2.1

Literature search strategy

The literature search and assessment were independently conducted by 3 authors (D.B.-L.T.- S.C.) through PubMed, Scopus®, and Web of Science up to December 2023.

After establishing the study protocol registered in PROSPERO (CRD 42023492384), the research question was formulated according to the PICOs model: patients with bladder cancer (P) undergoing RCUD with ureteral stent (I) versus without ureteral stent (C) to evaluate major complications, UIAS, UIAL, UTIs, and ureteral obstruction (meant as an acute rise in creatinine, or decreased urine output, or flank pain associated to imaging direct signs of obstruction) (O).

The following string was adopted for comprehensive research:

((((((stent)OR(ureteralstent)OR(ureteralcatheter)OR(stentless))AND(radicalcystectomy))AND(urinarydiver-sion))OR(ilealconduit))OR(neobladder))AND((compli-cation)OR(morbidity)OR(leak)OR(stricture)OR(obstruction)OR(stenosis))AND(bladdercancer)))))).

2.2

Studies selection

The Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA Statement-www.prisma-statement.org) was followed. After discarding the duplicates, the title, and abstracts were reviewed to limit the assessment to studies that closely aligned with the inclusion criteria. These selected studies then underwent full-text evaluation to confirm their suitability for the meta-analysis. Any discrepancies or uncertainties were solved by consensus by consulting a third experienced reviewer (A.V.). Noncomparative, retrospective, non-English articles, conference abstracts, letters to the Editor, notes, comments, and book chapters were excluded from consideration.

2.3

Publication bias assessment

The Risk of Bias version 2 (RoB version 2) [ ] was used for the risk of bias assessment. One author (F.D.) conducted the evaluation independently, using RoB2 for RCTs and nonrandomized prospective trials. Each domain identified a low, unclear, and high risk of bias. In instances of an unclear risk, confirmation was sought by consulting an experienced author (R.B.).

2.4

Data extraction and analysis

The baseline characteristics [age, gender (male), body mass index (BMI), history of smoking, Charlson Comorbidity Index (CCI) age-adjusted, history of abdominal surgery, and neoadjuvant chemotherapy] and surgical outcomes [estimated blood loss (EBL), operative time (OT), length of stay (LOS), major complications (Clavien ≥3), 30 day readmission, postoperative UIAS, postoperative UIAL, and postoperative urinary tract infection] were extracted.

As only means and standard deviations are permissible for meta-analysis a mathematical model was used to convert either median (range) or median [interquartile range (IQR)] to mean (standard deviation [SD]) [ , ]. The weighted mean difference (WMD) was used as a summary measure for continuous variables, whereas the odds ratio (OR) with 95% confidence interval (CI) was chosen for the dichotomous ones. The Chi ² test esteemed the heterogeneity among the studies, whereas the I ² described the percentage of the variability in effect estimates. According to Cochrane Library, the heterogeneity was considered as follows:

• •
  

  0% to 40%: might not be important;

  
  
• •
  

  30% to 60%: may represent moderate heterogeneity;

  
  
• •
  

  50% to 90%: may represent substantial heterogeneity;

  
  
• •
  

  75% to 100%: considerable heterogeneity.

A random-effect meta-analysis was performed to incorporate heterogeneity among the studies. All statistical analyses were performed using Review Manager ([RevMan] [Computer program]. Version 5.4. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014).

3.1

Baseline features

The patients in the stent group were younger (WMD -2.85 years, 95%CI -5.21; 0.49, P = 0.02), but less likely to undergo neoadjuvant chemotherapy (OR 0.59, 95%CI 0.37; 0.95, P = 0.03). No statistically significant differences were found in terms of gender (male), BMI, history of smoking, CCI age-adjusted, and history of abdominal surgery. Excluding BMI (I ² = 73%) and CCI age-adjusted (I ² = 88), heterogeneity among studies for the other variables was low. All baseline features are summarized in Supplementary Table 2 .

3.2

Surgical outcomes

There was no statistically significant difference between the stent and the stentless group in terms of EBL (100.34 ml, 95%CI -62.98; 263.66, P = 0.23), OT (-1.81 min, 95%CI -77.71; 74.10, P = 0.96), and LOS (1.15 days, 95%CI -0.94; 3.24, P = 0.28). A high level of heterogeneity was found for each outcome measure.

3.3

Postoperative complications and sequelae

The stent group showed higher odds of postoperative major complications (OR 3.00, 95%CI 1.06; 8.52; P = 0.04) than the stentless group. There was no statistically significant difference between the 2 groups regarding 30-day readmission ( P = 0.06), postoperative UIAS ( P = 0.09), postoperative UIAL ( P = 0.20), postoperative urinary tract infection ( P = 0.08), and postoperative ureteral obstruction ( P = 0.35). No statistically significant difference between the 2 groups was found regarding UIAS management in terms of ureteral reimplantation ( P = 0.28) or dilatation ( P = 0.36). A low level of heterogeneity was registered for all the outcome measures ( Fig. 2 ).

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