To show different approaches for sexual-sparing robot assisted radical cystectomy in women.

Radical cystectomy (RC) is a mainstay treatment for localized muscle invasive bladder cancer and high-risk non muscle invasive bladder cancer not responding to adequate endovesical therapy.<sup>1Stein JP, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients J Clin Oncol 2001 ;  19 : 666-675 [cross-ref]

Cliquez ici pour aller à la section Références</sup> In women traditionally RC is performed with hystero-adnexectomy and resection of the anterior vaginal wall, but this technique often brings sexual disorders. With time, vaginal sparing techniques have been developed to improve functional outcomes in women motivated to preserve their sexual function.<sup>2Veskimäe E, Neuzillet Y, Rouanne M, et al. Systematic review of the oncological and functional outcomes of pelvic organ-preserving radical cystectomy (RC) compared with standard RC in women who undergo curative surgery and orthotopic neobladder substitution for bladder cancer BJU Int 2017 ;  120 : 12-2410.1111/bju.13819Epub 2017 Mar 24PMID28220653.

Cliquez ici pour aller à la section Références, 3Ali-El-Dein B, Mosbah A, Osman Y, et al. Preservation of the internal genital organs during radical cystectomy in selected women with bladder cancer: a report on 15 cases with long term follow-up Eur J Surg Oncol 2013 ;  39 : 358-36410.1016/j.ejso.2013.02.004Epub 2013 Feb 17PMID23422323.  [cross-ref]

Cliquez ici pour aller à la section Références, 4Bai S, Yao Z, Zhu X, et al. The feasibility and safety of reproductive organ preserving radical cystectomy for elderly female patients with muscle-invasive bladder cancer: a retrospective propensity score-matched study Urology 2019 ;  125 : 138-14510.1016/j.urology.2018.09.035Epub 2018 Nov 14PMID30445122.  [cross-ref]

Cliquez ici pour aller à la section Références</sup> The indications for vaginal-sparing RC are absence of tumor in bladder neck or urethra and no sign of infiltration of anterior vaginal wall and parametria at preoperative staging.

Procedure steps as follows. Step 1: Bilateral adnexectomy and ureteral isolation until their distal portion. Step 2: Vesico-vaginal dissection. Step 3: Bilateral pelvic and common iliac node dissection. Step 4: Ureteral clamping and section. Step5: Posterolateral bladder pedicle dissection. Step 6: Anterior dissection of the bladder towards the urethra. In women, this should be achieved without injuring the Santorini plexus and innervation of the clitoris. Step 7: Bladder neck identification and urethral dissection. Cystectomy is completed. Step 8: En bloc hystero-adnexectomy with anterior vaginal wall preservation; the vaginal pedicles are spared too. Step 9: Specimen extraction from the vagina and vaginal suture.It is also possible to perform a fully sexual-sparing robotic RC by following the vesico-vaginal plan without dissecting the vaginal dome and leaving internal genitalia intact. This technique is typically carried out in case of young women with no pathological uterine and ovarian findings.Vesico-vaginal plan can also be developed after opening the vaginal dome. This approach gives the possibility to subsequently dissect the cervix, to identify and spare the vaginal pedicles and to perform an “en bloc” radical cystectomy, with preservation of the anterior vaginal wall.In case of neobladder, diversion is carried out intracorporeally following the principles of the Saint Augustin neobladder.<sup>5Asimakopoulos AD, Campagna A, Gakis G, et al. Nerve Sparing, robot-assisted radical cystectomy with intracorporeal bladder substitution in the male J Urol 2016 ;  196 : 1549-155710.1016/j.juro.2016.04.114Epub 2016 Jul 15PMID27423759.  [cross-ref]

Cliquez ici pour aller à la section Références</sup>

Robot assisted anterior pelvectomy with anterior vaginal wall preservation is a feasible and mini-invasive technique. For a satisfying functional result, it is crucial to preserve the vaginal neurovascular pedicles. This sexual-sparing approach must be carried out after a correct patient selection: women motivated to preserve their sexual function and ideally in the neobladder setting, when a posterior support for the urinary diversion is needed. Absence of tumor in bladder neck and urethra at magnetic resonance imaging could help patient selection.