Robotic cystectomy with intracorporeal diversion
Keyhole robotic surgery that removes the bladder for bladder cancer, along with nearby organs and lymph nodes, and then builds a new way for urine to leave the body, an ileal conduit or a neobladder, from a piece of bowel entirely inside the body.
Also called RARC, Robot-assisted radical cystectomy, Robotic radical cystectomy, Intracorporeal urinary diversion, ICUD, Totally intracorporeal robotic cystectomy, Intracorporeal ileal conduit, Intracorporeal neobladder
- Where
- Hospital operating room
- Anesthesia
- General anesthesia (fully asleep)
- Time in the room
- About 5 to 8 hours
- Hospital stay
- Usually 4 to 8 days
- Going home with
- With an ileal conduit: a urostomy bag and thin stents from the stoma for about 1 to 3 weeks. With a neobladder: a catheter, sometimes with a second tube through the belly, for about 2 to 3 weeks. Sometimes a drain for a few days.
- Back to normal
- About 6 to 12 weeks
- Back to work
- Desk work in about 4 to 8 weeks; physical jobs in about 2 to 3 months
Overview
A radical cystectomy removes the bladder. In men, the prostate and seminal vesicles are usually removed with it. In women, the uterus, cervix, and often the ovaries and the front wall of the vagina are removed, although some of these can be kept in selected women. The lymph nodes of the pelvis are removed too. Because urine then needs a new path out, the surgeon builds a urinary diversion from a short piece of small bowel: an ileal conduit, which drains into a bag on the belly, or a neobladder, a new bladder joined to the urethra so you pass urine the usual way.
In the robotic operation, your surgeon works through about six small keyhole cuts while seated at the da Vinci console in the same room, controlling a 3D camera and wristed instruments. Every movement comes from the surgeon's hands; the robot never moves on its own. Intracorporeal means inside the body: the diversion is also built inside the belly, with robotic instruments and staplers, rather than through a larger incision at the end of the operation (extracorporeal). The only larger cut is a small one, usually low on the belly, to remove the bladder in a bag. In some women it comes out through the vagina instead.
The iROC trial in the United Kingdom, published in 2022, randomly assigned 338 people to robotic cystectomy with intracorporeal diversion or to open surgery. Those in the robotic group spent slightly more days alive and out of the hospital in the first 90 days, had fewer blood clots and fewer wound problems, and regained activity sooner. Earlier, the RAZOR trial showed that robotic cystectomy controls cancer as well as open surgery. Even so, this is a major operation, and about half of people have at least one complication in the first 3 months, most of them treatable.
For muscle-invasive cancer, chemotherapy before surgery is recommended when it is safe for you, because it helps people live longer. Many people now receive immunotherapy along with it. Choosing between a conduit and a neobladder is one of the biggest decisions before surgery, and it depends on your health, your kidney function, where the cancer is, and how you want to live afterward.
The parts of your body involved
The bladder is a muscular bag low in the pelvis. Urine reaches it from the kidneys through the two ureters and leaves through the urethra. In men, the prostate sits just below the bladder; in women, the uterus and vagina sit just behind it. The lymph nodes that filter fluid from the bladder run along the large blood vessels on both sides of the pelvis. The small bowel lies just above, which is why a piece of its last part, the ileum, is the usual material for the new urinary path.
- Bladder
Stores urine. In bladder cancer, the tumor starts in the lining and can grow into the muscle wall.
- Ureters
The tubes carrying urine from the kidneys. They are cut near the bladder and later joined to the new conduit or neobladder.
- Prostate, or uterus and vagina
Organs next to the bladder that are usually removed with it, because cancer can spread into them. Some can be kept in selected people.
- Urethra and sphincter
The outflow tube and the ring of muscle that keeps you dry. A neobladder needs a healthy urethra and sphincter.
- Ileum
The last part of the small bowel. A short piece is used to build the diversion, and the bowel is joined back together.
- Pelvic lymph nodes
Filters along the pelvic blood vessels, removed to check for spread and to remove any cancer there.
Why it’s done
Removing the bladder is the most established way to cure bladder cancer that has grown into the muscle, or high-risk cancer that other treatments have not controlled. The intracorporeal robotic approach aims to do the same operation with less impact on the body.
- To cure muscle-invasive bladder cancer
With chemotherapy beforehand when possible, removing the bladder and nodes cures many people whose cancer has not spread beyond the pelvis.
- When BCG has not worked
High-risk cancer that keeps coming back after BCG treatment has a real chance of becoming invasive. Removing the bladder at this stage gives a high chance of cure.
- Exact staging
The pathology report shows how deep the cancer went and whether nodes were involved, which guides treatment after surgery.
- Smaller incisions and fewer wound problems
In the iROC trial, the intracorporeal robotic approach meant fewer wound complications and blood clots than open surgery.
- Controlling bleeding or pain
Sometimes the bladder is removed because the cancer causes bleeding or symptoms that cannot be controlled another way.
Other options
- Radical cystectomy with an ileal conduit, built through an incision
The same operation with the bladder removed robotically or through an open cut, and the conduit made outside the body through a small lower incision. Results for cancer control are similar.
- Neobladder
A new bladder made from bowel and joined to the urethra, built inside or outside the body. Read more about living with one.
- Continent cutaneous pouch
An internal bowel pouch emptied with a thin catheter through a small opening on the belly, with no outside bag. It is usually built outside the body.
- Bladder-sparing trimodality therapy
A thorough scope removal of the tumor followed by radiation with chemotherapy. For well-selected people with muscle-invasive cancer, it can keep the bladder with good long-term results, but it needs lifelong scope checks, and some people later need cystectomy.
- Partial cystectomy
Removing only the part of the bladder with cancer. Only a small number of people are suitable.
- More bladder treatments for non-invasive cancer
For high-risk cancer that has not grown into the muscle, newer medicines placed into the bladder or given by vein can sometimes keep the bladder, though with a higher chance of the cancer returning.
Getting ready
Tick items off as you go. Your checklist is saved on this device only.
Weeks to months before
The week before
The day before
The morning of surgery
In the operating room, step by step
Press play or pick a step. Each drawing shows what your surgeon is doing at that moment. Your team may do some steps differently.
1. Going to sleep and tilting head-down
The anesthesiologist puts you fully to sleep and places a breathing tube. A catheter is placed in the bladder. Your arms are padded and tucked, your legs are slightly apart, and the table is tilted steeply head-down so the bowel slides up out of the pelvis.
More detail
The tilt is usually about 25 to 30 degrees for the bladder removal, and many teams level the table somewhat while building the diversion. The anesthesia team limits IV fluids during the tilt to reduce swelling and protects your eyes and pressure points.
The surgeon sits at a console a few steps from you and moves every instrument with hand controls and foot pedals. The robot cannot move on its own or make decisions.
A camera on one arm gives the surgeon a bright, three-dimensional picture magnified about ten times, which helps them see small nerves and vessels.
The instruments are about the width of a pencil and bend like a wrist inside your body, so the surgeon can stitch and dissect through small openings.
A bedside assistant and a scrub nurse stay at the table, and the anesthesia team watches your breathing and blood pressure throughout. Most U.S. hospitals use the da Vinci system made by Intuitive.
After the operation
In the hospital
- Waking up
You wake in the recovery room with an IV, leg sleeves, and either a stoma bag with thin stents or a catheter for the neobladder, and sometimes a drain. Many programs avoid a tube through the nose into the stomach.
- Walking early
Nurses help you sit up the evening of surgery and walk the next day, several times a day. Walking is the best thing you can do for your bowels and lungs.
- Eating
Enhanced recovery programs start sips of liquid early and add food as your bowels wake up. Chewing gum may help. Slow bowels for a few days are common.
- Pain control
Scheduled acetaminophen, nerve blocks and other non-opioid medicines, with opioid pills only for bad moments.
- Learning your new system
An ostomy nurse teaches you and a family member to empty and change the bag. With a neobladder, you learn to rinse mucus from the catheter.
- Blood clot prevention
Blood thinner shots are given in the hospital and usually continued at home for about 4 weeks after surgery.
- Going home
Most people go home after 4 to 8 days, once they are eating, passing gas, walking, and comfortable caring for the bag or catheter.
At home
- Pain
Soreness at the cuts and in the belly for 2 to 4 weeks. Take acetaminophen as directed and opioid pills only if needed.
- Stoma and stents
Change the bag every few days, or sooner if it leaks. Mucus in the urine is normal because the conduit is made of bowel. The stents are removed in clinic after about 1 to 3 weeks.
- Neobladder catheter
Rinse the catheter as taught to clear mucus, which can block it. After about 2 to 3 weeks, often after an X-ray dye test, the catheter comes out and you start a timed voiding schedule.
- Drink plenty
Dehydration is a common reason for coming back to the hospital. Drink steadily through the day, more in hot weather, and watch for dark urine, dizziness or a dry mouth.
- Diet and bowels
Eat small, frequent meals and add foods back gradually. Bowel habits may be looser or more irregular at first.
- Activity and lifting
Walk several times a day. Avoid lifting more than about 10 to 15 pounds for about 6 weeks, and support the stoma area when you cough to lower the risk of a hernia.
- Showering
You can shower with the bag on or off. Water does not harm the stoma.
- Driving
Do not drive while taking opioid pills. Most people drive again in about 2 to 4 weeks.
- Sex and intimacy
When you feel ready, usually after about 6 weeks. Men may need erection treatments. Women may notice vaginal shortening or dryness, which can be helped.
- Work
Desk work in about 4 to 8 weeks; physical jobs in about 2 to 3 months.
Recovery timeline
- Day 0Surgery day
Surgery takes about 5 to 8 hours. You wake in the recovery room and may sit up that evening.
- Days 1 to 3Walking and first food
You walk several times a day, start eating, and begin learning to care for your stoma or catheter.
- Days 4 to 8Going home
Most people go home once eating, passing gas and confident with their care.
- Weeks 1 to 3Stents and catheter out
Conduit stents are removed in clinic. With a neobladder, the catheter comes out after the joins have healed, often after a dye test.
- Weeks 2 to 3Pathology review
Your surgeon reviews the stage, margins and lymph nodes and discusses whether treatment after surgery is advised.
- Weeks 4 to 12Getting stronger
Energy returns slowly. Most people are doing most daily activities by 6 to 12 weeks.
- About 3 monthsFirst scan and blood tests
A CT scan of the chest, belly and pelvis, and blood tests for kidney function and blood chemistry.
- 6 to 12 monthsNeobladder control improving
With a neobladder, daytime control usually improves over months, with nighttime control taking longer.
- Years 1 to 5 and beyondOngoing follow-up
Scans every 3 to 6 months at first, then less often, plus checks of kidney function and vitamin B12, and of the urethra in some people.
What it feels like
People who have had a cystectomy often say it was the hardest physical recovery of their lives, and also that they adapted to life with a new urinary system faster than they feared. The first weeks take patience.
Deciding on a diversion
Choosing between a bag and a neobladder can feel impossible, and many people grieve the loss of their bladder before surgery.
What helpsTalk with an ostomy nurse and, if possible, with someone who has each type. Ask your surgeon which choices are realistic for your health and cancer.
The night before
Fear about the size of the operation, about waking up with a bag, or about the cancer itself.
What helpsWrite down your questions, prepare your home, and let people help. Many find it helps to look at the stoma site marking and picture the bag before surgery.
Waking up
Grogginess, a sore throat, belly soreness, and many tubes. Some people feel overwhelmed seeing the stoma or the catheter for the first time.
What helpsAsk the nurse to explain each tube. Take your time looking at the stoma; it is pink, moist and has no feeling, so touching it does not hurt.
Slow bowels
Bloating, nausea or hiccups when the bowels are slow to wake, often around days 2 to 5. It can be discouraging.
What helpsKeep walking, eat small amounts, and tell your nurse early about nausea. This usually passes within days.
The first bag change
Many people feel clumsy, squeamish or sad doing it the first time.
What helpsPractice with the ostomy nurse several times before going home. Within a few weeks most people change the bag in a few minutes.
The first weeks at home
Tiredness, a poor appetite, and worry about leaks or dehydration. Some people feel low.
What helpsDrink steadily, rest between short walks, and call early with questions. Ostomy support groups and the United Ostomy Associations of America can help.
Learning to use a neobladder
After the catheter is out, you have to learn to empty by relaxing and gently pressing. Leakage, especially at night, is common at first and frustrating.
What helpsFollow the timed voiding schedule, set a night alarm, do pelvic floor exercises, and be patient. Control usually improves over 6 to 12 months.
Body image and intimacy
Many people worry how a partner will see them, or feel less like themselves.
What helpsTalk openly with your partner. Small bag covers, intimate wear and emptying the bag before sex help. Ask your team about erection and vaginal treatments.
How well it works
Success means the cancer is fully removed, the new urinary system drains well, your kidneys stay healthy, and you return to a full life.
- The pathology report
It shows how deep the cancer went, whether the edges are clear, and whether any lymph nodes had cancer. People who had chemotherapy first sometimes have no cancer left at all.
- Treatment after surgery
If the pathology shows high-risk features, your team may recommend immunotherapy after surgery, which in trials lowered the chance of the cancer returning.
- Follow-up scans
CT scans every 3 to 6 months at first, then less often, check for any return of the cancer and that the kidneys drain well.
- Kidneys and blood chemistry
Blood tests check kidney function, acid balance and, over the years, vitamin B12, because using bowel for urine can affect these.
- Neobladder control
Most people with a neobladder are dry during the day by about a year. Nighttime control is harder and some people use a pad at night. A few need to use a catheter to empty fully.
Risks
Every operation has risks. These are the ones people ask about most, with honest odds where good numbers exist. Your surgeon’s own results matter more than averages.
Common
Because this is a major operation, many people have at least one problem during recovery, most of them minor and treatable.
Bloating, nausea and slow return of bowel function for several days.
Often for dehydration, infection or slow bowels. Most stays are short.
Common in the first months, especially with stents or a catheter. Treated with antibiotics.
Most men have erection problems unless nerves are spared, and there is no ejaculation. Women may have vaginal shortening or dryness.
Leakage is common at first, especially at night, and improves over months. Some people, more often women, cannot empty the neobladder fully and need to use a thin catheter.
Less common
Clots in the legs or lungs. In the iROC trial they were less common after robotic intracorporeal surgery than after open surgery. Blood thinner shots for 4 weeks lower the risk.
Infection or opening of a cut. Less common with the robotic approach in the iROC trial.
Usually heals with the stents or catheter left in longer, sometimes with a drain.
Can block a kidney months or years later. Treated with a stent, a tube in the kidney, or repeat surgery.
A bulge beside the stoma can develop over time and may need a support belt or repair.
Too much acid in the blood, low vitamin B12, or a slow decline in kidney function, especially with a neobladder. Checked with blood tests and treated if needed.
Rare
Rare, but serious, and may need another operation.
The rectum lies behind the bladder. Injury is rare and is usually repaired at once.
Rare with the robotic approach. Transfusion is sometimes needed.
Rarely needed, for bleeding, dense scar or safety.
A small number of people die within 90 days of this operation, more often older people and those with heart, lung or kidney disease. Ask your surgeon about your own risk.
Call your care team or go to the emergency room if
- Fever of 101°F (38.3°C) or higher, or shaking chills.
- Little or no urine from the stoma or catheter for more than 2 hours, or a catheter that will not flush.
- Vomiting, not able to keep fluids down, dizziness when standing, or very dark urine (signs of dehydration).
- A swollen, tight belly, or no gas or bowel movement for 2 to 3 days with nausea.
- The stoma turns dark purple, black or very pale.
- Swelling or pain in one calf or thigh. Call 911 for sudden shortness of breath or chest pain.
- Redness spreading from a cut, pus, or a wound that opens.
- Pain in the side or back with fever, or a stent that falls out early.
Questions to ask your surgeon
- Am I a candidate for a neobladder, or is an ileal conduit better for me?
- Do you build the diversion inside the body, and how many of these do you do each year?
- Should I have chemotherapy, and immunotherapy, before surgery?
- Which organs will be removed, and can any be spared?
- Can nerves be spared for sexual function?
- Where will my stoma be, and who will mark it?
- How long will I stay in the hospital, and what will I need to manage at home?
- Will I need blood thinner shots after I go home?
- Who will teach me to care for the stoma or the neobladder?
- What does the pathology need to show for me to need treatment after surgery?
- What will my follow-up scans and blood tests be?
Words you may hear
- Pneumoperitoneum
- The gas-filled belly that makes keyhole surgery possible. Carbon dioxide is pumped in through a thin needle or the first port until the belly wall lifts like a tent (usually at a pressure of 12 to 15 mmHg), giving the camera and instruments room to work. The gas is let out at the end, and the little that remains is absorbed and breathed out over a day or two; it can cause shoulder-tip ache in the meantime.
- Radical cystectomy
- Removing the whole bladder along with nearby organs and lymph nodes.
- Urinary diversion
- A new path for urine to leave the body after the bladder is removed.
- Ileal conduit
- A short piece of small bowel that carries urine from the ureters to a stoma on the belly.
- Neobladder
- A new bladder made from bowel and joined to the urethra, so urine is passed the usual way.
- Stoma
- The small pink opening of bowel on the belly where urine drains into a bag.
- Urostomy bag
- A sealed bag worn over the stoma to collect urine.
- Intracorporeal
- Inside the body: the diversion is built inside the belly with robotic instruments.
- Extracorporeal
- Outside the body: the bowel is brought out through an incision to build the diversion.
- Ileum
- The last part of the small bowel, used to build the diversion.
- Ureteral stents
- Thin tubes from the kidneys through the new joins, protecting them while they heal.
- Muscle-invasive bladder cancer
- Bladder cancer that has grown into the muscle wall of the bladder.
- Neoadjuvant chemotherapy
- Chemotherapy given before surgery to improve the chance of cure.
- Enhanced recovery (ERAS)
- A set of steps before and after surgery, such as early eating and walking, that helps people recover faster.
- Ureteroenteric stricture
- Scar narrowing where a ureter joins the bowel, which can block urine.
- Parastomal hernia
- A bulge of bowel through the belly wall beside the stoma.
Common questions
Is robotic cystectomy better than open?
Cancer control is similar. In the iROC trial, robotic surgery with the diversion built inside the body meant slightly more days at home in the first 90 days, fewer blood clots and wound problems, and faster early recovery. The surgeon's experience matters a great deal.
What does intracorporeal mean, and does it matter?
It means the new urinary path is built inside your belly using the robot, so the only larger cut is a small one to remove the bladder. The bowel stays inside, which may help it recover sooner. Not all robotic surgeons build the diversion this way.
Should I choose a conduit or a neobladder?
A conduit is simpler, with fewer long-term issues, but you wear a bag. A neobladder lets you pass urine the usual way but needs more work to learn, may leak at night, and is not suitable for everyone. Quality of life is good with both for most people.
Will I be able to pee normally with a neobladder?
You will pass urine through the urethra, but by relaxing and gently pressing with your belly muscles rather than feeling a normal urge. You empty on a schedule, including once or twice at night.
Can I swim, travel and exercise with a stoma?
Yes. Bags are sealed and waterproof. Many people swim, travel, work and play sports. Avoid heavy lifting for the first months and ask about a support belt.
Will I have sex again?
Many people do. Men often need erection treatments, and orgasm is dry. Women may need lubricants or dilators. Ask about nerve-sparing and organ-sparing options before surgery.
How long until I feel normal?
Most people feel close to their usual selves by about 2 to 3 months, though energy can take longer to return fully.
Sources this page draws on
- JAMA, Effect of robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy on 90-day morbidity and mortality among patients with bladder cancer: a randomized clinical trial (iROC) (2022)
- The Lancet, Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial (2018)
- American Urological Association, American Society of Clinical Oncology and Society of Urologic Oncology, Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/SUO Guideline (2020)
- European Association of Urology, EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer
- American Cancer Society, Bladder Cancer Surgery
Written November 2026. This page explains what usually happens. It is not medical advice and does not replace a conversation with your own surgeon, whose plan for you comes first.