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Maqboul et al. Mini-invasive Surg 2021;5:44 https://dx.doi.org/10.20517/2574-1225.2021.54 Page 13 of 19

compares favorably with the ICUD and ECUD high-grade complication rates (21% and 24% respectively)
[1]
[14]
from the IRCC data , as well as those of large open series from high volume centers . When analyzed,
some RIN series found that high-grade gastrointestinal complications were particularly low, strongly
supporting the suggestion that keeping the bowel intra-abdominally and reducing its manipulation is
beneficial .
[5]
Oncological outcomes (see Table 2)
The influence of RIN on oncological outcomes is important to establish, and it has been suggested to result
from the pneumoperitoneum causing tumor seeding that changes the pattern of recurrence, the minimally
invasive approach reducing lymph node yield, and possibly an increase in positive surgical margins with or
without incomplete resection of tumor at the urethral margin . It has not been born out in the published
[15]
results that have shown non-inferiority of RARC with RIN [16,17] , and this is further supported by the results
of this review. In Table 2, the mean positive surgical margin of 1.86% (range 0%-6.4%), median lymph node
yield of 23 nodes (IQR = 7.5), and mean cancer-specific survival rates of 78% (range 72%-100%) over mean
follow up of 23.2 months (range 3-37 months) compares favorably with oncological outcomes from ORC
and RARC with ECUD series [18,19] .

Functional outcomes (see Table 3)
While perioperative and oncological outcomes may be comparable for robotic and open approaches,
naturally, the minimally invasive approach, analogous to potency and continence outcomes for robotic-
assisted prostatectomy, may have the potential to demonstrate superiority in functional outcomes. The
magnified view and dexterity afforded by robotic assistance may allow more accurate dissection around the
pelvic floor with nerve and pelvic organ preservation, notwithstanding QoL improvements from a more
[20]
physiologically functioning neobladder. The small study of Obrecht et al. (see Tables 1-3) examined
functional outcomes after RARC with RIN over 12 months follow up including urodynamic measurements,
bladder capacity, and a QoL assessment. Their results showed good functional outcomes with a median
bladder capacity of 400 mL, which are close to the normal physiological bladder capacity and day
continence rates of 100% . In this series, no patients required ISC, in keeping prior results of lower ISC
[20]
rates for robotic neobladder than open neobladders [21,22] . Similarly, from Table 3 in this review, the day
continence rate is 81.5% (range 68%-100%) while the night continence rate is 61% (range 55%-82%), where
continence was defined as using 0-1 pad. These results compare favorably to open neobladder series that
demonstrate daytime and nighttime continence rates of 80%-100% and 45%-90% respectively . Generally,
[22]
there is a paucity of potency or return to sexual activity outcome data in the literature after RIN.
Jonsson et al. has reported potency of 88% of men who underwent RIN and nerve-sparing technique with
[23]
potency defined as IIEF-5 ≥ 17 or the ability to perform intercourse. Tuderti et al. ’s study focusing on
[13]
female patients after pelvic organ sparing RARC with RIN, showed favorable functional outcomes with
daytime and nighttime continence rates 90.9% and 86.4% respectively and 72% of patients returning to
sexual activity at 12 months. Overall, for all series reviewed in Table 3, the mean potency or spontaneous
return to sexual activity rate was 33.51% (range 16%-72%). Although some results may show a trend towards
improved results for RIN, the claim of superiority of RIN over extracorporeal or open neobladder is difficult
to make until results from better-designed studies support it .
[24]
[25]
The early results of such studies are seen from Mastroianni et al. , who recently reported an interim
analysis from an ongoing randomized controlled trial between ORC vs. RARC with ICUD on Health-
related Quality of Life after 1-year using patient-reported questionnaires from EORTC group, generic
quality of life [QLQ-C30] and bladder cancer-specific instruments [QLQ-BLM30] questionnaires. Both
approaches have comparable baseline QoL, as patients of two groups reported worsening physical