Robot-assisted radical cystectomy (RARC) has become an increasingly preferred surgical approach for the management of muscle-invasive bladder cancer due to its minimally invasive nature and favorable perioperative outcomes. While multiple studies have confirmed oncologic equivalence between RARC and open radical cystectomy, the reporting of functional outcomes remains limited—particularly in female patients [1]. Postoperative urinary continence and sexual function are critical components of long-term quality of life for bladder cancer survivors, yet these aspects have often been overlooked in surgical planning and reporting [2,3].

This report presents sex-specific surgical strategies designed to preserve key anatomical structures and optimize functional recovery following RARC with intracorporeal neobladder reconstruction. By incorporating techniques derived from prostatectomy [4] and adapting them to the unique anatomical considerations in each sex [3-6], we aim to demonstrate how meticulous dissection, nerve preservation, and reconstructive methods can lead to improved continence and sexual function without compromising oncologic safety.

This study, including the use of anonymized surgical video, was approved by the Institutional Review Board (IRB No. 2023AN0487), and the requirement for informed consent was waived due to the retrospective and non-identifiable nature of the data.

In the male case, a 51-year-old patient with muscle-invasive bladder cancer and concomitant carcinoma in situ underwent RARC following neoadjuvant chemotherapy (Supplementary Video 1). A standard pelvic lymph node dissection was performed with exposure of the external iliac vessels and extension to Cloquet’s node. Functional preservation was prioritized through athermal early retrograde dissection of the neurovascular bundle using 30-degree lens toggling [7]. This technique allowed for enhanced visualization and minimized traction on the nerve.

Minimal apical dissection was carried out to preserve key periapical structures, including the detrusor apron, puboprostatic ligaments, and external urethral sphincter [4]. These efforts were complemented by a two-layer posterior reconstruction: the first layer between Denonvilliers’ fascia and the rhabdosphincter, and the second between the bladder neck and posterior urethra [8]. At 2 months, the patient demonstrated good daytime continence with one safetypad and maintained erectile function with a phosphodiesterase type 5 (PDE5) inhibitor, showing an Interntional Index of Erectile Function-5 (IIEF-5) score of 18.

In the female case, a 48-year-old patient with a prior history of chemoradiation therapy at an outside institution presented with recurrent carcinoma in situ. We planned a salvage cystectomy, and in consideration of the patient’s preference, robot-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder reconstruction was performed (Supplementary Video 2). Given the complexity and relative lack of discussion regarding female pelvic anatomy, functional preservation required specific strategies [6]. Autonomic nerves were preserved via a lateral-to-medial robotic dissection approach targeting the neurovascular bundles along the lateral upper vaginal wall. Urethral preservation was achieved by avoiding entry into the endopelvic fascia, thereby maintaining suspensory support structures [2-6].

Figure 1. Supplementary Video 2. Robot-assisted radical cystectomy with intracorporeal orthotopic neobladder reconstruction in a 48-year-old female patient. Functional preservation was accomplished through lateral-to-medial dissection along the lateral upper vaginal wall to spare the autonomic nerves, and urethral preservation by avoiding entry into the endopelvic fascia. Round ligament suspension, configured in a hammock- like fashion, was employed as an anti-hypercontinence strategy.

After opening the vaginal fornix, dissection proceeded between the anterior vaginal wall and the posterior bladder wall, similar to the toggling approach used in male patients [5,6]. Several techniques were used to reduce hypercontinence, including round ligament suspension and omental packing beneath the neobladder. The round ligament was suspended in a hammock-like fashion to prevent neobladder over-angulation and associated voiding dysfunction. Vaginal reconstruction was performed using transverse cuff closure to preserve vaginal width and length and reduce the risk of dyspareunia [3]. At two months, the patient reported voluntary voiding every 2 to 3 hours with minimal pad use. Uroflowmetry showed a peak flow rate of 23.0 mL/sec with a voided volume of 410 mL, and nighttime continence was achieved with fluid restriction and scheduled voiding. She remained sexually active without discomfort.

The preoperative, intraoperative, and postoperative clinical information of the two patients is summarized in Table 1.

Table 1 . Clinical and perioperative characteristics of two patients.

Variable	Case 1	Case 2
Sex/Age/ASA	Male/51/II	Female/48/II
Initial TURBT pathology	Urothelial carcinoma, T2 high grade with CIS	Urothelial carcinoma, T2 high grade with CIS
Neoadjuvant chemotherapy	Completed (gemcitabine/cisplatin)	Previously treated with CCRT (gemcitabine/cisplatin)
History of pelvic radiation	None
Surgical method/urinary diversion	RARC with ONB (TIUD)	RARC with ONB (TIUD)
Operative time/console time/ EBL	370 min/332 min/150 mL	430 min/379 min/250 mL
Lymphnode dissection type/yield	Standard PLND/28 nodes	Standard PLND/27 nodes
Pathologic stage	ypT3aN0	pTisN0
Margin status	Negative	Negative
Length of hospital stay	11 d	15 d
Major complications (≤90 d)	None	None

ASA, American Society of Anesthesiologists Physical Status Classification; TURBT, transurethral resection of bladder tumor; CIS, carcinoma in situ; CCRT, concurrent chemoradiotherapy; RARC, robot-assisted radical cystectomy; ONB, orthotopic neobladder; TIUD, totally intracorporeal urinary diversion; EBL, estimated blood loss; PLND, pelvic lymph node dissection..

Functional preservation is increasingly regarded as a key component of surgical success in radical cystectomy, alongside oncologic control. In male patients, adapting prostatectomy-derived techniques—such as 30-degree lens toggling for nerve-sparing, minimal apical dissection, and layered posterior reconstruction—can promote early continence and erectile function recovery [4,7,8]. In female patients, where functional outcomes have historically received less attention, robotic surgery enables more precise and customized dissection. Lateral-to-medial nerve-sparing, careful preservation of urethral and vaginal structures, and anatomic reinforcement techniques such as round ligament suspension all contribute to better functional outcomes [3,5,6].

This report highlights the importance of individualized surgical planning based on anatomical context and patient characteristics. By integrating meticulous dissection techniques with reconstructive strategies aimed at preserving nerve, urethral, and pelvic support, RARC can achieve not only oncologic efficacy but also meaningful long-term quality of life benefits. Future studies should aim to standardize definitions of continence and sexual function and to evaluate these outcomes across different surgical modalities in a more structured and comparative manner.

All authors have no conflicts of interest to declare.

No external funding was received for this research.

None.

Conceptualization: SGK, SHK. Data curation: SGY, HJJ. Project administration: SGY, SHK. Supervision: TIN, JSS, MGP. Writing – original draft: SGY. Writing – review & editing: SHK.

Video 1. Robot-assisted radical cystectomy with intracorporeal orthotopic neobladder reconstruction in a 51-year-old male patient. Key surgical steps included athermal early retrograde dissection for nerve preservation, minimal apical dissection to maintain the detrusor apron, puboprostatic ligaments, and external urethral sphincter, followed by two-layer posterior reconstruction.

Video 2. Robot-assisted radical cystectomy with intracorporeal orthotopic neobladder reconstruction in a 48-year-old female patient. Functional preservation was accomplished through lateral-to-medial dissection along the lateral upper vaginal wall to spare the autonomic nerves, and urethral preservation by avoiding entry into the endopelvic fascia. Round ligament suspension, configured in a hammock-like fashion, was employed as an anti-hypercontinence strategy.