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Ornaghi et al. Mini-invasive Surg 2021;5:42 https://dx.doi.org/10.20517/2574-1225.2021.50 Page 11 of 17

9.8 days. The difference in LOS compared to RARC in male patients was not significant [16,19] , as was the
[18]
comparison between female RARC and ORC .
We found that the postoperative complication rate after RARC was barely above 30%, with a high CCS
complication rate (≥ 3) of only 12%. A recent review analyzing the evidence and most recent findings on
gender-specific differences in BCa considering treatment and outcomes pointed out that women had a
[39]
significantly longer LOS, longer OT, higher 90-day mortality, and higher postoperative complication rate .
The results of our research, which focused on robotic surgery, showed that, thus far, the available evidence
on the rate of postoperative complications after RARC is still sparse and influenced by low sample sizes, but
it could be seen that this rate appears to overlap with the open approach and does not seem to be influenced
by gender [18,19] . This evolution could be due to the use of robotic surgery and should be investigated in
further prospective and randomized studies comparing genders and surgical approaches.

D a t a i n t h e l i t e r a t u r e r e g a r d i n g t h e a s s o c i a t i o n b e t w e e n h i g h e r r a t e s o f
complications/reoperation/readmission after RARC and gender are conflicting. An in-depth critical analysis
of complications following RARC and ICUD by Tan et al. found that the male gender was significantly
[40]
associated with the occurrence of 90-day major complications (OR = 6.98, 95%CI: 1.45-33.58, P = 0.015). As
the authors pointed out, however, this finding may be skewed by the threefold higher number of male
[26]
patients. Sharma et al. , in their study focusing on the comparison between ORC and RARC in surgical
control, found that female sex is not significantly related to an increased risk of 30-day complications in
[41]
pT3/T4 patients after RC. In the study by Hussein et al. , there was no evidence of a statistically significant
influence of gender on the risk of reoperation after RARC. Al-Daghmin et al. , instead, showed that female
[42]
gender (OR = 0.41, 95%CI: 0.20-0.83, P = 0.014) and BMI (P = 0.004) were independent predictors of 90-day
readmissions in their multivariable analysis. Only two articles collected by our research dealt with
readmission rates among women who underwent RARC. These studies showed that, considering the first 90
days after surgery, almost 30% of patients needed readmission. The difference between the risk of
readmission after RC in female patients was not found to be significantly influenced by the surgical
[18]
approach . These findings are consistent with the results shown by two relevant population-based analysis
comparing RARC and ORC including male and female patients [24,43] , but they differ from what was found in
a recent multicenter contemporary retrospective cohort comparative study by Soria et al. , in which the
[30]
readmission rate after RARC was significantly higher than after ORC. The authors attributed this difference
to the shortening of the LOS evidenced after RARC.

The main long-term complication that leads to reoperation in female patients who underwent RC is vaginal
dehiscence . The literature regarding this rare but potentially devastating complication is quite scarce;
[44]
however, it is important to report the relatively high percentage (7%) of patients who underwent
laparoscopic RC who required emergency surgical reoperation for transvaginal bowel evisceration due to
[44]
vaginal dehiscence recorded in the study by Kanno et al. . The authors, also citing the work by
[45]
Cronin et al. , hypothesized an association between higher incidence of vaginal dehiscence and minimally
invasive approach, which could be due to overuse of electrocautery during colpotomy or inadequate
suturing caused by difficulty in suturing the bottom of the pelvic floor. Considering also the high median
age of these patients (82 years old), according to the authors, a vagina-preserving approach might be one
[46]
option for older female patients during RC, if possible. According to Lin et al. , the authors of the largest
case series documenting vaginal failure after RARC and ICUD, prophylactically addressing potential vaginal
prolapse at the time of extirpative surgery is an emerging issue. However, considering the rarity of vaginal
failure in RARC, these procedures need to be carefully deliberated.