Page 45 - Read Online

Page 2 of 17 Ornaghi et al. Mini-invasive Surg 2021;5:42 https://dx.doi.org/10.20517/2574-1225.2021.50

significantly related with longer OT and lower EBL compared to the open procedure. The median LOS was 9.8 days
(range 6.5-21 days); no significant differences in LOS were found between open RC (ORC) and RARC in female
patients, as well as between RARC in women and men. The mean incidence of 30-day complications after RARC in
women was 32.9%, with 12% of high-grade complications, while the 30- and 90-day readmission rates were
20.8%, and 28%, respectively. Complications and readmission comparing RARC and ORC in female patients
appear to be overlapping. The mean rate of PSMs was 2.5% and the mean rate of pN+ was 12.7%; both these
outcomes were similar in RARC compared with ORC. The mean number of retrieved LN was 20.6 (range 11.3-35.5).
The LN yield resulted significantly influenced by the robotic approach [median 27 (range 19-41)] compared to the
open one [20.5 (range 13-28)]. After 12 months, the rate of women with daytime and nighttime continence was
66.7%-90.9% and 66.7%-86.4%, respectively, while that of sexually active women ranged 66.7%-72.7%. The
need for CIC ranged 12.5%-27.2%. Administering the EORTC-QLQ-C30 questionnaire after RARC and
intracorporeal neobladder, the global health status/QoL and physical and emotional functioning items improved
significantly over time.

Conclusion: RARC and UD in female patients is a feasible procedure with surgical outcomes overlapping with those
in the male patient population. Postoperative functional outcomes on continence, sexual function, and QoL are still
poorly investigated, although results inherent in the nerve-sparing approach appear promising.

Keywords: Bladder cancer, robot-assisted radical cystectomy, female, surgical outcomes, functional outcomes

INTRODUCTION
Bladder cancer (BCa) is the second most common genitourinary malignancy, with 81,400 new cases and
[1]
17,980 deaths estimated in 2020 in the United States . Although BCa is more frequent among men, among
women there are approximately 20,000 new cases and about 5000 women die each year from this disease .
[1]
Radical cystectomy (RC) with urinary diversion (UD) is considered the standard treatment for non-
metastatic muscle-invasive bladder cancer and high-risk non-muscle-invasive bladder cancer . Women
[2,3]
present an advanced stage at diagnosis more often, increasing the requirement of RC . In female patients,
[4,5]
the standard surgical procedure is represented by anterior pelvic exenteration including the removal of the
bladder, ovaries, uterus, and anterior vaginal wall . RC, whether open (ORC) or robot-assisted (RARC), is a
[2]
morbid and complex procedure that involves simultaneous surgeries on the urinary and gastrointestinal
tracts, as well as the retroperitoneum, with a substantial complication rate that may increase the length of
hospital stay (LOS) and readmissions . The robotic approach is increasingly performed worldwide .
[7]
[6]
Reportedly, progress in robotics has helped to develop standardized mini-invasive procedures which seem
to offer oncological outcomes similar to open procedures and that are associated with reduced peri- and
post-operative morbidity (decreased postoperative pain, incisional morbidity, blood loss, and transfusion
rate) and shorter LOS, with an earlier return of bowel function [8-10] . After performing RARC, ileal conduit
remains the most common type of reconstruction, even though an orthotopic neobladder (ONB) could
offer a better quality of life (QoL) by maintaining body image and normal voiding in suitable patients .
[11]
According to a recent review on gender-differentiated oncological and functional outcomes after RC, being
a woman negatively affects oncologic outcome secondary to delays in diagnosis, treatment, and
misdiagnosis. Moreover, functional outcomes (urinary, sexual, and overall QoL) are poorly assessed in
women using non-validated and non-standardized measures . Recent frontiers of improvement seem to be
[5]
offered by totally intracorporeal reconstruction [intracorporeal urinary diversion (ICUD)] vs.
extracorporeal UD (ECUD) and the nerve-sparing (NS)-RARC . However, data on postoperative
[12]
[13]
outcomes in female patients are still scarce and confusing, especially concerning the robotic approach.