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 not responding to adequate endovesical therapy. 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 vaginal-sparing techniques.

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 the preoperative MRI. Functional results were evaluated with the aid of five questions out of the Bladder Cancer Index questionnaire. Complications were reported according to the Clavien-Dindo classification and cancer control was evaluated by recurrence-free and cancer-specific survival.

Results: A total of 22 female patients underwent RARC with neobladder diversion. Neoadjuvant chemotherapy was given in 17 (77%) cases. Clavien-Dindo grades III-IV complications occurred in four (18%) cases. After a mean follow-up of 29 (interquartile range 16-44) months, six (27.3%) patients developed distant metastases, and one (4.5%) woman loco-regional relapse. Sexual-sparing surgery was performed in 19 (86%) patients, and in the others the anterior vaginal wall was resected, but neobladder was still performed. During daytime, no patients reported total incontinence and 73% (11/15) reported total continence or only occasional leaks. Sexual results showed that seven of 15 (47%) 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.