Presented by: Sij Hemal M.D.
University of Southern California- USC Institute of Urology

Introduction

Patients with prior lower abdominal/pelvic surgery may harbor post-surgical intra-abdominal adhesions that may distort surgical planes making future dissection challenging. Such a “hostile” abdomen is considered to be a relative contraindication for subsequent complex robotic urologic surgery, such as robotic radical cystectomy with intracorporeal urinary diversion (RRC-ICUD). Herein, we evaluated outcomes of patients undergoing RRC-ICUD with a history of prior lower abdominal/pelvic surgery stratified by type of previous abdominal insult.

Materials

From 07/2010 to 12/2021, 445 consecutive patients underwent RRC-ICUD for bladder cancer. Patients with previous abdominal surgery (PAS) were divided into 4 cohorts: PAS within surgical Region of Interest (sROI); pelvic vs abdominal PAS; major vs minor PAS; and approach of PAS [minimally invasive (MIS) vs open]. Outcomes of interest were operative times (OTs), overall 30-day complication rate, readmission rate and genitourinary (GU) complications. Multivariate analyses was utilized to assess impact of the type of PAS on the outcomes of interest (p<0.05 significance level).

Results

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Our cohort included 445 patients: 266 with no PAS and 179 with PAS; 156 (89%) with PAS in sROI vs 19 (11%) with PAS not in sROI; 113 (64%) Major vs 63 (36%) Minor PAS; 82 (47%) with Pelvic PAS vs 93 (53%) with abdominal PAS; 22 (37%) with prior MIS vs 38 (63%) with open PAS. Oncologic outcomes: no significant differences between soft tissue positive margins amongst all 4 cohorts. Multivariate analysis: previous pelvic surgery and type of approach of PAS did not adversely impact perioperative outcomes (all p>0.05). PAS in sROI trended towards a higher overall GU complication rate (RR=3.8, p=0.08). Prior major PAS trended towards a higher 30-day complication rate (RR=1.9, p=0.06) and higher GU complication rate (RR=2.1, p=0.07). Across the models, BMI independently predicted longer OT (p=0.02)(Fig. 1).

Conclusion

RRC-ICUD is feasible in a previously operated abdomen with relatively noninferior perioperative and oncologic outcomes. However, patients with PAS in the sROI or major PAS should be counseled on a higher peri- and post-operative complication rate. Obese patients are likely to have prolonged operative times and may be counseled on preoperative weight loss.

Funding

No sources of funding were utilized. This was an IRB approved study.

Lead Authors

Michael Eppler, MD
University of Southern California- USC Institute of Urology

Co-Authors

Aref Sayegh, MD
University of Southern California- USC Institute of Urology

Monish Aron, MD, MBA, FACS
University of Southern California- USC Institute of Urology

Mihir Desai, MD
University of Southern California- USC Institute of Urology

Inderbir Gill, MD
University of Southern California- USC Institute of Urology

Giovanni Cacciamani, MD
University of Southern California- USC Institute of Urology