## 4 Discussion
Considering that the time-consuming procedure in robotic and laparoscopic surgery is suturing, the use of mechanical staplers in our technique greatly facilitates the procedure and significantly reduces the operative time. Compared to other techniques (such as the Y-shaped and the W-shaped Hautmann, the Studer pouch, or the Padua Ileal Bladder), our approach offers the advantage of being completely done with the use of staplers, avoiding the manual sewn of the intestinal tract, reducing intestinal manipulation as well as the operative time while providing a more standardized procedure [22; 42]. In this way, the procedure presents only two critical time-consuming points which are the correct measuring of the intestinal tract to be resected (which would result otherwise in asymmetrical horns) and the correct insertion of intestinal loops into the arms of the mechanical staplers in order to achieve a complete detubolarization. In this regard, those points could be further improved in order to reduce the operative time required to construct the described neobladder. Despite some authors having documented the detrimental effects of staples in the urinary tract, recent studies have reported how the rate of stone formation was comparable to that reported in the literature for hand-sewn ileal reservoirs [43; 44]. In addition, the possibility to use biodegradable and absorbable staplers in the future could eliminate this eventuality [45]. We believe that our results will encourage the use of staplers more frequently for the intracorporeal robotic neobladder approach and, as previously reported, improve the standardization of the procedure. As reported in the literature, despite trends toward the centralization of robotic radical cystectomy and orthotopic neobladder reconstruction at high-volume centers, in order to improve the experience with this procedure, population-based studies have shown a decreasing utilization of orthotopic urinary diversion among patients undergoing radical cystectomy with up to 85.5% of patients who underwent an incontinent diversion [46; 47]. Considering the advantages associated with orthotopic neobladder and the decreasing and concerning the trend of similar procedures being performed, it should be imperative to increase the number of urinary continent diversions, overcoming the limitations related to the intracorporeal reconstruction and the steep learning curve of the surgical technique [48]. The idea underlying the VON, both in its open and robotic intracorporeal approach, was to simplify the surgical technique and lower the learning curve, permitting us, therefore, to increase the number of procedures performed. A simpler and standardized technique could indeed extend the number of procedures to different centers facilitating, in addition, the diffusion of orthotopic neobladder reconstruction in non-high-volume centers. We are conscious that a larger sample size, as well as a longer follow-up, are required to properly evaluate this technique, albeit the satisfactory results obtained with our open technique could represent a first step in this direction [34]. More robust data could be obtained from a larger series with a longer follow-up, also permitting us to consider oncologic and functional outcomes. Finally, although the non-spherical configuration of our technique could be considered a restriction since the spherical configuration is considered the ideal shape for maintaining a good storage volume, it should also be emphasized that despite our neobladder being packaged with 36 cm of ileum--a measure among the shortest used for neobladder packaging techniques--the volume obtained is excellent, between 250 and 290 cc (which is not dissimilar from the volume obtained in the FloRIN), and could reach 400-500 cc due to the expansion of the reservoir in time [23; 49]. Further studies are required to assess the functional outcomes of the VON, requiring a thorough urodynamic examination as well as a proper evaluation of day and night-time continec