[One clip too many]. / Ein Clip zu viel.

A patient with a Mainz II pouch due to muscle invasive bladder cancer presented to our urology department with de novo hydronephrosis on the left kidney after a regular colonoscopy. In the course of diagnostic workup, it was found that the neo-ostia were removed and clipped as a "polyp". Via rendezvous technique of antegrade ureterenoscopy and colonoscopy after nephrostomy placement urine outflow was successfully reconstituted by inserting a biliary stent into the left neo-ostium, which consolidated after stent removal as a permanent state.

Intracorporeal Versus Extracorporeal Neobladder After Robot-assisted Radical Cystectomy: Results From the International Robotic Cystectomy Consortium.

OBJECTIVE: To compare perioperative and oncologic outcomes of intracorporeal (ICNB) and extracorporeal neobladder (ECNB) following robot assisted radical cystectomy (RARC) from a multi-institutional, prospectively maintained database, the International Robotic Cystectomy Consortium (IRCC). METHODS: A retrospective review of IRCC database between 2003 and 2020 (3742 patients from 33 institutions across 14 countries) was performed (I-79606). The Cochran-Armitage trend test was used to assess utilization of ICNB over time. Multivariate logistic regression models were fit to evaluate variables associated with receiving ICNB, overall complications, high-grade complications, and readmissions after RARC. Kaplan Meier curves were used to depict recurrence-free, disease-specific, and overall survival. RESULTS: Four hundred eleven patients received neobladder, 64% underwent ICNB. ICNB utilization increased significantly over time (P <.01). Patients who received ICNB were readmitted and received neoadjuvant chemotherapy more frequently (36% vs 24%, P = .03, 35% vs 8%, P <.01, respectively). ICNB was associated with older age (OR 1.04, 95% CI 1.01-1.07, P = .001), receipt of neoadjuvant chemotherapy (OR 4.63, 95% CI 2.34-9.18, P <.01), and more recent RARC era (2016-2020) (OR 12.6, 95% CI 5.6-28.4, P <.01). On multivariate analysis, ICNB (OR 5.43, 95% CI 2.34-12.58, P <.01), positive surgical margin (OR 4.88, 95% CI 1.29-18.42, P = .019), longer operative times (OR 1.26, 95% CI 1.00-1.58, P = .048), and institutional annual RARC volume (OR 1.09, 95% CI 1.05-1.12, P <.01) were associated with readmissions. CONCLUSION: Utilization of ICNB increased significantly over time. Patients who underwent RARC and ICNB had shorter hospital stays and fewer 30-d reoperations but were readmitted more frequently compared to those who underwent ECNB.

Guar bean in urinary cytology: a morphologic pitfall.

INTRODUCTION: Various types of contaminants can be encountered in cytologic specimens. This study describes a vegetable material that we encountered in ileal conduit urine specimens. We aim to describe the cytomorphology and the source of origin of this vegetable material. MATERIAL AND METHODS: The cytology database for the past 5 years (January 2015-April 2020) was searched for ileal conduit urine cytology specimens with a reported vegetable contaminant. The details of the ostomy procedure and device used were recorded. Histologic sections were prepared from the ostomy devices as well as from guar beans and seeds. RESULTS: A total of 17 urinary specimens from 8 patients were identified that showed the presence of a vegetable contaminant. All the patients were using Coloplast (Minneapolis, MN) SenSura Mio ostomy device. The urine cytology showed presence of polygonal thick-walled cells with a dark brown/orange core with irregular outlines. Similar cells were also seen in the histologic sections prepared from the ostomy adhesive and the guar seed and bean. CONCLUSIONS: Guar gum is a naturally occurring hydrocolloid that is used in ostomy wafer adhesives. Correct identification and familiarity with the cytomorphology of the guar cells in samples of ileal conduit urine is essential to avoid a potential diagnostic pitfall when evaluating urine cytology specimens from these diversion specimens.

The mystery of the ureteric stent in the lumen of the terminal ileum.

A 65-year-old comorbid female patient presented to our urology department with a history of multiple interventions to treat severe overactive bladder symptoms. She had a history of clam ileocystoplasty, which was then converted to an ileal conduit due to failure to resolve her symptoms. She subsequently developed multiple complications, most significantly ureteroileal stenosis, managed with bilateral ureteric stents. She later decided on bilateral nephrostomies and subsequent antegrade stent insertion. At follow-up, the proximal end of the left stent remained within the kidney and the distal end was free within the abdominal cavity. There was further migration of the stent in its entirety into the lumen of the terminal ileum on subsequent imaging. She denied any significant gastrointestinal symptoms, signs or peritonitis. Consideration was made for the endoscopic removal of the stent by the gastrointestinal team; however, the patient refused any further procedures preferring to be monitored.

Comparison of Removing Double-J Stent With and Without Cystoscopy in Kidney Transplant Patients: A Randomized Clinical Trial.

PURPOSE: The ureteric stent can be attached to the Foley catheter in kidney transplantation to exclude cystoscopy for its removal. It is rarely practiced in renal transplantation. There has been no randomized trial to evaluate the outcome of this procedure on major urologic complications. MATERIALS AND METHODS: One hundred sixty-three kidney transplant patients were randomized into an intervention group in which the stent was attached to the Foley catheter and removed together and a control group in which stent was removed by cystoscopy. In both groups, stents were removed around the 8th post-operative day. RESULTS: From March 2016 to June 2017, out of 234 kidney transplants performed in our center, one hundred Sixty-three (69.6%) patients met the study inclusion criteria.  91patients (55.8%) were allocated to the intervention group. Mean days before JJ removal for intervention and control groups ("per-protocol" group) were 8.08 ± 1.52 and 8.57 ± 1.58, respectively (P = .09). There was no difference between groups regarding major urologic complications (P = .679). Visual analog scale pain scores were significantly higher in the control group (p = .001). The procedure reduced 63-120 USD from the cost of operation in the intervention group. CONCLUSION: In selected kidney transplant patients, attaching stent to the Foley catheter and removing both of them early may be a safe maneuver regarding major urological complications, reduces pain, and eliminates the cost of cystoscopy.

Internal double-J stent was associated with a lower incidence of ureteroileal anastomosis stricture than external ureteral catheter for patients undergoing radical cystectomy and orthotopic neobladder: A systematic review and meta-analysis.

OBJECTIVE: Proper techniques used in procedures might play an important role in reducing ureteroileal anastomosis stricture (UIAS) for patients undergoing orthotopic neobladder. The present study was to evaluate the efficacy of internal double-J stent versus external ureteral catheter on UIAS for patients undergoing radical cystectomy and orthotopic neobladder. METHODS: A comprehensive search of the literature referring to the topic was performed on 10th January 2019 in PubMed, EMBASE and Google Scholar, by using key words as radical cystectomy, orthotopic neobladder, stricture, stenosis. The Cochrane Collaboration's RevMan 5.3 software was employed for data analysis. The incidence of UIAS was evaluated as primary outcome. RESULTS: Five studies were included eventually. The incidence of UIAS was lower in the group of internal double-J stent than that in the group of external ureteral catheter (odds ratio [OR], 0.49; 95% CI, 0.25-0.97; p = 0.04) with a low heterogeneity (I2 = 0%). Besides, internal double-J stent group had a trend of a shorter length of stay than external ureteral catheter group. CONCLUSIONS: Based on the present meta-analysis, internal double-J stent placement was associated with a lower incidence of UIAS than external ureteral catheter for patients undergoing orthotopic neobladder. In addition, a trend of a shorter hospital stay was also detected, thus, internal double-J stent placement may be favored in the view of the enhanced recovery after surgery (ERAS).

Iliac-Ileal Conduit Fistula.

One of the possible complications of chronic ureteral stenting is an artery-urinary tract fistula, although it is very rare. If it occurs, it is an emergency that needs surgery because of hemorrhage. We describe a case of an iliac-ileal conduit fistula, which is extremely rare, that was successfully treated by endovascular stent grafting.

Safety and Effectiveness of Externalized Ureteral Catheter in Tubeless Percutaneous Nephrolithotomy.

PURPOSE: To review the safety and effectiveness of tubeless percutaneous nephrolithotomy (PCNL) with an externalized ureteral catheter (EUC) compared with standard PCNL with nephrostomy tube and tubeless PCNL with double-J (DJ) stent following uncomplicated PCNL and the absence of residual stones. MATERIALS AND METHODS: Patients with kidney stones who underwent uncomplicated PCNL between January 2000 to December 2017 and had no residual stones were retrospectively evaluated. The 766 patients were divided into standard PCNL with nephrostomy tube (group 1; 350 patients), tubeless PCNL with DJ stent (group 2; 189 patients), and tubeless PCNL with EUC (group 3; 227 patients). Demographic characteristics, stone-related factors, perioperative and postoperative parameters were analyzed. RESULTS: Demographic and stone-related characteristics were comparable. The differences in the mean operative time and complication rates were not significant. Postoperative hospitalization period was shorter in group 3 (3.19 ± 2.2 days) compared with group 1 (4.12 ± 2.4 days; p < .001) but not to that of group 2 (3.44 ± 2.8 days; p = .680). Postoperative pain score was lower in group 3 (3.24 ± 1.1) compared with both group 1 (6.36 ± 1.7; p < .001) and group 2 (4.85 ± 1.1; p < .001). Urine leakage complication was lower in group 3 (0.4%) compared with group 1 (2.9%, p = .038) but not to that of group 2 (0.5%; p = .897). CONCLUSIONS: Tubeless PCNL is effective and safe for uncomplicated PCNL in the absence of residual stones. Tubeless PCNL with EUC is associated with decreased pain, hospitalization time, and urine leakage compared with standard PCNL. However, it is only associated with decreased pain when compared with tubeless PCNL with DJ stent.

Comparison of Postradical Cystectomy Ileus Rates Using GIA-80 Versus GIA-60 Intestinal Stapler Device.

OBJECTIVE: To assess the impact on recovery of bowel function using an 80 mm versus 60 mm gastrointestinal anastomosis (GIA) stapler following radical cystectomy and urinary diversion (RC/UD) for bladder cancer. METHODS: We identified 696 patients using a prospectively maintained RC/UD database from January 2006 to November 2010. Two nonrandomized consecutive cohorts were compared. Patients between January 2006- and December 2007 (n = 180) were treated using a 60 mm GIA stapler, and 331 patients between January 2008 and December 2010 were subject to an 80 mm GIA stapler. All patients were treated on the same standardized postoperative recovery pathway. After accounting for baseline patient and perioperative characteristics, using a multivariable logistic regression model, we directly compared rates of postoperative ileus using a standardized definition. RESULTS: Of 511 evaluable patients, ileus was observed in 32% (57/180) for 60 mm GIA versus 33% (110/331) for the 80 mm GIA. Preoperative renal function, age, gender, body mass index, and type of diversion were comparable between cohorts. On multivariate analysis, stapler size was not significantly associated with the development of ileus (GIA-60 vs GIA-80: OR 1.11; 95% CI 0.75, 1.66; P = .6). Positive fluid balance was associated with an increased risk (P = .019) and female sex a decreased risk (P = .008) of developing ileus compared to patients with negative fluid balance. CONCLUSION: The size of the intestinal bowel anastomosis (GIA 80 mm vs 60 mm) does not independently impact the time to bowel recovery following RC/UD.

Transperineal Approach for Intracorporeal Ileal Conduit Urinary Diversion Using a Purpose-built Single-port Robotic System: Step-by-step.

INTRODUCTION: To describe a step-by-step technique for single-port transperineal intracorporeal ileal conduit urinary diversion using a purpose-built robotic platform. TECHNICAL CONSIDERATIONS: In one male cadaver, the da Vinci SP1098 surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used to perform intracorporeal ileal conduit urinary diversion by a transperineal approach after radical cystoprostatectomy and bilateral pelvic lymph node dissection. The surgery was completed through a 2.5-cm perineal incision through which a GelPOINT Mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) and a dedicated 25-mm multichannel port accommodating a 12-mm × 10-mm oval articulating robotic camera, three 6-mm double-jointed articulating robotic instruments, and a 6-mm accessory laparoscopic instrument were placed. Moreover, at the planned level of the cutaneostomy, a 12-mm port to accommodate the Endo-GIA was placed. The primary outcomes were the technical feasibility, the operative time, and the record of eventual procedural complications. The intervention was successfully completed without any conversion or need for additional ports. The total operative time was 200 minutes. Operative time for urinary diversion was 90 minutes. CONCLUSION: We demonstrated the feasibility of single-port transperineal intracorporeal ileal conduit urinary diversion using the SP1098 purpose-built robotic platform. Limitations include the preclinical setting. The applicability in the clinical model is awaited to be tested after the platform will be commercially available.

Role of bowel suspension technique to prevent early intestinal obstruction after radical cystectomy with ileal orthotopic neobladder: A retrospective cohort study.

OBJECTIVE: We investigate the impact of the bowel suspension technique (BST) on paralytic ileus and early intestinal obstruction (≤60days) after radical cystectomy (RC) with ileal orthotopic neobladder (IONB). METHODS: We retrospectively reviewed 310 patients who underwent RC with IONB for bladder cancer between 2001 and 2017. After forming the Studer IONB, ileal continuity was restored by side-to-side stapled anastomosis. Then, we suspended stapled anastomotic portion of bowel on the posterior peritoneum not to fall into the pelvic cavity. The clinicopathologic characteristics of patients were examined and the onset of paralytic ileus and early intestinal obstruction were identified. Logistic regression analysis was used to identify predictors associated with paralytic ileus and early intestinal obstruction. RESULTS: Of the 310 total patients, paralytic ileus and early intestinal obstruction were identified in 100 (32.3%) and 15 (4.8%), respectively. When patients were divided into two groups (BST [-] vs. BST [+]), the rates of paralytic ileus were not significantly different (64/205[31.2%] vs. 36/105[34.3%], P = 0.585). However, early intestinal obstruction that required surgical treatment was significantly decreased (14/205[6.8%] vs. 1/105[1.0%], P = 0.024). On multivariate analysis, older age was commonly associated with paralytic ileus and early intestinal obstruction (P = 0.008 and P = 0.016). BST was inversely associated with early intestinal obstruction (95% CI: 0.01-0.85, P = 0.034), but not related to paralytic ileus. CONCLUSION: BST significantly reduced early intestinal obstruction without increasing paralytic ileus after RC with IONB. BST could be used as useful technique to reduce severe bowel complications.

Contemporary techniques and outcomes of robotic cystectomy and intracorporeal urinary diversions.

PURPOSE OF REVIEW: Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is being increasingly performed worldwide. This review summarizes recent technical developments and outcome data for RARC with ICUD. RECENT FINDINGS: With the recent description of intracorporeal continent cutaneous diversion, all classes of urinary diversion can presently be performed totally intracorporeally. The summary of our seven cases of intracorporeal continent cutaneous diversion in this article brings the number of reported cases in the literature to 17. Additional recent advancements in ICUD focus on novel technical descriptions and outcome data. Several intracorporeal orthotopic ileal neobladder techniques have been described with intermediate perioperative outcomes. There is some rationale for reduced overall, wound, gastrointestinal and genitourinary complications with ICUD. SUMMARY: RARC with intracorporeal diversion is a feasible option for patients with bladder cancer. Prospective and randomized outcome data are needed to better characterize the benefit of ICUD in patients following radical cystectomy.

[Migration speed of uropathogens : Determination in the ureteral splint in a practice-like in vitro model]. / Wanderungsgeschwindigkeit von uropathogenen Erregern : Bestimmung im Ureterkatheter im praxisnahen In-vitro-Modell.

BACKGROUND: A urostomy with an ileum conduit or a skin fistula leads to a high infection risk for the kidneys and the ureter of the patient. Therefore, the prevention of retrograde colonization of the artificial drain (splint) with e. g. contaminated urine is the most important objective of infection prevention measurements. We performed an in vitro experiment to determine the migration speed of clinically relevant bacteria in a commercially available splint catheter system. METHODS: The migration speed of bacteria in commonly used splint catheters was determined in a practice-like in vitro model. Two storage vessels were connected with splints. The second vessel contained a bacterial suspension of the test bacteria Escherichia coli, Proteus mirabilis, and Staphylococcus aureus in artificial urine. The two vessels were incubated at 36 °C for 24-72 h. The microbial count in the catheters was determined after each experiment to investigate the migration distance. RESULTS: The average migration speed was 0.63 cm/h for E. coli, 0.80 cm/h for S. aureus, and 0.94 cm/h for P. aeruginosa. This results in a colonization distance of approximately 80 cm in 3 days. CONCLUSION: If the system, e. g., the stoma pouch is contaminated, it can be expected that during the common application time of a splint of 10-14 days, the complete splint will be contaminated due to the high bacteria migration speed. Consequently there is a high infection risk for kidneys and ureters. A return stop feature in the stoma pouch should minimize this risk. However, it is of upmost importance to not applying the splint through the return stop to prevent any contact with potentially contaminated urine.

Infectious complications associated with the use of temporary prostatic urethral stents in patients with benign prostatic hyperplasia.

INTRODUCTION: To examine the infectious outcomes after the insertion of the temporary prostatic urethral stent (TPUS) in benign prostatic hyperplasia (BPH) patients. MATERIAL AND METHODS: Between November 2007 and September 2012, ninety TPUS were used in 33 patients with BPH at our institution. All patients had negative urine cultures prior to the first stent insertion. TPUS were sent for cultures at time of removal or exchange. Stents were removed at the time of definite surgical intervention, at 4-6 weeks, or when patients elected another course of treatment. Colonization was defined as asymptomatic positive stent culture. Infection was defined as symptomatic positive stent culture requiring treatment. Infection and colonization rates are reported. Logistic regression was used to examine the predictors of infection at any point. Predictors examined were age, body mass index, history of prostate cancer, diabetes mellitus, hyperlipidemia, coronary artery disease, neurologic disorder, erectile dysfunction and the sequence of stent placement. RESULTS: The majority of the subjects, 72% (24/33) had 1-2 stents, 9.0% (3/33) had 3-4 stents, 6.0% (2/33) had 5-6 stents, and 12% (4/33) of patients had more than 6 stents. From the 69 available culture results, the symptomatic infection rate was 16% (11/69) (95% CI: 8.2%-26.7%). The colonization rate was 58% (40/69) (95% CI: 45.5%-69.7%). None of the predictors examined were identified as a predictor of infection. There was no colonization detected when stents were removed in the first 20 days. CONCLUSION: Infection rates with TPUS in BPH patients are acceptable and early removal may prevent colonization.

[Bladder augmentation and urinary diversion in children and adolescents]. / Blasenaugmentation und -ersatz bei Kindern und Jugendlichen.

BACKGROUND: In children and adolescents, the indication for continent urinary diversion or bladder augmentation is rare. Today, for most patients with a neurogenic bladder, conservative treatment (clean intermittent catheterization [CIC] and pharmacotherapy) is the method of choice, while for patients with bladder exstrophy-epispadias complex (BEEC), primary reconstruction is recommended. Only after failure of conservative treatment or primary reconstruction should bladder augmentation or urinary diversion be considered. Other rare indications include patients with malignant tumor involving the lower urinary tract (e. g., rhabdomyosarcoma). DISCUSSION: In patients with a hyperreflexive, small capacity, and/or low compliance bladder with a normal upper urinary tract, bladder augmentation (bowel segments/ureter) is an option. For those unable to perform CIC via the urethra, a continent cutaneous stoma should be offered. In patients with irreparable sphincter defects and normal renal function, a continent cutaneous diversion is an option and in those with a competent anal sphincter the rectosigmoid pouch can be offered. CONCLUSION: In this review, surgical options with their advantages and disadvantages are discussed.

[Urinary diversion with continent umbilical stoma: Which techniques are suitable for which patients?]. / Harnableitung mit kontinentem Nabelstoma: Welche Patienten und welche Techniken sind geeignet?

BACKGROUND: Continent cutaneous diversions play a secondary role even in many centers for urinary diversion. The result is that knowledge about, indications and operation technique does not exist in many clinics. RESULTS: The general complication rates of the various forms of urinary diversion are not significantly different. There is no quality of life study showing a significant advantage for either form of urinary diversion. The functional results of neobladders in females with up to 70% hypercontinence are worse than in men, resulting in 2.4-fold more continent urinary diversions in men compared to women. The complication rates of the various forms of continent cutaneous pouches are different. CONCLUSION: Continent cutaneous pouches are an option for all patients with non-existing or functionally unusable urethra and as primary indication in all women with bladder cancer, consulting in very good quality of life and perfect body image. Age (<75 years), manual skills and psychological ability are selection criteria. As far as the results and complication rates are concerned the ileocecal pouch with an appendix umbilical stoma is the best option. In cases of non-existing appendix, alternatives are a neoappendix, serosal lined tapered ileum and ileal invagination nipple.

Two-Port Approach Compared to Standard Laparoscopic Radical Cystectomy.

BACKGROUND AND OBJECTIVES: Two-port laparoscopic radical cystectomy (LRC) using a multichannel platform through the umbilicus and one additional 10-mm in the right iliac fossa has been recently described. We compare the perioperative and early results of this technique with a cohort of patients simultaneously treated in our institution with four-port LRC and a 7 to 10 cm midline incision. MATERIALS AND METHODS: A matched-pair study comparing perioperative outcomes, postoperative visual analog pain scale (VAPS), and morbidity of two-port (n=30) and four-port (n=30) LRC. Preoperative and perioperative data analyzed and compared included demographics, type of urinary diversion, operative time, blood loss, transfusion requirements, decrease in serum hemoglobin, operative complications, analgesic needs, length of stay, number of nodes removed, and other pathologic information. Complications in the first 3 months were evaluated according to the Clavien-Dindo classification. RESULTS: There was no significant difference between the two groups regarding patient age, gender, body-mass index, American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, tumor stage, percent of positive nodes, positive margin rate, number of nodes retrieved, proportion of neobladders, secondary carcinoma in situ, incidental prostate cancer, or need of systemic chemotherapy. Median operative time was 20 minutes higher in the two-port procedure, but this difference was not statistically significant (p=0.2). Estimated blood loss and differential hemoglobin change were lower in the two-port technique (each p=0.03), but no difference was detected regarding the intraoperative or postoperative transfusion rate. Length of hospital stay was also equivalent. Differences were not observed either in the number or severity of complications. VAPS at days 2, 3, and 5 was significantly lower for two-port LRC (p<0.01). CONCLUSIONS: Two-port LRC performed through an umbilical platform and an accessory 10-mm port seems technically equivalent to standard four-port LRC. Perioperative outcomes regarding hospital stay and complications are tantamount. Diminished blood loss and, especially, less postoperative pain favor the reduced-port approach in this complex urologic minimally invasive procedure.

[Continent urinary diversion following anterior exenteration]. / Kontinente Harnableitung nach vorderer Exenteration.

BACKGROUND: Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir). RESULTS: Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field. CONCLUSION: Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).

Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial.

BACKGROUND: Open radical cystectomy (ORC) and urinary diversion in patients with bladder cancer (BCa) are associated with significant perioperative complication risk. OBJECTIVE: To compare perioperative complications between robot-assisted radical cystectomy (RARC) and ORC techniques. DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized controlled trial was conducted during 2010 and 2013 in BCa patients scheduled for definitive treatment by radical cystectomy (RC), pelvic lymph node dissection (PLND), and urinary diversion. Patients were randomized to ORC/PLND or RARC/PLND, both with open urinary diversion. Patients were followed for 90 d postoperatively. INTERVENTION: Standard ORC or RARC with PLND; all urinary diversions were performed via an open approach. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcomes were overall 90-d grade 2-5 complications defined by a modified Clavien system. Secondary outcomes included comparison of high-grade complications, estimated blood loss, operative time, pathologic outcomes, 3- and 6-mo patient-reported quality-of-life (QOL) outcomes, and total operative room and inpatient costs. Differences in binary outcomes were assessed with the chi-square test, with differences in continuous outcomes assessed by analysis of covariance with randomization group as covariate and, for QOL end points, baseline score. RESULTS AND LIMITATIONS: The trial enrolled 124 patients, of whom 118 were randomized and underwent RC/PLND. Sixty were randomized to RARC and 58 to ORC. At 90 d, grade 2-5 complications were observed in 62% and 66% of RARC and ORC patients, respectively (95% confidence interval for difference, -21% to -13%; p=0.7). The similar rates of grade 2-5 complications at our mandated interim analysis met futility criteria; thus, early closure of the trial occurred. The RARC group had lower mean intraoperative blood loss (p=0.027) but significantly longer operative time than the ORC group (p<0.001). Pathologic variables including positive surgical margins and lymph node yields were similar. Mean hospital stay was 8 d in both arms (standard deviation, 3 and 5 d, respectively; p=0.5). Three- and 6-mo QOL outcomes were similar between arms. Cost analysis demonstrated an advantage to ORC compared with RARC. A limitation is the setting at a single high-volume, referral center; our findings may not be generalizable to all settings. CONCLUSIONS: This trial failed to identify a large advantage for robot-assisted techniques over standard open surgery for patients undergoing RC/PLND and urinary diversion. Similar 90-d complication rates, hospital stay, pathologic outcomes, and 3- and 6-mo QOL outcomes were observed regardless of surgical technique. PATIENT SUMMARY: Of 118 patients with bladder cancer who underwent radical cystectomy, pelvic lymph node dissection, and urinary diversion, half were randomized to open surgery and half to robot-assisted laparoscopic surgery. We compared the rate of complications within 90 d after surgery for the open group versus the robotic group and found no significant difference between the two groups. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01076387, www.clinicaltrials.gov.