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Thinagaran et al. Mini-invasive Surg 2021;5:46 https://dx.doi.org/10.20517/2574-1225.2021.53 Page 15 of 18

[20]
14.2% by Ong et al. . Interestingly addressing the issue of potential PSM from incidental prostate cancer in
[43]
patients undergoing male NS RARC, Chessa et al. , reported no difference in prostate cancer PSM rates.
Prehabilitation, rehabilitation, adjunctive strategies and lifestyle changes

ERAS protocols have been gaining in popularity and are now utilized by most robotic urology centres.
Surgeons have recognized the importance of preparing patients for a major operation such as an RARC
with a multimodal approach, becoming increasingly part of “prehabilitation” programs, aiming to institute
lifestyle changes and improve physical fitness before surgery is undertaken. Preoperative smoking cessation
has shown to positively impact post-operative outcomes , and, for example, Minella applied
[44]
prehabilitation tactics in a randomised controlled study group with exercise, nutritional advice and anxiety
reducing interventions, finding that patients who went through the program did better than the control
group at their 4-week post-operative functional capacity evaluation . Although some of the evidence is
[45]
conflicting, penile and pelvic floor rehabilitation has been described as part of post-operative follow up for
any radical pelvic surgery not only to improve potency but also urinary continence and bowel function
postoperatively . In fact, the field of bladder cancer surgery may learn from prostatectomists who employ a
[46]
number of pre-, intra- and post-operative strategies to improve functional outcomes with both urinary
continence and erectile function.

With respect to erectile function, maximizing post-operative recovery begins with pre-operative work up
when the patient’s erectile function is assessed objectively. Modalities may include a thorough clinical
[47]
assessment to stage the disease, IIEF-6 questionnaire, psychosocial assessment including partner factors ,
[49]
sleep assessment and, if necessary, penile doppler ultrasound . Similarly, starting pelvic floor exercises
[48]
with pelvic floor muscle training (PFMT) before the procedure may benefit post-operative continence in
[50]
patients undergoing orthotopic neobladder . Intra-operative strategies stress the importance of the
accessory pudendal arteries preservation for erectile function , as well as other techniques such as the
[51]
application of dehydrated human amniotic membrane which has been proposed to accelerate nerve
regeneration . Postoperatively a multiple modal approach is advocated for rehabilitation of both erectile
[52]
[50]
and urinary function. Ongoing PFMT as well as biofeedback have been used to improve continence . For
penile rehabilitation, strategies include phosphodiesterase-5 inhibitors, intracavernosal injection therapy,
vacuum erection devices, MUSE Alprostadil urethral suppository, pelvic floor therapy, penile
vibrostimulation, hormonal factor correction, penile implant, hyperbaric oxygen therapy, extracorporeal
shockwave therapy, psychosocial therapies and nerve grafting techniques .
[53]

Clearly not all of these strategies will apply to bladder cancer patients undergoing male NS RARC with or
without neobladder, but by inference, patients will likely have less comorbidities, and be highly motivated to
gain as much quality of life functionally after their procedure as possible. The success of these strategies for
patients undergoing prostate cancer surgery would suggest these adjunctive treatments are worthy of
further investigation for the field of bladder cancer surgery.

In conclusion, male NS RARC for appropriately selected patients, in experienced hands will offer good
functional outcomes leading to a better quality of life for those patients who benefit. Results from the series
reviewed suggest the technique is both feasible and safe, without compromising longer term oncological
results. With the more widespread use of ERAS protocols, and the introduction of prehabilitation and
lifestyle programs, patients will also be able to contribute more proactively to their functional recovery, and
help with the technical success of the operation. In addition to basic surgical expertise, there are a number
of adjunctive strategies aiming to improve urinary and erectile function, and the results demonstrated for