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Page 14 of 18 Thinagaran et al. Mini-invasive Surg 2021;5:46 https://dx.doi.org/10.20517/2574-1225.2021.53

Continence figures are relevant to those patients undergoing orthotopic neobladder at the same time as
male NS RARC and satisfactory continence is defined in the studies to be dry enough to maintain with a
maximum of one pad per day. In this review, 85.06% day time continence rate (range 54.5%-100%) and
72.48% night time continence rate (range 46.7%-88%) were noted overall in patients whose NVBs were
preserved [13,17,18,20-22,26,29-31,33-40] . This is in contrast to the results of some studies, for example, Tyritzis et al. ,
[38]
who noted no significant difference in continence rates between their NS and non-NS groups of patients
with 88.2% and 88.9% respectively for day time continence rates at 12 months.

With the legitimate concerns for NS being the potential for clinical understaging and incomplete tumour
excision, it is of note that overall surgical margin negativity was 98.2% in our review, equivalent to 1.8%
positive surgical margins (PSM) (range 0%-6.4%). This compares favourably to other series performing
[41]
non-NS minimally invasive radical cystectomy achieving 2.2% PSM and an overall 6% found from the
results of the International Robotic Cystectomy Consortium . Much of this will be explained by patient
[42]
selection which rules out pT3-4 tumours, accounting for a significant proportion of PSM cases in other
studies.

[26]
Examining some of the studies reviewed in more detail, Nyame et al. , had a very select patient group of <
40 years old men and performed bilateral nerve and apex sparing radical cystectomy who showed excellent
outcomes both oncologically with 0% PSM and 66.7% recurrence free survival and functionally with all their
patients being potent and continent after 28.3 months follow up. However, the demographics show that
bladder cancer affects much older patients, and once again patient selection is critical. Many patients in
their late 60s, early 70s may not regard potency as a priority, but this is not always the case, and although
patients below the age of 65 years have better outcomes postoperatively with respect to erectile function,
[13]
older patients should at least be offered the opportunity to maximise their quality of life after treatment .
Canda et al. , investigated 27 patients who underwent RARC with Studer Neobladder and found that such
[40]
procedures, although technically challenging, have good surgical and pathological outcomes and satisfactory
morbidity and functional results. They did caution, however, that further studies with more patients and
[38]
[40]
longer follow-ups are necessary . Tyritzis et al. , mentioned above, studied functional and oncological
outcomes of patients (both male and female) that underwent RARC with totally intracorporeal neobladder.
A large proportion of their cohort (41/70; 58.6%) was treated with NS procedures. Sexual function and day
time continence at 12-month was satisfactory at between 70% and 90%. They supported the findings of
Canda et al. , that the complications and both functional and oncological outcomes were comparable to
[40]
open radical cystectomy, demonstrating that RARC with Robotic neobladder and NS approach is a feasible
and safe alternative . Haberman et al. , evaluated the effects on post-operative erectile function of a
[38]
[27]
bilateral cavernosal nerve-sparing approach to RARC in a preoperatively potent population. Their
retrospective study reviewed data from 254 patients from 2003 to 2012 who had RARC. 29 out of 33 men
under the age of 65 years had bilateral nerve-sparing procedure. Postoperatively, 45% of them were able to
maintain satisfactory erections for penetrative intercourse with or without use of Viagra type medication. A
further 21% recovered erectile function using intracavernosal injections (ICI), while 34% were unable to use
ICI or decided recovering their potency was no longer an issue. They further observed no significant
difference between those who recovered potency and those who did not based on a number of parameters,
including comorbidities, operating time, tumour stage and age of patient. Despite NS, there was no PSMs
and no local cancer recurrence. Based on these results, they concluded that NS RARC improved
[27]
[18]
postoperative erectile function without having to compromise oncologic outcomes . Colombo et al. , also
showed good outcomes in their patient cohort but acknowledged patients were highly selected comprising
only 8.8% of all the patients who had a radical cystectomy during the study period. A similar patient cohort
demographic was noted by Haberman et al. , with only 11.4% of their patients having a NS operation and
[27]