**6. Others techniques for neo-bladder**

Some other worldwide groups have developed shaping techniques, equally safe and effective, some of them are resume in the next lines.

The *Karolinska modified Studer "U"*a 55–60 cm ileum is isolated 25 cm proximal to the ileocecal valve. After antimesenteric incision and detubularization the posterior plate is created and its follow by an anterior closure using the initial 15 cm approximately. The rest of the segment is part of the chimney and in his lower side proximal to the pouch is kept open to stend the ureters later. The uretero-ileal anastomosis is perform in the free-top of the chimney once the Simple J ureteric stents were previously introduce [22, 23].

The *Padua Intracorporeal Neo-Bladder* starts with a segment of 42 cm portion of the ileum, detubularization of the distal part 8 cm is perform, follow by detubularization of the distal side 24 cm, the left horn is created with a stapler. The first 8 cm ileum segment is folded and sutured to the first 8 cm ileum segment, creating the posterior plate. To complete the anterior wall, the last 16 cm of the posterior plate are folded to configure it, both edges are suture together. The urethro-ileal anastomosis is performed and the uretero-ieal anastomosis is performed over the posterior wall [23].

The *modified Studer "U"* from University of Southern California, starts with the identification of the most mobile terminal ileum to reach the urethra. 11 cm towards the ileocecal valve for distal end of the pouch, 22 cm for apex of the posterior plate. 44 cm for proximal end of the pouch and beginning of the chimney. The distribution goes to bowel detubularization, creation of the posterior plate and rotation 90o counterclockwise. Urethto – ileal anastomosis and cross folding of the pouch is perform. The uretero ileal anastomosis is performed end-to-side [24].

The *Hautmann W*, a 50 cm of the ileum is isolated and divided into a right and left limb, then the ileum is detubularized and suture to create the posterior plate by and ascending and descending loop. Urethro-ileal anastomosis is performed by a tension-free Van Velthoven technique. The half of the anterior wall is closure and uretero ileal anastomosis is made on each chimney once the ureters were spatulated [22, 23].

The *Pyramid Pouch* starts with the selection of a 50 cm segment of the ileum > 15 cm proximal to the ileocecal valve. The utethral-ileal anastomosis is done at this point, following by the detubularization and formation of the posterior plate except the 2 cm uppermost portion as chimneys. 10 cm of the anterior plate are closure to accomplish the anterior wall. Uretero-ileal anastomosis an end-to-side is performed over the proximal end of both ileal limbs [22, 23].

### **7. Literature review**

The benefits of robotic-assisted laparoscopic surgery rely mainly on the enhancement implied to the ergonomics of the surgeon and a reduction of the learning curve for some procedures. The down size is the lack of tactile feedback during the procedure and the associated costs. Specific improvements to roboticassisted radical cystectomy are decreased intra-operative blood loss, reduced blood transfusion rates and a shorter length of hospital stay days. Due to the minimally invasive procedure, the surgical time have a tendency to increase in the robotic approach radical cystectomy.

Menon et al. was the first to describe a nerve-sparing robotic-assisted radical cysto-prostatectomy and extra-corporeal urinary diversion back in 2003 [10]. The completely intra-corporeal urinary diversion was reported by Gill et al. in the year 2000. The intra-corporeal urinary diversion was performed in a laparoscopic radical cystectomy and since then the technique found it's way to more recent robotic procedures [25]. The robotic-assisted radical cystectomy (RARC) continues to evolve and the first randomized controlled trial comparing it with open radical

cystectomy (ORC) was published in 2009 [26]. The international literature includes multiple articles of technique and complications of RARC but a scarce number of randomized controlled trials comparing its oncologic outcomes and/or benefits with a different approach.

As previously mentioned, the first randomized controlled trial (RCT) to confirm the viability and oncologic safety of the RARC in comparison to ORC was published by Nix in 2009. Nix and his group found a median surgical time longer for RARC, lesser intra-operative blood loss, shorter time to bowel sounds and shorter hospital stay in comparison with ORC [26]. In contrast, controversial findings have been reported comparing RARC and ORC. A meta-analysis of the RCT's found no significant difference in peri-operative complications, length of hospital stay, time to flatus, lymph node yield and positive surgical margins [27]. A lower intraoperative blood loss and longer surgical time is a consistency among the studies.

Comparative findings (surgical, peri-operative complications and oncologic) between randomized controlled trials are described (**Table 1**).

#### **7.1 Oncologic results and safety of the robotic-assisted approach**

The Robot-assisted radical cystectomy versus open radical cystectomy trial (RAZOR) is a phase 3 non-inferiority study to compare the oncologic outcomes, complications, pelvic nodes burden, cost and morbidity [29]. At the beginning 350 patients were randomized but only 150 patients underwent RARC and 152 patients ORC after exclusions. The 2-year progression-free survival was 72.3% (95% CI 64.3–78.8) in the RARC group and 71.6% (95% CI 63.3–78.2) in the ORC group, these results demonstrated non-inferiority of robotic surgery VS open approach (difference 0.7%, 95% CI −9.6–10.9%, *p* non-inferiority=0.001). Local recurrences were similar in both groups (RARC 4%, ORC 3%). Twenty two percent and 23% had distant metastasis in RARC and ORC respectively and no port-site recurrences were reported [29]. Results from the International Robotic Cystectomy Consortium confirmed 16% in distant disease-recurrence, 11% local disease-recurrence, 1% peritoneal carcinomatosis and 0.4% port site recurrence [30].

In a RCT update from the Memorial Sloan Kettering Cancer Center, no statistical differences were reported in disease-recurrence (p=0.4), cancer-specific survival (p=0.4) and overall-survival (p=0.8) between RARC and ORC groups. The authors reported a median follow-up of 4.9 years [31].

In a recent meta-analysis, the disease-recurrence was analyzed in 458 patients with no difference between RARC and ORC (RR 0.94, 95% CI 0.69–1.29) [32]. In the same study, all included articles reported the rate of positive surgical margins (PSM) of 541 participants, it stated no difference between a robotic and open approach (RR 1.16, 95% CI 0.56–2.40) [32]. Tang et al. pooled data from 3 different RCTs and his collaborative group reported that both approaches have similar rate of PSM [33]. A Cochrane review found similar outcomes in the time-to-recurrence and PSM rates for both surgical approaches [34].

The CORAL trial update described similar five-year survival for open, roboticassisted and laparoscopic radical cystectomy. The 5-year recurrence-free survival was 60%, 58% and 71%; 5-year cancer-specific survival was 64%, 68% and 69%; and 5-year overall survival was 55%, 61% and 61% for open, robotic-assisted and laparoscopic radical cystectomy, respectively [35].

#### **7.2 Operative time**

The RARC operative time has been reported to be the longer in comparison to the open approach, with a mean difference from 68.51–90 minutes [32, 36, 37]. Tang et al.


#### *Modern Approach to Diagnosis and Treatment of Bladder Cancer*

