Lower urinary tract symptoms (LUTS) affect up to 90% of patients with multiple sclerosis(MS), significantly impacting quality of life and potentially compromising upper urinary tract(UUT) function. For LUTS refractory to first- and second-line treatments, incontinent urinary diversion, such as ileal conduit, may be indicated when intermittent catheterization is not feasible. However, this surgery is not frequently offered due to its concerns regarding morbidity. The use of robotic-assisted surgery has increased significantly due to its well-recognized advantages, including reduced perioperative morbidity and faster recovery, which could be beneficial in neurological patients. The aim of this study was to evaluate the surgical and functional outcomes of totally intracorporeal robotic-assisted cystectomy and ileal conduit in MS patients.

This retrospective, single-center study included all MS patients who underwent totally intracorporeal robotic-assisted cystectomy with ileal conduit diversion between September 2021 and January 2025. Demographic data, disease characteristics (Expanded Disability Status Scale (EDSS), MS subtype, disease duration), preoperative bladder management, renal function, and quality of life (QoL, assessed using the Qualiveen-Short Form questionnaire) were collected. All procedures were performed using the same robotic-assisted technique. Postoperative complications (according yo Clavien-Dindo), readmissions, renal outcomes, and QoL changes were analyzed. Results are reported as median [interquartile range (IQR)] or mean ± standard deviation as appropriate.

Twenty-five patients where included of whom 16 women, with a median follow-up of 15[5-30] months. Median disease duration was 20[15-27] years; mean preoperative EDSS was 7.5, 68% were ASA3 and 88% wheelchair-bound. The main indications for urinary diversion were inability to perform self-catheterization (40%), recurrent urinary tract infections (8%), renal impairment (8%), or a combination of these indications (44%).
All procedures were completed robotically with no conversions or intraoperative complications with a median operative room time of 210[163-263]minutes. 72% of patients presented Clavien-Dindo I–II events and 44% III–IV. Digestive complications occurred in 12%. Median length of hospital stay in the surgical ward was 16[14-23]days and 84% of patients were discharged within 3weeks. At discharge, 56%were stent-free.
Whitin the first 6 postoperative months, 68% of patients were readmitted including 44% for endoscopic reintervention after obstructive pyelonephritis. The readmission rate decreased to 24% in the second postoperative semester. Only 3 of 25 patients had persistently recurrent urinary tract infections after urinary diversion.
At 1 postoperative year, no significant deterioration in renal function was observed (preop eGFR:114±27 vs. postop:110±23ml/min; p=0.54). QoL significantly improved (Qualiveen-SF:1.8±0.9 vs. 1.0±0.8; p=0.01). Two patients died during follow-up from causes unrelated to surgery.

This study is the first to report outcomes of robotic intracorporeal cystectomy with intracorporeal urinary diversion exclusively in MS patients. 
Despite the fragility of this population, the minimally invasive surgical approach proved feasibility with no conversions to open surgery and no significant increase in EDSS in the first post-operative year.
While the guidelines emphasize UUT protection, the primary indication in this cohort was the inability to perform self-catheterization due to advanced disease.
Post-operative readmissions in the first year were mostly related to re-stenting after failure of JJ stent removal. Mean Qualiveen score at one year was significantly lower showing significant improvement in QoL after urinary diversion despite the morbidity.

Totally intracorporeal robot-assisted cystectomy with ileal conduit diversion appears feasible in selected patients with MS and is associated with significant improvement in quality of life while preserving renal function. However, early postoperative morbidity and readmission rates remain high and should be carefully weighed against the expected functional benefits. Careful patient selection and postoperative management are critical in this highly vulnerable population.