Here our surgical technique on robotic genitalia preserving female cystectomy is presented. A 59 year-old female patient with muscle invasive bladder cancer was referred to our hospital for robotic radical cystectomy and intracorporeal Studer-pouch construction. Incomplete trans urethral resection of bladder cancer was performed 2 months ago at a peripheral hospital and pathological examination revealed muscle invasive, high-grade papillary urothelial carcinoma (T2GIII). She had undergone two open abdominal surgeries (appendectomy and cesarean section) 30 and 35 years previously. Laboratory tests including blood urea nitrogen, serum creatinine, hemogram, ALT, and AST were within normal limits. A CT scan of the abdomen and pelvis revealed several masses within the bladder, measuring up to 1 cm in greatest dimension. On the other hand, peri-vesical fatty tissue and upper urinary tract were normal in appearance.

Surgical Technique: Ureters are dissected in the retroperitoneal area down to the broad ligament where its most distal part is reached. Then, ureters are double clipped and distal ends are sent for analysis. On the anterior abdominal wall parietal peritoneum lateral to the medial umblical ligament is opened and Retzius space is entered, endopelvic fascia is exposed. At this stage, median umblical ligament is kept intact to suspend the bladder up in order to facilitate the posterior dissection. Peritoneum is incised posterior to the bladder where it folds over to the uterus. Adhesions from previous cesarean section are taken down. As downward dissection continues, vesico-vaginal space is entered. Dissection continues toward to the peritoneum, posterior bladder pedicles are developed, and cut. Distal ureteral stumps are dissected off of the anterior vaginal wall to be included in the surgical specimen. Having completed the posterior dissection, urachus is severed at the level of umblicus to expose the area anterior to the bladder. Urethra and bladder neck are identified and endopelvic fascia on each side of the urethra are opened. Most proximal urethra is dissected from the anterior vaginal wall without disturbing lateral paravaginal tissues. Bladder neck is suture tied and occluded to prevent spillage of urine to the peritoneal cavity at the time of division. Urethra is divided; its most proximal margin is excised and sent for frozen section analysis. Lastly, lateral bladder pedicles are taken down and specimen is entrapped in a bag. Surgery lasted for about 2 hours. There was minimal bleeding less than 100 ml. No major perioperative complications were seen.

In conclusion, robotic genitalia preserving female cystectomy is surgically feasible without significant bleeding and major surgical complications. Paravaginal tissues thought to be crucial for external sphincteric function are left untouched with this technique.