Response to Editorial Commentary: Perioperative Complications and Omission of Ureteral Stents During Robot-Assisted Radical Cystectomy with Intracorporeal Ileal Conduit

We appreciate the editorial commentaries^1,2,3 to our study and would like to address several salient points. We agree with Moon et al¹ that urinary tract infection (UTI), and resultant hospital readmission, is frustratingly common and a significant source of morbidity after radical cystectomy. Our data⁴ add to the growing body of literature supporting omission of ureteral stents to reduce post-operative complications.

Drs. Pingle and Lenis³ posit that the risk of UTI associated with ureteral stents may be related to duration in place and whether UTIs could be significantly reduced by removing stents 3 days after surgery rather than omitting altogether. First, one must pose the question what is the presumed benefit of stenting: Is it to reduce the risk of urine leak or ureteral stricture? Our study and others have indicated no clear difference in these outcomes with routine omission of ureteral stents.⁵ If the suggestion is that shorter stent duration is favored, then it follows that avoiding placement completely could be advantageous as we have shown here. A concern was also raised that follow-up may be too short to discern a difference in ureteral stricture rates between stented and unstented patients. While ureteroenteric anastomotic stricture was not a primary endpoint, it is acknowledged that this is a time-dependent phenomenon with delayed strictures possibly identified with longer follow-up. We have previously shown at a population level and in our own data that nearly all strictures after radical cystectomy are detected within the first 9 months.^6,7 With a median follow up of 12 months in the current cohort, we do not anticipate that further follow-up would substantially change our findings.

There were 2 patients in the unstented group versus 0 in the stented group with a detected urine leak. This difference was not statistically significant and previously published data have shown no difference in rate of urine leaks between stented and unstented patients⁸, commensurate with our findings. Of the two leaks which were identified in our study, one leak was incidentally discovered on drain creatinine testing requiring no intervention. The second was from the end of the ileal conduit rather than the ureteroenteric anastomosis, a complication which would not have been prevented by stent use.

We acknowledge the potential for selection bias and limits of generalizability in this retrospective study and are actively accruing to our randomized clinical trial of modifications to radical cystectomy (NCT06703476), which will provide much needed prospective data to better define the benefits and risks of ureteral stent use for patients undergoing radical cystectomy. Until then, we hope that this study encourages readers to carefully consider surgical dogma in their practice that might warrant closer, evidence-based inspection.