Robotic intracorporeal neobladder (RIN) is increasingly the modality of choice for intracorporeal urinary diversion in high-volume Robotic Urology centers. This article details the modern technique of RIN, explains specific tips and tricks to facilitate timely operative progression as well as weighs the outcomes from recently published series. An OVID/EMBASE database search was done using keywords: robotic, cystectomy, intracorporeal neobladder, orthotopic, and intracorporeal urinary diversion. The inclusion criteria were original studies on Robot-Assisted Radical Cystectomy (RARC) with RIN series, available in full text in English, published over the last ten years with a specific analysis of oncological and functional outcomes. Pooled data analysis of the 10 studies included shows 80% of patients had organ-confined disease (≤pT2), 1.86% of patients had positive surgical margin, median lymph node yield of 23 nodes (IQR = 7.5), and cancer-specific survival rate of 78% (range 72%-100%) over a mean follow up of 27.43 months (range 13-37 months). Functionally, the median day continence rate is 81.5%, night continence rate is 61%, and rate of return to spontaneous sexual activity is 33.5%. This compares favorably with outcomes of The International Robotic Cystectomy Consortium -Extracorporeal Urinary Diversion data and data from open radical cystectomy (ORC) neobladder series with long term follow up. High-volume robotic centers have successfully introduced programs for RARC, with RIN demonstrating its safety and feasibility. Their results suggest potential to improve perioperative and functional outcomes over ORC. Moreover, under mentorship, surgeons can learn the technique of RARC and RIN without these outcomes being significantly affected.

To the Editor We read with great pleasure the article titled 'Rectal Metastasis of Renal Cell Carcinoma'. We agree with the authors that metastasis of renal cell carcinoma to the large intestine is indeed rare (1). The authors have mentioned that delayed recurrence 21 years after surgery was the longest delay; however, there are reports describing recurrence occurring as late as 30 years after nephrectomy (2, 3).The American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN) have specific guidelines for surveillance protocol for renal cell carcinoma following resection depending on the stage at the diagnosis (4, 5). It would enhance the reader's knowledge had there been mention of the patient's stage at the diagnosis, with appropriate recommendation on surveillance.

To the Editor We read the article titled 'Delayed Metastasis of Renal Cell Carcinoma' with great interest. We agree with the authors that the possibility of delayed recurrence must be considered even a decade following curative treatment of renal cell carcinoma (1). However, while renal cell carcinoma is associated with late recurrence, the phenomenon leading to this entity is not well known (2). Previous studies have shown that predictors of late recurrence are young age at the diagnosis, clear cell histology, absence of sarcomatoid features, and low Fuhrman grade ( 3). An independent study also stated that risk factors for late recurrence depend on the size of the tumor at diagnosis, stage at the diagnosis, and histopathology (4). For this reason, the American Urological Association and National Comprehensive Cancer Network (NCCN) have laid down specific surveillance protocols as mentioned in our previous correspondence (5).

Background: Intravesical Bacillus Calmette–Guérin (BCG) instillation is an established form of immunotherapy for intermediate and high-risk bladder cancers. Mandatory cystoscopic surveillance is commonly performed under general anaesthesia (GA) to facilitate biopsy or other procedures. However, it is resource-intensive with unclear clinical benefit. Methods and patients: We performed a two-cycle audit, before and after changing post-BCG surveillance policy, from GA cystoscopy to local anaesthetic flexible cystoscopy (LAFC) on trans urethral laser ablation (TULA) lists, where patients may undergo a tumour biopsy or laser ablation. In the first cycle, we audited 53 patients undergoing 114 post-BCG rigid cystoscopies from January 2018 to December 2019. In the second cycle, there were 56 patients undergoing 99 post-BCG LAFCs on TULA lists in 2020. Results: In the first audit cycle cohort, the mean patient age was 72.29 ± 8.98 years and 48 were men; malignant histology was identified only on five occasions (three grade progressions). Fourteen patients required overnight admission. In the second audit cycle cohort, the mean patient age was 70.44 ± 9.17 years and 47 were men. Four had a grade progression, while another a stage progression. Out of 99 LAFCs, 47 confirmed normal bladder appearance. A biopsy was taken during other 52 cystoscopies: 17 (33%) confirmed malignancy. Fifteen patients showed findings that were labelled as recurrence, but only two required a further GA procedure to deal with recurrence. One patient was admitted for post-procedure bleeding, which settled with irrigation. Conclusion: Local anaesthetic TULA procedure is a safe and effective alternative for a GA rigid cystoscopy to survey bladders of patients on intravesical BCG therapy. Level of evidence: 3

Aim:In keeping with the ethos of surgical oncology, male nerve sparing (NS) robotic assisted radical cystectomy (RARC) aims to maximise functional outcomes without sacrificing oncological outcomes. This review details the surgical technique of male NS RARC as well as discussing strategies that may be employed in tandem with surgery to improve post-operative recovery and longer-term quality of life.Methods: An OVID/EMBASE database search was done with key words of robotic, cystectomy, male and nerve sparing. Publications with no description of post-operative functional outcome were excluded. A total number of 25 relevant publications were selected investigating male NS RARC, assessing functional outcomes along with other surgical standard indicators.Results: Most series contained small numbers of patients with largely retrospective data and the associated bias of selection. Mean follow up of 27.06 months (range 2.8-58 months) was noted overall. Study design, technique, definitions and measurements of continence and erectile function are heterogeneous across series. With a mean follow up of 27.06 months (range 2.8-58 months), a post-operative satisfactory erectile function of 54.32% (range 9%-100%) and satisfactory day time continence of 90% (range 54.5%-100%) and night time continence of 80.55% (range 46.7%-88%) was found with a mean positive surgical margin rate of only 1.8% (range 0%-6.4%). Conclusion:Male NS RARC for appropriately selected patients will offer good functional outcomes. Results from the series reviewed suggest the technique is both feasible and safe, without compromising longer term oncological results.