**Abstract**

The purpose of this chapter is to provide a step-by-step description of the robot-assisted radical cystectomy with an intra-corporeal neo-bladder technique and a recent review of its outcomes. The procedure is also known as anterior pelvic exenteration or cysto-prostatectomy in the case of female or male respectively. Radical cystectomy (RC) is the gold standard treatment for muscle-invasive bladder cancer, but there are also several surgical indications for non-muscle-invasive bladder cancer. In the past years, minimally invasive surgery and the da Vinci system technology have played a major role in this procedure, with description of brand-new techniques and specific approaches for the creation of a continent urinary reservoir. The following chapter provides a detailed description of the robot-assisted radical cystectomy (RARC) with Y-shaped intra-corporeal bladder as well as a literary review of distinct perioperative, functional and oncological outcomes from the available RARC randomized controlled trials. Despite its high cost and complexity, the intra-corporeal technique has become widely popular around the world and is used more frequently each time. The described data in this chapter, demonstrates that morbidity can be reduced whilst simultaneously offer non-inferior oncological results and less intraoperative blood loss in contrast to the open RC approach.

**Keywords:** radical cystectomy, neo-bladder, urinary diversion, robotic surgery, bladder cancer

### **1. Introduction**

The Radical Cystectomy with extended pelvic lymph node dissection has evolved dramatically with the emergence of new robotic technological advancements.

Bladder cancer is a broad-spectrum disease, from papillary urothelial noninvasive tumor to aggressive invasive lesions that require radical and multi-modal management [1]. Radical cystectomy (RC) has been the gold standard treatment for muscle-invasive bladder cancer [2, 3].

Historically, in the early 1800s, RC was performed with an open approach however the principles for the current technique were published in 1949 by Marshall and Withmore. Both authors listed some important disadvantages of this procedure such as its high impact on morbidity, overall survival rate and patient's quality of life [4, 5].

Over the years, this procedure has been redefined thanks to the increasing new technology developed around minimally invasive approaches (laparoscopy and robotic-assisted laparoscopy), that implies numerous advantages compared with standard procedures, including decreased blood lost, postoperative narcotic use, time to flatus, time to bowel movement and length of stay [2, 6–9].

Menon and his group developed the robotic-assisted technique and approach to the prostate at the beginning of the 2000s. Based on the rationale that radical prostatectomy could be performed with the robot-assisted approach, this principle was applied to multiple surgeries including radical cystectomy and urinary diversion [10–12].

Initial laparoscopic experience on radical cystectomy was described by two main groups, the first one leaded by Parra et al., who reported their initial experience in the department of Surgery of Saint Louis University School of Medicine in Missouri in 1992 and the second by Sanchez de Badajoz et al., who described several case reports of RC, lymph node dissection and laparoscopic urinary diversion in 1995 in the department of Surgery of the University of Malaga, Spain [4, 12, 13].

First reports of robotic-assisted radical cystectomy (RARC) were reported by Menon and colleagues in Egypt in 2003, where they concluded and published that this approach was both safe and feasible. Recent publications explore the potential to improve morbidity and oncological outcomes [4, 10, 14].

According to the National Inpatient Sample, RARC has gained popularity among urologic surgeons as the preferred minimally invasive approach for bladder malignancies and continues to evolve throughout time. Nowadays, highly experienced surgeons have adventured to perform intra-corporeal urinary diversion reconstruction and have compared general and oncological outcomes as well as health-related quality of life in a large number of patients [4–15].
