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Ornaghi et al. Mini-invasive Surg 2021;5:42 https://dx.doi.org/10.20517/2574-1225.2021.50 Page 13 of 17

The paucity of available data as well as the heterogeneity in outcome definition, measurement, and
reporting has hampered the usefulness of the current evidence base on female sexual function after RARC
and UD. However, the results shown appear promising with a percentage of sexually active women at the
12-month evaluation ranging from 66.7% to 72.7% [13,22] . Using FSFI, after an initial worsening of the results
over the first 3 months after surgery, it is possible to denote a significant improvement at 12 months of
follow-up, even if in comparison with the baseline the results remain significantly reduced. These results
support what was already highlighted by Bhatt et al. in their study on a subset of women who underwent
[53]
RC with neurovascular preservation and ONB. They found that FSFI score could be preserved compared
with women who did not undergo NS, who had a significant decline.

As already known from previous studies, significant differences in emotional problems, role functioning,
fatigue, and appetite were noted among women undergoing RC compared with controls of the general
[47]
population . One study specifically compared outcomes of men compared with women undergoing RC
and ileal conduit and found that men have worse sexual function outcomes than women, whereas women
experience a greater burden in postoperative cognitive function and future perspective . The data available
[54]
in the literature on the impact of different types of UD on HRQoL show a significant advantage of ileal
ONB compared to ileal conduit in terms of HRQoL . Based on the findings of Tuderti et al. , using the
[13]
[55]
EORTC-QLQ-C30 questionnaire among female patients who underwent RARC and iN, global health
status/QoL and physical and emotional functioning items improved significantly over time (all P ≤ 0.04).

It is important to remember that evidence in the literature for functional outcomes after RARC in female
patients is relatively recent and, for the moment, we lack objective measurements and standardized methods
of detection of important outcomes such as urinary continence, sexual function, and QoL . The current
[12]
need is therefore for more in-depth evaluations in randomized controlled trials with prolonged follow-up to
identify the most appropriate surgical procedure for the specific patient and improve preoperative
counseling.

Our systematic review has some limitations. First, the studies collected were all retrospective and most of
them were based on single-center cohorts. Therefore, the results may have been exposed to selection bias or
bias due to missing data. Second, the sample size was in many cases extremely low, which may have
influenced the results by abnormally increasing their significance. Third, the median follow-up of the
collected studies was generally short, which may have affected an accurate description of postoperative
long-term complications and a proper characterization of functional recovery; prospective randomized
studies with extended follow-up would be useful to determine more accurately post-RARC functional
outcomes and long-term surgical outcomes. Fourth, our research was limited to English-language records,
which may have affected the choice of eligible items.

Conclusions
RARC and UD for BCa in female patients is a feasible procedure with surgical outcomes overlapping with
those in the male patient population. The comparison between RARC and ORC in the female cohort
showed a non-inferiority of the robotic approach in terms of postoperative complications and readmission
with the added possibility of reducing EBL and increasing the LN yield even if at the expense of a prolonged
OT. Postoperative functional outcomes on continence, sexual function, and QoL are still poorly investigated
in the available literature, although results inherent in the NS approach appear promising. More
standardized templates for reporting functional outcomes as well as randomized prospective studies to
better compare techniques and provide the best counseling are required.