Stesura Seveso Archivio Italiano di Urologia e Andrologia 2022; 94, 2150 ORIGINAL PAPER No conflict of interest declared. muscle-invasive bladder cancer and a valid option for selected patients with high-grade non-muscle invasive bladder cancer (3, 4). Even with improvements in surgical techniques and peri- operative care, RC is a technically challenging operation and is associated with comparatively high perioperative morbidity and mortality (5, 6). The incidence of compli- cations after the surgery has been reported to be in the range of 11-70% and late morbidity in contemporary series has been 19 to 58% (6, 7). It has been shown that complications after RC and urinary diversion severely affect the patients’ quality of life (8). Therefore, improv- ing surgical techniques to reduce postoperative complica- tions is required. In this study, we investigated the effect of ureteroileal anastomosis retroperitonealization on peri- operative complications of radical cystectomy with ileal conduit urinary diversion. PATIENTS AND METHODS We retrospectively reviewed medical data of all patients who underwent RC between 2016 and 2021 at two high- volume referral urology centers. Three different expert surgeons had performed the operations. Our inclusion criteria were 1. RC was performed to man- age bladder urothelial carcinoma; 2. The ileal conduit was performed as urinary diversion; 3. The ureteroileal anasto- mosis was performed according to Wallace 1 technique. Our exclusion criteria were 1. Patients with anatomical single kidney and ureter; 2. Those with incomplete med- ical charts which did not provide appropriate data about all of the variables that were investigated in this study. Patients who met all of the inclusion criteria and lacked the exclusion criteria were entered into the study. We collected data regarding patients’ characteristics and all of the postoperative complications within 90 days of surgery. Any deviations from the normal postoperative course were considered complications (9). Perioperative mortality was determined as death from any cause within 90 days of operation. Procedure Antiplatelet and anticoagulant medications were stopped at least 1 week before the operation. All patients received mechanical bowel preparation. We utilized elastic com- Background: Radical cystectomy (RC) has been considered the standard management of muscle-invasive bladder cancer. Despite the improvements in surgical techniques and perioperative care, RC is still associated with high perioperative morbidity and mortality. Objective: This study aims to evaluate the effect of retroperi- tonealization of ureteroileal anastomosis on perioperative com- plications of RC with ileal conduit urinary diversion. Patients and methods: This is a retrospective cohort study. We reviewed medical charts of 876 patients who underwent RC between 2016 and 2021. Based on the inclusion and exclusion criteria, 748 patients entered the study. According to retroperi- tonealization of the ureteroileal anastomosis, patients were cate- gorized into two groups (group I without retroperitonealization of the ureteroileal anastomosis and group II with retroperi- tonealization of the ureteroileal anastomosis). Patients’ charac- teristics and occurrences of any complications and high-grade complications were compared between these groups. Results: In comparing the complication categories between the two groups, fewer patients in group II suffered from gastroin- testinal, urinary, and cardiac events (p values were 0.018, 0.021, and 0.013, respectively). Moreover, fewer patients in group II experienced any complications and high-grade compli- cations (p values were < 0.001 and < 0.001, respectively). The length of hospital stay was also significantly shorter in group II (p < 0.001). Conclusions: RC is associated with comparatively high perioper- ative morbidity and mortality. In the present study, 61% of the patients experienced at least one complication postoperatively. Retroperitonealization of the ureterointestinal anastomosis may decrease perioperative adverse events of RC with ileal conduit urinary diversion. KEY WORDS: Radical cystectomy; Complication; Retroperitonealization. Submitted 6 May 2022; Accepted 19 May 2022 INTRODUCTION Bladder cancer is a global disease, with 573.278 incident cases and 212.536 deaths in 2020 worldwide (1). About 25% of patients with bladder cancer are diagnosed with muscle-invasive bladder cancer (2). Since the early 1960s, radical cystectomy (RC) and pelvic lymphadenec- tomy have been considered the standard management of The effect of retroperitonealization of ureteroileal anastomosis on perioperative complications of radical cystectomy with ileal conduit urinary diversion Ali Ariafar, Mehdi Salehipour, Shahriar Zeyghami, Mehran Rezaei Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran. DOI: 10.4081/aiua.2022.2.150 Summary 151Archivio Italiano di Urologia e Andrologia 2022; 94, 2 Retroperitonealization of ureteroileal anastomosis pressive stocking as mechanical prophylaxis for deep vein thrombosis. Ceftriaxone 1 gr, metronidazole 500 mg, and pantoprazole 40 mg were administered intravenously when anesthesia was initiated and maintained for the time of hospital admission postoperatively. The nasogas- tric tube was not inserted routinely. RCs were performed according to the procedure suggest- ed by the International Consultation on Bladder Cancer (10). Lymph node dissection included the removal of all lymphatic tissues around the external iliac and internal iliac arteries and from the obturator region bilaterally. After completion of RC and lymph node dissection, a seg- ment of 10-20 cm of ileum approximately 20 cm proximal to the ileocecal valve was isolated. The stapled ileoileal anastomosis was performed. The mesentery window was closed with interrupted sutures, and the conduit was flushed with saline and povidone-iodine until the irrigant is clear. Afterward, ureters were conjoined, with the left ureter transposed to the right side of the pelvis through a tunnel prepared at the base of the sigmoid mesentery in front of the common iliac vessels. Tension-free ureteroileal anastomosis was accomplished according to Wallace 1 technique (11) with 5-0 polydioxanone sutures and was stented intraoperatively for at least 30 days. In completing cutaneous rosebud stoma formation, in patients who were operated on from 2016 to mid-2018, we only brought the segment directly to the anterior abdominal wall (group I). In patients who were operated on from then to 2021, we placed a peritoneal flap over the ureteroileal anastomosis in that stage of surgery. The flap was sutured to the con- duit and the lateral peritoneum so that the ureteroileal anastomosis was completely covered by the peritoneum and effectively retroperitonealized (group II). We per- formed this surgical technique with the purpose of sepa- rating the ureterointestinal anastomosis from the peri- toneal cavity and decreasing intraperitoneal urine extrava- sation. Before wound closure, we placed an 18-24fr drain tube through the abdominal wall and a 24fr Foley catheter via the urethra into the pelvic cavity. Postoperatively, patients were managed in the intensive care unit. Subcutaneous daily administration of low- molecular-weight heparin, or every 8 hours unfractionat- ed heparin in patients with renal failure, was started 24 hours after surgery and maintained for at least 4 weeks postoperatively. Further postoperative management was continued in the urology ward according to our standard- ized clinical care pathways for cystectomy. A day after sur- gery, mobilization was initiated as soon as the patient could be ambulated. On the third postoperative day, if the patient had bowel movements, he/she was allowed to take sips of water. If the patient tolerated drinking water, the diet advanced gradually to a soft diet. We started a regu- lar diet two weeks postoperatively. The amount of drained fluid out of the Foley catheter and the drain tube was measured continuously. If the creatinine concentration of drained fluid was 30% more than the concomitant serum creatinine concentration, the patient is presumed to have urine leakage. More diagnostic studies including abdominopelvic sonog- raphy, supine and upright abdominopelvic X-rays, and intravenous contrast-enhanced abdominopelvic CT scan were requested in case of persistent postoperative azotemia, sepsis or symptoms and signs of peritonitis to rule out urinary extravasation or other possible intra- abdominal complications. Statistical analysis Mean ± standard deviation and range of quantitative vari- ables and frequencies of the qualitative variables are pre- sented. According to the characteristics of the variables, the Mann-Whitney U test or chi-square test were used to compare the two groups. P-value < 0.05 was considered Table 1. Patients’ characteristics. Total Group I Group II P-value* n = 748 n = 362 (48.4%) n = 386 (51.6%) Age (years), mean ± SD (range) 64.97 ± 7.31 64.82 ± 6.88 65.11 ± 7.70 0.527 (44-84) (49-83) (44-84) ≥ 70 years old, n (%) 216 (28.9) 97 (26.8) 119 (30.8) 0.224 Sex 0.803 Male, n (%) 586 (78.3) 285 (78.7) 301 (78.0) Female, n (%) 162 (21.7) 77 (21.3) 85 (22.0) Body mass index (kg/m2), 24.37 ± 4.92 24.42 ± 4.61 24.33 ± 5.19 0.435 mean ± SD (range) (16.99-34.96) (17.09-34.96) (16.99-34.83) Current smoking, n (%) 470 (62.8) 222 (61.3) 240 (62.2) 0.493 DM, n (%) 246 (32.9) 124 (34.3) 122 (31.6) 0.574 Cerebrovascular comorbidities, n (%) 40 (5.3) 19 (5.2) 23 (6.0) 0.673 Cardiovascular comorbidities, n (%) 185 (24.7) 113 (31.2) 112 (29.0) 0.512 Pulmonary comorbidities, n (%) 26 (3.5) 11 (3.0) 15 (3.9) 0.527 Routine dialysis, n (%) 50 (6.7) 12 (3.3) 18 (4.7) 0.348 Previous abdominopelvic surgery, n (%) 137 (18.3) 72 (19.9) 65 (16.8) 0.281 Neoadjuvant chemotherapy, n (%) 245 (32.8) 113 (31.2) 132 (34.2) 0.385 Poor (< 4 MET) functional capacity, n (%) 154 (20.6) 82 (22.7) 72 (18.7) 0.176 ASA score 0.443 1, n (%) 78 (10.4) 36 (9.9) 42 (10.9) 2, n (%) 511 (68.3) 242 (66.9) 269 (69.7) 3, n (%) 159 (21.3) 84 (23.2) 75 (19.4) Serum creatinine (mg/dl), 1.86 ± 1.29 1.48 ± 1.00 1.57 ± 1.1 0.329 mean ± SD (range) (0.8-8.1) (0.8-8.0) (0.7-8.0) Hemoglobin concentration (g/dl), 13.11 ± 1.78 13.10 ± 1.71 13.12 ± 1.85 0.708 mean ± SD (range) (7.1-18.5) (10.0-16.0) (7.1-18.5) Preoperative anemia, n (%) 323 (43.2) 156 (43.1) 167 (43.3) 0.963 NLR, mean ± SD (range) 5.80 ± 1.52 5.71 ± 1.56 5.78 ± 1.54 0.436 (2.10-8.99) (2.34-8.98) (2.10-8.99) Hypoalbuminemia, n (%) 297 (39.7) 149 (41.2) 172 (44.6) 0.348 Clinical T stage 0.466 1, n (%) 18 (2.4) 10 (2.8) 8 (2.1) 2, n (%) 569 (76.1) 282 (77.9) 287 (74.4) 3, n (%) 135 (18) 60 (16.6) 75 (19.4) 4, n (%) 26 (3.5) 10 (2.8) 16 (4.1) Operative time (min), 351.31 ± 99.93 351.33 ± 98.23 351.30 ± 101.63 0.918 mean ± SD (range) (180-560) (180-540) (180-560) Blood Loss (cc), 803.93 ± 386.10 825.03 ± 395.90 784.15 ± 376.11 0.141 mean ± SD (range) (200-5100) (200-5100) (210-4000) Intraoperative Blood Transfusion, n (%) 394 (52.7) 202 (55.8) 192 (49.7) 0.097 Surgeons 0.666 I, n (%) 255 (34.1) 118 (32.6) 137 (35.5) II, n (%) 273 (36.5) 137 (37.8) 136 (35.2) III, n (%) 220 (29.4) 107 (29.6) 113 (29.3) Group I without retroperitonealization of the ureteroileal anastomosis; group II with retroperitonealization of the ureteroileal anastomosis. * Group I vs II. MET: Metabolic equivalent; ASA: American Society of Anesthesiology; NLR: Neutrophil to lymphocyte ratio; Hypoalbuminemia: serum albumin concentration < 3.5 g/dl. Archivio Italiano di Urologia e Andrologia 2022; 94, 2 A. Ariafar, M. Salehipour, S. Zeyghami, M. Rezaei 152 as a significant level. Statistical analyses were performed using the IBM SPSS Statistics for Windows, version 24 (IBM Corp., Armonk, N.Y., USA). RESULTS Out of 876 RCs that were performed in five years, 748 patients did not have the exclusion criteria and met all of the inclusion criteria; consequently, enrolled in the study. Table 1 shows the summary of the patients’ characteris- tics. Men accounted for 586 (78.3%) of patients. The mean age at RC was 64.97 ± 7.315 years, the mean body mass index (BMI) was 24.37 ± 4.92 kg/m2, the mean operative time was 351.31 ± 99.93 minutes, and the mean estimated blood loss was 803.93 ± 386.1 ml. The average length of stay after RC was 7.66 ± 4.26 days. Five hundred ninety-nine complications were recorded in 456 (61%) patients within 90 days of surgery. To enhance the comparability among populations, we classified our complications using the modified Clavien grading system (9) and category grouping reported by Shabsigh et al. (12). In our study, the most common com- plication categories were gastrointestinal 147 (19.7%), wound-related 133 (17.8%), genitourinary 81 (10.8%), and infectious 78 (10.4%). Ileus 116 (15.5%), surgical site infection (SSI) 112 (15.0%), hydronephrosis 54 (7.2%), urine leakage 39 (5.2%), and urinary tract infec- tions 39 (5.2%) were the most frequent complications. Table 2 represents a comprehensive breakdown of our complications. The highest complication grade in each patient was Clavien grade I in 220 (29.4%), grade II in 114 (15.2%), grade III in 51 (6.8%), grade IV in 53 (7.1%), and grade V in 11 (1.5%) patients (Table 3). Eleven (1.5%) deaths were recorded within 90 days of surgery. No patient died intraoperatively. Five patients died from gastrointestinal events, three from infectious events (sepsis), two from cardiovascular events, and one from a cerebrovascular event. Group I and II consisted of 362 and 386 patients, respec- tively. Patients’ characteristics were not significantly dif- ferent between these groups. The number of patients who were operated on by each surgeon was not significantly different between the two groups (Table 1). Incidences of sepsis, wound dehiscence, renal failure, urine leakage, and myocardial infarction, were significantly lower in group II (p values were 0.001, 0.001, 0.047, < 0.001, and 0.044, respectively). In comparing the complication cate- gories between the two groups, fewer patients in group II suffered from gastrointestinal, urinary, and cardiac events (p values were 0.018, 0.021, and 0.013, respectively). Moreover, fewer patients in group II experienced any complications and high-grade complications (p values were < 0.001 and < 0.001, respectively). The length of hospital stay was also significantly shorter in group II (p < 0.001) (Table 2). DISCUSSION Despite recent advances in surgical techniques, RC is still highly morbid with complications occurring in up to two-thirds of patients within 90 days (6, 7, 13-17). Various factors have been related to post-RC complica- tions and prognosis. Maffezzini et al. have demonstrated that advanced age of more than 70 years and Charlson Comorbidity Index > 3 are associated with worse post-RC prognosis (18). It has been shown that in patients under- going RC, low serum albumin concentration is a signifi- Table 3. Highest Clavien complication grade in each patient. Highest Clavien complication grade Total n (%) Group I n (%) Group II n (%) I 220 (29.4) 98 (27.1) 122 (31.6) II 114 (15.2) 49 (13.5) 65 (16.8) III 51 (6.8) 40 (11.0) 11 (2.8) IV 53 (7.1) 47 (13.0) 6 (1.6) V 11 (1.5) 6 (1.7) 5 (1.3) Table 2. Summary of complication categories and types. Category Complications Total n (%) Group I n (%) Group II n (%) P-value* of patients of patients of patients Gastrointestinal 147 (19.7) 84 (23.2) 63 (16.3) 0.018 Postoperative ileus 116 (15.5) 63 (17.4) 53 (13.7) 0.166 Anastomotic bowel leakage 11 (1.5) 8 (2.2) 3 (0.8) 0.104 Gastrointestinal bleeding 10 (1.3) 6 (1.7) 4 (1.0) 0.460 Diarrhea 18 (2.4) 12 (3.3) 6 (1.6) 0.116 Infectious 78 (10.4) 43 (11.9) 35 (9.1) 0.209 FUO 16 (2.1) 7 (1.9) 9 (2.3) 0.707 UTI 39 (5.2) 15 (4.1) 24 (6.2) 0.202 Sepsis 28 (3.7) 22 (6.1) 6 (1.6) 0.001 Wound 133 (17.8) 70 (19.3) 63 (16.3) 0.281 SSI 112 (15.0) 53 (14.6) 59 (15.3) 0.805 Wound dehiscence 23 (3.1) 19 (5.2) 4 (1.0) 0.001 Genitourinary 81 (10.8) 49 (13.5) 32 (8.3) 0.021 Hydronephrosis 54 (7.2) 29 (8.0) 25 (6.5) 0.418 Renal failure 7 (0.9) 6 (1.7) 1 (0.3) 0.047 Urine leakage 39 (5.2) 30 (8.3) 9 (2.3) < 0.001 Cardiac 15 (2.0) 12 (3.3) 3 (0.8) 0.013 Arrhythmia 5 (0.7) 3 (0.8) 2 (0.5) 0.602 Myocardial infarction 10 (1.3) 8 (2.2) 2 (0.5) 0.044 Congestive heart failure 4 (0.5) 3 (0.8) 1 (0.3) 0.286 Pulmonary 22 (2.9) 13 (3.6) 9 (2.3) 0.308 Pneumonia 12 (1.6) 6 (1.7) 6 (1.6) 0.911 Pleural effusion 7 (0.9) 4 (1.1) 3 (0.8) 0.642 Lung edema 3 (0.4) 3 (0.8) 0 0.073 Bleeding 21 (2.8) 14 (3.9) 7 (1.8) 0.089 Anemia requiring transfusion 21 (2.8) 14 (3.9) 7 (1.8) 0.089 Thromboembolic 10 (1.3) 7 (1.9) 3 (0.8) 0.169 Deep venous thrombosis 10 (1.3) 7 (1.9) 3 (0.8) 0.169 Pulmonary embolism 3 (0.4) 2 (0.6) 1 (0.3) 0.526 Neurologic 10 (1.3) 6 (1.7) 4 (1.0) 0.460 Cerebrovascular event 5 (0.7) 4 (1.1) 1 (0.3) 0.156 Delirium 6 (0.8) 3 (0.8) 3 (0.8) 0.937 Surgical 7 (0.9) 5 (1.4) 2 (0.5) 0.221 Rectal injury 6 (0.8) 3 (0.8) 2 (0.5) 0.602 Obturator nerve injury 2 (0.3) 0 2 (0.5) 0.170 Miscellaneous 7 (0.9) 3 (0.8) 4 (1.0) 0.768 Death 11 (1.5) 6 (1.7) 5 (1.3) 0.681 All complications 456 (61) 246 (68.0) 210 (54.4) < 0.001 High-grade complications 115 (15.4) 93 (25.7) 22 (5.7) < 0.001 Hospital stay, 7.66 ± 4.26 8.54 ± 5.71 6.84 ± 1.78 < 0.001 mean ± SD (range) (5-73) (5-73) (5-18) Group I without retroperitonealization of the ureteroileal anastomosis; group II with retroperitonealization of the ureteroileal anastomosis. * Group I vs II. FUO: Fever of unknown origin; UTI: urinary tract infection; SSI: Surgical site infection. 153Archivio Italiano di Urologia e Andrologia 2022; 94, 2 Retroperitonealization of ureteroileal anastomosis cant predictor of mortality and serious adverse events (19). Other factors that are associated with adverse out- comes after RC include sarcopenia, an increased BMI, female gender, prior abdominopelvic surgery, extravesi- cal disease, and prior pelvic radiotherapy (20-22). Although the majority of the post-RC complications are minor, it has been reported that up to 20% of patients will experience a major complication (23, 24). Multiple studies reported that more common complication cate- gories are gastrointestinal, infectious, wound-related, and genitourinary (12, 25). In our study, five hundred nine- ty-nine complications were recorded in 456 (61%) patients within 90 days of surgery. 15.4% of our patients experienced major (≥ grade III) complications. Our observation was comparable with the study by Shabsigh et al. (12) reporting that the overall complication rate was 64% and the major complication rate was 13%. Hautman et al. (25) also reported complications in RC and ileal neobladder cases using the same standards. In their study, 58% of the patients experienced at least one com- plication within 90 days of surgery. In our cohort, the most common complication categories were gastrointesti- nal, wound-related, genitourinary, and infectious. Ileus, SSI, hydronephrosis, urine leakage, and urinary tract infections were the most frequent complications. This distribution was similar to the results obtained from other studies (12, 25). Retroperitonealization of the ureteroileal anastomosis during RC is mainly performed to prevent the herniation of the small bowel lateral to the conduit and the effect of performing this maneuver on perioperative complications has not been thoroughly studied. In this concept, Soleimani et al. compared the postoperative complications of transperitoneal vs extraperitoneal RC. They reported that early gastrointestinal complications including oral intake intolerance, ileus, intestinal obstruction, and anas- tomosis leakage were lower in the extraperitoneal RC group. Also in this group, the rate of postoperative urine leakage and wound-related complications were lower (26). Kulkarni et al. investigated the transperitoneal and extraperitoneal RC complications and reported that the rates of gastrointestinal complications, reoperation, and intestinal obstruction were significantly lower in the extraperitoneal approach. They noted that extraperi- tonealization of the neobladder or conduit may make postoperative urinary leakages amenable to less invasive managements such as simple extraperitoneal drainage or transurethral catheterization alone (27). In our study, the incidences of sepsis, wound dehiscence, renal failure, urine leakage, and myocardial infarction, were signifi- cantly lower in group II (p values were 0.001, 0.001, 0.047, < 0.001, and 0.044, respectively). In comparing the complication categories between the two groups, fewer patients in group II suffered from gastrointestinal, genitourinary, and cardiac events (p values were 0.018, 0.021, and 0.013, respectively). Overall, fewer patients in group II experienced any complications (246 (68.0%) vs 210 (54.4%), p < 0.001) and high-grade complications (93 (25.7) vs 22 (5.7%), p < 0.001). The length of hospi- tal stay was also significantly shorter in group II (8.54 ± 5.71 vs 6.84 ± 1.78, p < 0.001). One of the possible reasons for these findings, which according to the nature of our intervention seems to be rational, might be a decrease in the rate of postoperative urine leakage from ureteroileal anastomosis. It has been reported that post-RC urinary extravasation may lead to a prolonged hospital stay, chemical peritonitis, and ureteroileal anastomosis stricture (28), which in turn may result in renal deterioration. Also, severe urinary leakage has been associated with perioperative mortality (29). In our investigation, hospital stay was significantly longer in patients with postoperative urine leakage than in those who did not suffer from this complication (12.38 ± 4.16 vs 7.22 ± 3.99, p < 0.001). Besides, the rate of urine leak- age was significantly lower in group II (30 (8.3%) vs 9 (2.3%), p < 0.001). However, it must be stated that only a limited number of studies with controversial results investigated the effect of retroperitonealization of the ureterointestinal anastomosis on post-RC urine leakage. Kavaric et al., as a part of their modification of the Wallace technique, retroperitonealized the conduit by suturing the serosa of the conduit to the posterior peritoneum above the anastomosis, thus placing the ureterointestinal anastomosis in the retroperitoneum. They reported that their technique significantly decreased postoperative urine leakage (30). As mentioned earlier, Soleimani et al. reported that the rate of postoperative urine leakage was lower in the extraperitoneal than transperitoneal RC group (26). Contrary to these findings and our assumption, in Kulkarni et al.’s study, although the rate of post-RC urine extravasation was not signifi- cantly different in the extraperitoneal vs transperitoneal approach, the rates of gastrointestinal complications, reoperation, and intestinal obstruction were lower in the former group (27). This suggests that other causative fac- tors might have a role in the decrease in perioperative adverse events. Due to our study design, we could not assess whether the decrease in the rate of urine leakage is a true cause of lower complications occurrence in the group with retroperitonealization of the ureteroileal anas- tomosis or not. Further investigations to clarify the patho- physiology of these findings are required. The present study is among the few investigations that have assessed the effect of retroperitonealization of ureteroileal anastomosis on the perioperative complica- tions of RC. Albeit, the current study has several short- comings including its retrospective design and the short duration of follow-up. In addition, it is possible that some minor adverse events were not recorded. However, major adverse events or deaths were probably not overlooked. Also in this study, we only enrolled patients with ileal conduit diversion and ureteroileal anastomosis that was performed according to the Wallace technique; other types of urinary diversions and ureterointestinal anasto- moses were not covered. Finally, based on the study design, we were not able to factor out time and experience in the earlier group rather than the latter group. However, it must be noted that the operations were performed by surgeons with more than a decade of experience in radical cystectomy in high-vol- ume urology centers and we have not changed our post- operative care during the five-year period of the study. Thus, it seems that these factors might have a negligible effect on our comparison and interpretation. Archivio Italiano di Urologia e Andrologia 2022; 94, 2 A. Ariafar, M. Salehipour, S. Zeyghami, M. Rezaei 154 CONCLUSIONS RC is associated with comparatively high perioperative morbidity and mortality. 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Regan JB, Barrett DM. Stented versus nonstented ureteroileal anastomoses: is there a difference with regard to leak and stricture? J Urol. 1985; 134:1101-3. 29. Hensle TW, Bredin HC, Dretler SP. Diagnosis and treatment of a urinary leak after ureteroileal conduit for diversion. J Urol. 1976; 116:29-31. 30. Kavaric P, Eldin S, Nenad R, et al. Modified Wallace anasto- motic technique reduces ureteroenteric stricture rates after ileal con- duit urinary diversion. Int Braz J Urol. 2020; 46:446-55. Correspondence Ali Ariafar, MD Mster20012002@yahoo.com Mehdi Salehipour, MD salehipour@sums.ac.ir Shahriar Zeyghami, MD zeyghamishahryar@yahoo.com Mehran Rezaei, MD (Corresponding Author) mrezaei1986@gmail.com Department of Urology, Shiraz University of Medical Sciences, Shiraz (Iran)