Initial evaluation for all patients includes a detailed history and physical examination followed by laboratory studies and radiographic imaging. Clinical staging with computed tomography is important to evaluate for locally advanced or metastatic disease, as this could affect decision-making regarding surgical treatment. For patients found to have locally or regionally advanced disease a bone scan may also be warranted. Although some reports also suggest utility of positron emission scans (PET scans) in diagnosing occult metastatic disease, our experience is that these have been of limited utility over traditional imaging and furthermore are not typically covered by insurance [3]. Although beyond the scope of this review, neoadjuvant chemotherapy has been demonstrated to provide a survival advantage to patients with muscle invasive disease, and thus, most of our patients will receive neoadjuvant chemotherapy prior to radical cystectomy [4]. Typically, for patients who receive chemotherapy, we advise waiting 2–4 weeks after the completion of chemotherapy to allow blood counts and platelet counts to recover.

Given that the population of muscle-invasive bladder cancer patients is older and often has a long history of smoking, it is imperative that the urologist identify any factors that may suggest underlying pulmonary or cardiovascular disease, both of which may need further evaluation. Those with a history of chronic obstructive pulmonary disease (COPD) or other chronic lung disease processes should undergo at minimum pulmonary function testing and arterial blood gas analysis. Carbon dioxide insufflation leads to significant pulmonary alterations including reduced lung volumes, hypercarbia, hypercapnia, and reduced venous return. While these physiologic changes are usually of no consequence in the healthy patient, they can be poorly tolerated if there is underlying pulmonary disease and hypoxemia can develop both during and after the operation [5]. Cardiac disease, including congestive heart failure and arrhythmias should be noted as both may require more invasive monitoring during surgery due to the effect of decreased cardiac preload and resulting acidosis from CO₂ resorption, respectively. Other important factors include neurologic or musculoskeletal disease, which may affect patient positioning at the time of surgery. A history of renal insufficiency is also important and may affect the choice of continent vs. incontinent urinary reconstruction [6].

The only absolute contraindications to RARC would include an uncorrected bleeding disorder, bowel obstruction, or presence of peritonitis or intra-abdominal abscess. However, as previously mentioned, individuals with severe pulmonary disease may not tolerate laparoscopic surgery and in some cases should forego this approach. While there are no absolute contraindications to RARC in terms of previous surgeries, prior abdominal operations may pose a particular challenge to gaining intra-abdominal access. A good knowledge of the surgical history as well as all incisions will help dictate where the Veress needle should be placed. In some situations, the Hasson technique may be more appropriate.

Nutritional deficiency is not an uncommon finding in cancer patients and may have a significant impact on surgical outcomes. Gregg et al. retrospectively reviewed a cohort of over 500 patients who underwent radical cystectomy at a single institution. Patients with preoperative nutritional deficiency, defined as albumin <3.5 g/dl, body mass index <18.5, or preoperative weight loss over 5 %, had higher 90-day mortality rates (16.5 % vs. 5.1 %) and lower overall survival at 3 years (44.5 % vs. 67.6 %) compared to non-nutrient-deficient patients. After controlling for other variables, preoperative nutritional deficiency was associated with higher all cause mortality [7]. While the role of perioperative total parenteral nutrition or enteral feedings has not been completely defined, patients should be screened for these nutritional risk factors and perhaps evaluated by a dietician before surgery.

Patient preparation begins with a thorough discussion of the surgery and expectations both during the perioperative and postoperative period. Patients should be extensively counseled regarding the options for urinary reconstruction. For those patients who select an ileal conduit, it is helpful to provide them with an appliance to wear before surgery in order to become familiar with the appliance. Consultation with an enterostomal therapist is strongly advised in efforts to determine the optimal stoma site. In instances in which a stomal therapist is not available, it is imperative for the surgeon to mark the stoma on both the left and right sides in both the sitting and recumbent positions. Additional preoperative recommendations include smoking cessation which should always be encouraged as this has been shown to reduce the risk of postoperative complications [8]. Antiplatelet medications or nonsteroidal anti-inflammatory inhibitors should be held 7–10 days prior to surgery. Urinary tract infections should be treated with a test of cure prior to surgery.