The impact of early versus delayed ureteral ligation on renal function after robot-assisted radical cystectomy

Introduction: During robot-assisted radical cystectomy (RARC), each ureter is ligated and transected to complete the surgery. However, the timing of ureteral ligation-whether early or late during surgery-varies in real-world practice. We hypothesize that early ligation of the ureter may cause a degree of renal distress. This case-control study compared perioperative and functional outcomes of early vs. late ureteral ligation during RARC. Materials and methods: Data were obtained from a prospectively-maintained institutional database covering January 2020-May 2024. Only patients who received intracorporeal ileal conduit or neobladder were considered. The population was divided into two groups based on the timing of ureteral ligation: early ureteral ligation upon isolation (EL) (before January 2021) vs. late ligation just before completing the cystectomy (LL) (since January 2021). Baseline and perioperative data were analyzed. Cox and logistic regression analyses evaluated the impact of covariates on renal function and complications. Results: 55 patients were included in the analysis (18 ileal conduit; 37 neobladder). Twenty-five patients underwent EL, while 30 had LL. Baseline characteristics were comparable, except for a higher BMI and greater likelihood of neoadjuvant chemotherapy in the LL group. Operative time was longer in EL group (p = 0.007). Postoperative AKI occurred in 20 % of patients, with no significant difference (p = 0.9). However, EL was associated with higher overall and major complication rate (p = 0.02). At median follow-up of 16 months, eGFR was significantly lower in EL group (p = 0.003). Cox regression analysis showed EL significantly associated with increased probability of >= 25 % eGFR reduction and eGFR <60 ml/min (HR 10.3 and 7.3, p < 0.04). Conclusions: While the timing of ureteral ligation does not impact immediate surgical outcomes, our experience suggests that early ureteral ligation might be associated with an increased risk of renal function decline after RARC.