Radical cystectomy is considered a morbid, surgically and oncologically challenging, and complex surgery. Tremendous effort has been invested in the field in the form of investigating and developing different forms of urinary diversions aiming to enhance both functional and cosmetic outcomes for improving patients’ quality of life. This included the formation of continent reservoirs and orthotopic neobladders. Subsequently, it was followed by the integration of ERAS (Enhanced Recovery After Surgery) protocol that promoted earlier ambulation, earlier advancement in diet, and standardization of surgical and anesthesiologic factors that led to a decrease in hospital stay.¹ Robotic radical cystectomy was described in the early 2000s.² Yet, the greatest leaps in popularizing the approach only occurred in recent years with technique standardization and robust support from prospective landmark trials (the RAZOR and iROC trials). The RAZOR trial was a prospective noninferiority trial published in 2018; it showed comparable oncological outcomes of the robotic-assisted radical cystectomy (RARC) approach to open radical cystectomy (ORC). Although the technique of diversion used in this trial was extracorporeal diversion, several benefits of the robotic approach were observed, including decreased blood loss (300 vs 700 mL, P < .001), decreased need for perioperative blood transfusion (24% vs 45%, P < .001), and decreased hospital stay (6 vs 7 days, P = .02).³ However, for patients to fully benefit from the minimally invasive approach, an intracorporeal urinary diversion (ICUD) may be necessary. This was evaluated in the iROC trial. iROC was a randomized prospective trial published in 2022. RARC+ICUD was compared to ORC. The main outcome was days spent outside the hospital and alive within 90 days of surgery; this was greater in RARC+ICUD than in ORC (82 vs 80 days, P = .01). The iROC also demonstrated decreased intraoperative blood loss, decreased thromboembolic events (1.9% vs 8.3%), and lower wound-related complications (5.6% vs 16%) in favor of the robotic approach, although the operative times were slightly longer. Patients who had ORC had a worse quality of life at 5 weeks but not at 12 weeks after surgery. Oncological outcomes were comparable between the groups.⁴

The robotic approach may facilitate better neurovascular bundle preservation for improved potency and possibly continence outcomes, as seen in robotic radical prostatectomy. Martini et al reported for RARC in a cohort of 732 patients, of whom 158 patients had erectile function analysis performed, 31% had full potency, and 24% more were potent with the assistance of oral medications. Unilateral nerve sparing (OR = 3.85, P < .001) and bilateral nerve-sparing (OR = 6.25, P < .001) were strong predictors for erectile function. Patients who underwent neobladder diversion had daytime continence of 86% and nighttime continence of 66%. Nerve-sparing approach has not emerged as a significant predictor for continence outcomes.⁵

An organ-sparing approach in females has a role in preserving hormonal and sexual function, and if desired, also fertility. Different methods have been described in the literature both for preserving the ovaries, performing salpingectomy (to decrease future ovarian cancer development), and preserving the whole genital tract. Historically 3% to 14% of involvement of the female genital tract was reported for muscle-invasive disease. Hence, it was not commonly used. Lately, there has been an increased interest in performing full or partial organ preservation. Patel et al published about the feasibility of the technique on 188 patients; in their cohort 8.5% underwent robotic surgery.⁶ In the study no difference was found in positive margin status for organ-sparing vs nonorgan-sparing approach (4.3% vs 7.9%, P = .19); recurrence-free survival and overall survival were comparable between the groups. Miura et al demonstrated in their study that 76 females who underwent radical cystectomy with U-shaped ileal neobladder and organ sparing had comparable day- and nighttime continence rates to male counterparts. However, the self-catheterization rate was higher for females (6.6% vs 1.1%, P = .013).⁷ Lavallée and Wiklund demonstrated in a cohort of 23 females who underwent organ preservation during RARC+ICUD with neobladder (Figure 1) that 13/15 females resumed sexual function, 70% had daytime continence, and 80% had nighttime continence.⁸

The incorporation of indocyanine green in the robotic system allows a possible method for assessing ureteroenteric anastomosis vascularity to reduce stricture rates. Ahmadi et al found that 47 patients who underwent RARC with ICUD had a lower ureteroenteric stricture rate than 132 patients who didn’t undergo indocyanine green–assisted anastomosis in a median follow-up time of 12 months (0% vs 10.6%, P = .02).⁹

Robotic radical cystectomy with cutaneous ureterostomies (Figure 2) is an underutilized approach that can be appealing to a selected group of patients who are older, morbid, and with limited life expectancy, who may benefit from a shorter surgery with the advantages of the robotic approach, and without the need for performing intestinal anastomosis.¹⁰ In addition, it can be offered to patients with inflammatory bowel disease or short-bowel syndrome when harvesting intestinal segments may not be advised.

Yet, one shortcoming of this diversion is remaining stent dependent due to high stricture rates at the level of skin anastomosis.

Single-port (SP) robotic approach to radical cystectomy has recently been described. Mehrazin et al discussed the surgical technique of performing radical cystectomy using the SP approach performing different types of urinary diversions including neobladder.¹¹ It appears that operative times can be maintained. The SP approach was found to have less narcotic use and shorter return of bowel function after surgery. Before larger comparative studies are performed, the SP approach can be considered in patients with hostile abdomen where working space is limited, pushing further the use of robotic surgery to patients who would otherwise be offered an open approach.

Radical cystectomy is a lengthy surgery that can pose ergonomic challenges for surgeons. While underreported, the robotic approach may benefit surgeons with better ergonomics. Monfared et al reported that the robotic approach is associated with lower postoperative discomfort and muscle strain in both upper extremities, but with increased static neck positioning.¹² Shugaba et al compared the laparoscopic to robotic approach in different types of surgeries and found that the robotic approach was associated with lower cognitive and musculoskeletal demands than laparoscopic surgery.¹³

The robotic approach is heavily incorporated in the field of urology, particularly in radical prostatectomy and commonly in kidney surgeries. The adoption of RARC+ ICUD is slowly gaining momentum, providing reduced perioperative morbidity without hindering oncological outcomes, potentially improving potency outcomes, and decreasing ureteroenteric stricture rates. Additionally, it may lead to lower incidence of peritoneal adhesions facilitating easier abdominal reentry for stricture repair or other surgical indications. Nonetheless, further long-term studies are needed to validate and establish the advantages of the robotic approach.