Step-by-Step Approach to Robot-Assisted Female Cystectomy, Anterior Exenteration, and Pelvic Organ Preserving Approaches

Zachary Dovey, Peter Wiklund

Research output: Chapter in Book/Report/Conference proceedingChapterpeer-review


In their lifetime, women will have a 0.27% or 1 in 400 risk of being diagnosed with bladder cancer, approximately four times less than men. The standard treatment for localized muscle invasive bladder cancer (MIBC), as well as carefully selected higher risk non-muscle invasive bladder cancer (NMIBC), is radical cystectomy (RC), which may be done by open (ORC) or robotic (RARC) approaches. The randomized controlled RAZOR trial is the largest study comparing ORC with RARC to date, demonstrating non-inferiority of RARC. At 3 years follow-up, comparing ORC versus RARC, disease-free survival (DFS) (65.4% vs. 68.4%), overall survival (OS) (68.5% vs. 73.9%), complication rates (69% vs. 67%), and outcomes related to quality of life (QOL) were not significantly different. For females, regardless of whether the procedure is open or robotic, the standard operation is anterior exenteration with removal of the bladder and urethra, an EPLND and removal of the gynecological organs. With a view to improving postoperative functional outcomes, pelvic organ prolapse (POP) can also be undertaken in carefully selected patients. After evidence acquisition with searches of PubMed, Scopus, and Web of Science databases using appropriate terms, 71 references with relevance to female RARC are reviewed. A detailed explanation of the step-by-step technical approach to female RARC by anterior exenteration and POP is outlined. Reviewing the literature reveals, apart from some evidence of an increase risk in urinary tract infection and perioperative anemia requiring transfusion, there is no gender-specific increase risk of adverse perioperative outcomes. Similarly, for either standard or POP female RARC, if neobladder is the modality of urinary diversion, females may have an increased risk of long-term incontinence, but otherwise there are no gender-specific differences in functional or oncological outcomes reported. With regard to female POP RARC, the published evidence suggests it is feasible and, when patients are carefully selected, has the potential to improve functional outcomes without compromising oncological outcomes. Although there is a paucity of learning curve analyses specific to female RARC, the data available shows female RARC can be taught in high volume robotic programs without adversely influencing outcomes. Moreover, as high volume robotic programs gain experience, single port RARC and RARC in elderly patients over 80 is becoming more widespread, with early reports of favorable results.

Original languageEnglish
Title of host publicationRobotic Urologic Surgery
Subtitle of host publicationThird Edition
PublisherSpringer International Publishing
Number of pages14
ISBN (Electronic)9783031003639
ISBN (Print)9783031003622
StatePublished - 1 Jan 2022


  • Anterior exenteration
  • Comparative outcomes for men and women
  • Pelvic organ preservation
  • Quality of life
  • Robotic cystectomy


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