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Page 2 of 19 Maqboul et al. Mini-invasive Surg 2021;5:44 https://dx.doi.org/10.20517/2574-1225.2021.54

Keywords: Neobladder, cystectomy, robotic, intracorporeal, orthotopic

INTRODUCTION
Surgical treatment of muscle-invasive (MIBC) and high-risk non-muscle-invasive bladder cancer is
uniformly recommended. However, despite the emergence and global spread of robotic techniques, there is
still some controversy over the suggested advantage of robotic-assisted over open approaches. Moreover,
the choice of intracorporeal urinary diversion (ICUD), which is technically challenging, adds to this debate,
further polarised by robotic intracorporeal neobladder (RIN), the most difficult technical option of all.
Nevertheless, robotic cystectomies remain steadfast in their belief that their approach is superior despite the
lack of clear scientific proof by randomized controlled trials. It is reflected in the widespread adoption of
RARC and RIN by high-volume robotic urological centers. Between 2015 and 2018, 70% in North America
[1]
and 50% in Europe of Radical Cystectomy (RCs) performed were done robotically , with an increase in
ICUD from 9% to 97% between 2005 and 2015 . This increase in ICUD was primarily accounted for by
[2]
centers performing intracorporeal ileal conduit, which increased from 2% to 81%, rather than RIN, which
only increased from 7% to 17% . RIN is regarded as one of the most technically challenging procedures in
[2]
robotic urology. Its steep learning curve (LC), lack of indisputable evidence of patient benefit, and the
economic drawbacks of prolonged theater time may all explain why its widespread adoption has been
slower. Nevertheless, as urological centers gain experience with clearly defined mentorship programs and
published outcomes with increasingly long follow-up in appropriately selected patients, RIN has shown to
provide equivalent oncological outcomes and long-term quality of life (QoL) compared to the open
approach. This review will detail the current techniques for RIN, highlight patient selection, discuss the
results of published series to date as well as key ongoing trials and outline some of the related issues,
including Enhanced Recovery after Surgery (ERAS) protocols, the LC for the procedure and economics.

Patient selection
Patient selection is crucial to a successful operative outcome and will be influenced by surgeon experience,
clinical factors affecting the decision to undertake a robotic procedure, and specific patient factors related to
the choice of neobladder itself. Generally, the ideal patient for Robot-Assisted Radical Cystectomy (RARC)
will be under 75 years of age, slim with a BMI of less than 30, have a T2 tumor without locally advanced
disease, have good performance status with minimal co-morbidities, and no history of prior abdominal
radiation or surgery . As surgeons gain experience, these guidelines will be flexed, but whatever the
[3]
surgeon experience is, patients with BMI > 35, complex cardio-respiratory co-morbidities and prior
abdominal or vascular surgery, pelvic trauma or radiotherapy, and locally advanced disease will prove
challenging. Even with these factors in mind, further consideration is required when selecting patients for
RIN, such as the physiological and cognitive requirements to adapt to a neobladder that can significantly
impact the outcome and patient’s quality of life. The main contraindications for orthotopic neobladder are
renal and liver impairment, tumor invading the prostatic apex and bladder neck (which would result in a
positive intraoperative urethral margin). In addition, there are relative contraindications as the lack of
patient’s motivation or cognitive impairment, preventing adherence to the bladder-training program,
physical limitations hinder the ability to intermittently self-catheterize, and a damaged urethral sphincter
that would result in severe incontinence .
[4]

Technique
To date in the literature, the majority of published series have used the Studer U modified neobladder, the
largest series of which was from Karolinska detailing the technique and outcomes of 158 patients since its
introduction in 2003 . Other techniques used for RIN include modified Hautmann W, the Padua, the Y
[5]
[6]
technique, the Florence, the Vescica Ileale Padovana, the Pyramid pouch, and the Camey Reservoir . This