Posterior funnel-shaped flap: A potential solution for tension-free ileourethral anastomosis in robotic-assisted intracorporeal neobladder reconstruction

Objective: Robotic-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder reconstruction has emerged as a minimally invasive option for muscle-invasive bladder cancer, but ileourethral approximation remains a major technical challenge, especially in patients with a short or bulky mesentery. Achieving a tension-free anastomosis is crucial for both functional and oncological outcomes. We describe a novel posterior funnel-shaped flap (Faria’s flap) designed to overcome this limitation and facilitate safe, tension-free ileourethral anastomosis. Patient and Surgical Technique: We report the case of a 63-year-old male with muscle-invasive urothelial carcinoma (cT3N0M0), treated with neoadjuvant chemotherapy followed by RARC and intracorporeal Y-shaped ileal neobladder reconstruction. During surgery, the ileal loop failed to reach the urethra. To address this, we developed a posterior funnel-shaped flap: a 10-cm longitudinal incision was created in the distal ileum, followed by posterior suturing that produced a funnel configuration, extending the ileal reach while preserving vascular integrity. The anastomosis was then performed without tension. Reconstruction was completed with a modified Y-shaped neobladder. Console time was 4 h 10 min, estimated blood loss 310 mL, and no intraoperative complications occurred. The patient was discharged on day 6, with catheter removal on day 16 and stent removal on week 3. At follow-up, he achieved complete daytime and nighttime continence, normal voiding, and no residual urine. Conclusion: The posterior funnel-shaped flap represents a feasible modification to facilitate ileourethral anastomosis in robotic intracorporeal neobladder reconstruction. This technique provides additional reach while reducing anastomotic tension and supporting favorable functional outcomes. Although early results are encouraging, further studies with larger cohorts are required to validate its oncological and functional benefits.