Robot-assisted radical cystectomy with neobladder diversion in females: Safety profile and functional outcomes

Objective Radical cystectomy (RC) is a standard treatment for localized muscle invasive bladder cancer and high-risk or very high-risk non-muscle invasive bladder cancer. In women, traditionally RC is performed with hystero-adnexectomy and resection of the anterior vaginal wall, often resulting in sexual disorders. Vaginal-sparing techniques have been developed to improve functional outcomes. The present study explores the safety and the functional outcome of this approach. Methods We retrospectively analyzed all consecutive female patients undergoing robot-assisted RC (RARC) with neobladder diversion between October 2017 and February 2022. The indications for vaginal-sparing RC were absence of tumor on bladder neck or urethra and no sign of infiltration of posterior bladder wall at preoperative staging on MRI. Functional results were evaluated with the aid of five questions out of the Bladder Cancer Index (BCI) questionnaire. Complications were reported according to Clavien-Dindo classification and cancer control was evaluated for recurrence free and cancer specific survival. Results A total of 22 female patients underwent RARC with neobladder. Neoadjuvant chemotherapy was given in 17 (77%) cases. Clavien-Dindo III-IV complications occurred in four (18%) cases. After a mean follow-up of 29 (interquartile range 16–44) months, six patients (27%) developed distant metastases, and one woman (5%) loco-regional relapse. Sexual-sparing surgery was performed in 19 (86%) patients, in the others the anterior vaginal wall was resected, but neobladder was still performed. During daytime, no patients reported total incontinence and 73% reported total continence or only occasional leaks. Sexual results showed that 47% of women regained sexual activity after surgery, with a quality reported as “good” or “very good” in 40% of all 19 cases. Conclusion RARC in female with anterior vaginal wall preservation is feasible. The approach showed a good safety profile, with satisfying results on continence and sexual activity. Sexual-sparing approaches should be carried out after correct patient selection.