Clinical Application Research Of Nerve-sparing Robot-assisted Laparoscopic Radical Cystectomy

Objective:To investigate the clinical feasibility and efficacy of nerve-sparing robot-assisted laparoscopic radical cystectomy.Methods:We retrospectively reviewed the clinical data of 12 male patients received robot-assisted laparoscopic radical cystectomy at our center from March 2016 to May2018.The age ranged from 45 years to 65 years.All patients have normal erectile function before surgery,and all preoperative international erectile function questionnaire-5（IIEF-5）scores were more than 17.Robot-assisted laparoscopic prostatocystectomy and pelvic lymphadenectomy were performed with preservation of bilateral neurovascular bundles,internal accessory pudendal artery and pubic bladder complex.All patients were suggested to take PDE5I postoperatively.The sexual function after operation was evaluated regularly.Results:All procedures were completed successfully and the surgical margin was negative.There were no serious intraoperative or postoperative complications.Postoperative pathology showed invasive high-grade urothelial carcinoma or Cis,including 9 cases with stage T₂N₀M₀or below,and 1 case with stage T_3aN₀M₀tumor,and 1 case with stage carcinoma in situ.Brick ileal cystectomy was performed in 3patients because of short urethral preservation and 1 case of highly suspected sphincter injury.Robot-assisted pure laparoscopic radical cystectomy with orthotopic ileal neobladder was performed in 8 patients.The follow-up period was 12 to 36months（mean 20.7 months）.The urine control was good in eight cases accepted robot-assisted pure laparoscopic radical cystectomy with orthotopic ileal neobladder.There was no tumor recurrence or metastasis.The average IIEF-5 scores at 3,6 and12 months after operation were 10.9±6.9,12.3±6.9 and 14.1±8.0,respectively.At 12months of follow-up,five（41.7%）patients were able to maintain adequate erectile function with drug support,there patients（25%）had erectile function but failed to perform satisfactory sexual intercourse,and 4 patients（33.3%）did not have erectile function.Among the four patients without erectile function,one patient was considered to be related to urethral sphincter injury,the other one might be related to short urethral retention,and the reasons for the remaining two cases were considered to be neuroanatomical variation.In the five patients who were satisfied with their sexual life,the quality and satisfaction of their sexual life were decreased when they stopped using tadalafil 15 months after the surgery,but they were still able to have a successful sexual life.Conclusion:Nerve sparing robot-assisted laparoscopic cystectomy is a safe and technically feasible procedure with ideal functional results for the patients who desire to preserve sexual function.It is a safe and feasible clinical operation with good urinary control,high safety and satisfactory effect of tumor removal.However,the operation needs expensive equipment,the operation is complex,and the learning curve for the operators is long.At the same time,perfect postoperative management plays an important role in the recovery of sexual function.