Background/Objectives: Radical cystectomy (RC) is the standard treatment for muscle-invasive and high-risk non-muscle-invasive bladder cancer, but it often results in significant functional impairments, including sexual and urinary dysfunction, adversely affecting quality of life (QoL). Sexual-sparing robotic-assisted radical cystectomy (RARC) has been introduced to mitigate these effects. This review evaluates the oncological and functional outcomes of sexual-sparing RARC in male and female patients. Methods: A systematic literature search identified 15 studies including 793 patients who underwent sexual-sparing RARC using techniques such as nerve-sparing, capsule-sparing, and pelvic organ-preserving approaches. Data on oncological and functional outcomes were analyzed. Results: Sexual-sparing RARC achieves oncological outcomes comparable to open RC, with negative surgical margin (NSM) rates exceeding 95% in most studies. RFS and CSS rates were robust, often surpassing 85% at intermediate follow-ups. Functional outcomes were also favorable, with continence rates exceeding 90% and erectile function recovery surpassing 70% in well-selected male patients. Female patients undergoing pelvic organ-preserving techniques demonstrated improved continence, preserved sexual function, and enhanced QoL. Patient selection emerged as critical, favoring those with organ-confined disease and good baseline function. Conclusions: Sexual-sparing RARC offers a promising balance between oncological control and functional preservation, making it an effective option for selected patients. Further research is needed to refine techniques and establish standardized protocols for broader adoption.
