Objective: To compare perioperative, postoperative and functional outcomes between stapled (ST) and handsewn (HS) intracorporeal orthotopic neobladder (iON) configuration during robot-assisted radical cystectomy (RARC).

Methods: Our single centre institutional bladder cancer dataset was queried for 'RARC' 'stapled' and 'handsewn' iON. Baseline, peri- and postoperative features of patients treated between January 2018 and July 2023 were collected. Continuous and categorical variables were compared using Kruskal-Wallis and chi-square tests. The Kaplan-Meier method was applied to assess functional outcomes. Cox regression analysis was performed to identify predictors of continence recovery.

Results: Overall, 116 patients were enrolled (HS-iON, 60 patients). There were no differences in perioperative outcomes, except for the hospital length of stay, being shorter in the HS-iON cohort (P < 0.001). There were no differences in the 30- (P = 0.17) and 90-day (P = 0.69) postoperative complications. The stone rate was lower in the HS-iON cohort (P = 0.01). At Kaplan-Meier analysis, patients with HS-iON had higher day- (P < 0.001) and night-time (P < 0.001) continence recovery probabilities. At multivariable analysis, the only independent predictor of continence recovery was 'sex-sparing approach'. Excluding patients who underwent sex-sparing procedures, the HS approach was the only predictor of night-time continence recovery (hazard ratio 2.6, 95% confidence 1.27-5.34; P = 0.009).

Conclusions: Hand sewing may represent a preferable option for iON configuration during RARC. ST-iON did not prove to either reduce operative times or perioperative complications, while seemed to significantly impact on the risk of stone formation and continence recovery. Whenever oncologically feasible, a sex-sparing approach should be preferred to improve day- and night-time continence recovery.