Introduction

Radical cystectomy is the standard treatment for muscle-invasive bladder cancer. In selected female patients, vaginal preservation has been proposed as a strategy to maintain sexual function and pelvic anatomy, while aiming to achieve adequate oncological control.

Objectives

To present a clinical case and surgical video of robot-assisted radical cystectomy with vaginal preservation, describing the surgical technique, perioperative outcomes, management of an intraoperative complication, and subsequent oncological treatment strategy, in line with current evidence.

Materials and Methods

We report the case of a 62-year-old female who presented with isolated gross hematuria. Cystoscopy revealed a large bladder tumor predominantly involving the anterior wall. Transurethral resection was incomplete due to tumor size. Initial pathology demonstrated a high-grade, muscle-invasive carcinoma with a pure squamous phenotype. Staging with a CT scan of the chest and abdomen showed no evidence of distant disease. Given the uncertain benefit of neoadjuvant chemotherapy in this histological context, upfront surgical management was selected. The patient underwent robot-assisted radical cystectomy with hysterectomy and bilateral salpingo-oophorectomy, vaginal preservation, bilateral pelvic lymph node dissection, and ileal conduit urinary diversion (Bricker).

Results

The procedure was completed successfully. During left pelvic lymph node dissection, an inadvertent transection of the obturator nerve occurred and was immediately repaired with a primary end-to-end suture. The postoperative course was uneventful, with drain removal on postoperative day five and discharge on day seven. Functional recovery was satisfactory, with no clinically significant motor deficit. Final pathology revealed high-grade urothelial carcinoma with extensive squamous differentiation, perivesical fat invasion, and nodal involvement (pT3aN2). Given the high risk of recurrence, PD-L1 negativity, and preserved renal function, adjuvant chemotherapy with cisplatin and gemcitabine was initiated.

Conclusions

Robot-assisted radical cystectomy with vaginal preservation is a feasible surgical option in selected female patients. Available evidence suggests that, when appropriately indicated, this approach may allow preservation of sexual function without compromising oncological outcomes. Multimodal treatment remains essential in patients with high-risk pathological features.