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Page 12 of 17 Ornaghi et al. Mini-invasive Surg 2021;5:42 https://dx.doi.org/10.20517/2574-1225.2021.50

We found that the rate of PSMs in women undergoing RARC was only 2.5%, and that of pN+ was 12.72%.
[18]
Comparing ORC and RARC, no significant difference was found regarding PSMs or pN+ . The study by
[27]
Matulewicz et al. , instead, showed that female sex was significantly correlated with a higher risk of PSMs
(P = 0.001), but this difference was significant especially in ORC (male vs. Female: 11.8 vs. 15.2) compared to
RARC (11.0 vs. 10.2); in addition, in the study by Sharma et al. , the increased incidence of PSMs in
[26]
women did not achieve significance on multivariable analysis. An important pathological outcome on
which the literature is not consistent is the LN yield: in some studies, this was significantly increased with
RARC [18,24,27] , while, in others, the LN yield was similar between open and robotic techniques [9,26] . Based on
the findings in our review, restricting the cohort to women only, the impact of robotic surgery appears
significant in the number of LNs removed, although the topic should be further investigated given the
[18]
paucity of available data . Moreover, based on the reviewed studies, gender does not seem to affect LN
yield [16,19] .

Previous systematic reviews focusing on functional outcomes in female patients undergoing RC have found
a preponderance of small retrospective studies with significant heterogeneity on this topic [5,12,47-49] . The
urinary function was the most well-studied outcome with daytime UI, nighttime UI, and self-catheterization
rates ranging significantly across studies due to heterogeneity in definitions for continence, inclusion
criteria, and lack of questionnaire adoption [13,47] . In a systematic review aimed to evaluate female sexual
dysfunction post RC, considering it an important predictor of HRQoL, the authors found that the most
frequently reported sexual disorders were loss of sexual desire and orgasmic disorders (49% and 39%
respectively); however, they highlighted the lack of use of standardized instruments to adequately assess
functional outcomes of RC in women .
[48]

Research in the field of genital-sparing cystectomy (GSC) techniques to improve functional outcomes after
cystectomy is gaining prominence . Gross et al. and Wishahi et al. recently investigated the impact of
[50]
[51]
[52]
GSC and subsequent ONB compared with standard RC in maintaining functional outcomes such as urinary
continence in women. The former found superior continence rates for GSC and ONB compared with
standard RC, without a negative impact on oncological outcome . The latter showed that GSC with ONB
[51]
led to a minimal incidence of hypercontinence (7.80%), while standard RC led to a higher incidence
[52]
(28.88%) . A recent systematic review of the literature regarding OSC techniques showed that preservation
of the genital or pelvic organs, in both men and women, yields better sexual outcomes than standard RC
without compromising oncologic outcomes; however, the authors emphasized that none of these techniques
could be recommended as superior to standard RC, and that large-scale prospective and multi-institutional
studies are needed to identify patients suitable for these techniques .
[50]
According to our research, the results on functional outcomes inherent to RC in female patients are scarce,
and those related specifically to the robotic approach are even more reduced: only three studies collected
dealt with this issue, and all of them analyzed the topic on a cohort of patients undergoing NS or SS-RARC
and subsequent iN. The achieved results vary widely depending on the follow-up time of the patients. While
the study by Canda et al. showed poor outcomes related to continence in the two female patients available
[21]
[22]
with a follow-up of only 5-6 months, the results of Tyritzis et al. already show a recovery of both daytime
and nighttime continence in female patients at 6 months (40%), which was further improved at 12-month
follow-up (66.7%). Even more promising results were achieved in the recent study by Tuderti et al. , in
[13]
which continence reached even higher percentages of female patients (90.9% daytime, 86.4% nighttime). In
our results, hypercontinence and subsequent need for CIC ranged from 12.5% to 27.2%. These results are
consistent with what has been shown by previous systematic reviews on the subject that collected data on
patients of both genders [5,47,49] .