.2% in the modified group, p = 0.03) [23]. Additional benefits of the modified technique included shorter operative times and lower complication rates. Our study corroborates these findings, demonstrating that covering only the UIA with a peritoneal flap and anchoring the conduit to the internal abdominal wall offers a substantial advantage in preventing PSH formation. This may reduce reliance on prophylactic mesh, thereby avoiding mesh-related complications. Notably, our study also documented improvements in ileus rates, LOS, and UIA-related complications, outcomes not fully examined in Li’s study. These broader clinical benefits and consistent methodology support the wider adoption of our technique.

Multivariate Cox regression analysis confirmed that our modified technique significantly reduced the risk of both early and late complications, including ileus. Only one patient in the modified group developed paralytic ileus, which resolved spontaneously, while four patients in the conventional group experienced mechanical ileus requiring surgery. This difference may be attributed to peritoneal readaptation, as described by Roth B. et al. [12], who found that reapproximation of the peritoneal layer after cystectomy and extended lymphadenectomy resulted in bowel recovery and fewer early complications. By applying a similar strategy, our modified technique reduced complication rates and shortened median hospital stay from 14 to 10 days (p = 0.04). Furthermore, the higher incidence of ileus in the conventional group may have been influenced by inconsistent adherence to the Enhanced Recovery After Surgery (ERAS) protocol before the modified technique was implemented.

This study is among the first to systematically evaluate posterior conduit fixation and retroperitonealization techniques, providing valuable insights into their clinical benefits. A key finding was the significant correlation between the modified surgical technique and reduced complication rates. Interestingly, patients in the modified group presented with more advanced pathological stages on histology - none had pT1 disease, while significantly more had pT2 and pT4 disease. These findings typically suggest that more challenging surgeries are associated with a greater risk of complications. Despite this, over 53% of patients met all five RC-pentafecta criteria, with the modified group outperforming the conventional group in at least two quality metrics (p = 0.03 and 0.02). This underscores the technique’s ability to improve not only morbidity but also overall surgical quality. However, multivariate analysis demonstrated that patients with pT3 disease, were stronger predictors of delayed complications than those with pT2 disease, reinforcing our original hypothesis. Remarkably, the modified technique appeared to mitigate several challenges associated with major surgery, potentially lowering treatment costs and LOS. The underlying reasons for these improvements warrant further exploration.

This study has several limitations. The results may not apply fully to laparoscopic or robotic approaches, as we exclusively perform open RC. While no formal selection criteria have been established for choosing one technique over the other, the historically high incidence of postoperative ileus at our institution prompted the adoption of the modified technique to reduce postoperative complication rates [3]. Future research should assess the efficacy of this approach in high-risk populations, such as obese patients or those with hypoalbuminemia. Despite these limitations, the modified surgical technique represents a promising advancement in reducing postoperative complications in patients following RC with IC urinary diversion. Surgeons should consider incorporating these modifications into clinical practice to enhance patient outcomes. Future research should focus on conducting prospective randomized controlled trials to further validate the benefits of posterior conduit fixation and retroperitonealization. Furthermore, mechanistic studies may elucidate the biological basis for the observed reduction in complications. Long-term follow-up studies will be essential to evaluate the durability and broader impact of these surgical improvements.

Conclusion

Our data suggest that posterior conduit fixation combined with retroperitonealization of the UIA represents a significant advancement in the surgical management of patients undergoing RC with IC urinary diversion. This modified technique offers a promising strategy for reducing postoperative complications, thereby improving patient outcomes and quality of life. Further research, including prospective randomized controlled trials, is warranted to validate these results and explore the broader applicability of this approach across diverse clinical settings.

Abbreviations

RC

Radical cystectomy

IC

Ileal conduit

UIA

Ureteroileal anastomosis

LOS

Hospital length of stay

PSH

Parastomal hernia

BMI

Body mass index

HRs

Hazard ratios

Cis

Confidence intervals

Authors’ contributions

V.M performed conceptualization and determined methodology with data curation, formal analysis and writing– original draft. K.P was in charge for supervision and data curation. M.A did project administration and data curation. A.M was involved in conceptualization, methodology and formal analysis, while R.A and S.E both analyzed and interpreted the patient data regarding type of postoperative complications. All authors read and approved the final manuscript.

Funding

No sources of funding to declare.

Data availability

The datasets used and/or analysed during the current study are included in this published article and are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was reviewed and approved by a certified ethical board of the Clinical Center of Montenegro (Nr 03/01-517-1). Verbal informed consent was obtained and documented in the medical records.

Consent for publication

No written consent was required by the ethical board.

Competing interests

The authors declare no competing interests.