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Ornaghi et al. Mini-invasive Surg 2021;5:42 https://dx.doi.org/10.20517/2574-1225.2021.50 Page 3 of 17

This systematic review aimed to comprehensively summarize the current evidence in the literature on
surgical and functional outcomes after RARC in female patients, to identify the gaps and direct future
investigations.

METHODS
Literature search strategy and study selection
A systematic review of the English-language literature published in the last 15 years (from 1 January 2005 to
31 December 2020) was performed. The US National Institutes of Health’s PubMed Database was carefully
scrutinized according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses
[14]
(PRISMA) statement . The research was performed using the following search string: [radical cystectomy
AND robot AND female AND (surgical outcome OR functional outcome)]. According to the aim of this
study, all eligible texts reporting the peri- and post-operative outcomes under examination in female
patients treated with RARC for BCa were included in the systematic review. After a first screening based on
study title and abstract, all articles were examined based on full-text and excluded with reasons when
inappropriate. The following types of articles were excluded from the systematic review: review articles, case
reports, editorial/author replies or comments to other articles, studies reporting data without gender
differentiation, studies from the same database with potential overlapping patients, and studies that dealt
with research unrelated to our topic.

Outcomes of interest
Our primary outcomes were peri- and post-operative surgical outcomes [operative time (OT), estimated
blood loss (EBL), LOS, 30- and 90-day complication rates according to Clavien-Dindo Classification System
[15]
(CCS) , and 30- and 90-day readmission rates] and postoperative functional outcome [daytime and
nighttime continence, sexual activity, need for clean intermittent catheterization (CIC), and health-related
QoL (HRQoL) evaluation]. As secondary endpoints, we considered postoperative pathological outcomes
[pT stage, lymph node (LN) yield, positive surgical margins (PSMs), and positive LN (pN+)].

RESULTS
Evidence synthesis
Figure 1 reports the flow diagram of the selection process used for this systematic review. From a total of
296 articles screened, 17 were initially assessed for eligibility. Of these, 9 were subsequently excluded after
full-text evaluation and eight were selected and critically analyzed by the authors.

Study population and design
Overall, our systematic review included 514 patients (438 considering RARC only). Regarding the articles
which included both male and female patients, given the topic of our systematic review, we focused
particularly on female patients, in total 305 (229 considering RARC only). The characteristics of the eight
identified studies together with the peri- and post-operative outcomes achieved are reported in Table 1.

Eligible articles were published between 2009 and 2020 involving female patients who underwent RARC
from December 2003 to June 2018. All selected studies had a retrospective design; only one was a
multicenter study , whereas all others were based on data collected in a single institution. Four of the eight
[16]
[22]
[21]
[13]
studies were from the USA [17-20] , one from Turkey , one from Sweden , one from Italy , and one from
Korea . Three of them were comparative articles: two reported gender comparison data [16,19] and one
[16]
compared RARC and ORC .
[18]