Traditionally, the female radical cystectomy involves removal of the uterus, fallopian tubes, ovaries, anterior vaginal wall and urethra in addition to the bladder. However, wide resection may result in sexual dysfunction including dyspareunia, foreshortened vaginal wall, poor lubrication and orgasmic difficulty. Furthermore, for women with an orthotopic neobladder, the urethra is spared and anastomosed to the ileal pouch, often resulting in hypercontinence and urinary retention. Pelvic organ prolapse may occur from disruption and denervation of pelvic floor musculature and anterior vaginectomy and the resultant vaginal repair may lead to vaginal discharge and significant distress for women. Unfortunately, prospective studies on these issues specific to women are non-existent,¹ and retrospective studies often explain a single center’s experience and prompt patient recall bias.²

Radical resection follows the classical Halstedian principle of en bloc resection to maximize cancer control. The lethality of bladder cancer perpetuates this dogma; radical excision equals negative surgical margins and improved patient survival. Yet up to 20% of patients may have pathologically positive nodes. Conversely, approximately a quarter of patients who received neoadjuvant chemotherapy may not have any microscopically detected bladder cancer,³ and less than 5% of malignancies involve the ovaries.⁴ The diametrically opposing outcomes should give us pause to re-think the benefit of the “radical” cystectomy and be open to routinely sparing uninvolved organs as we often do in other disease states.

Sparing the uterus and the associated suspensory ligaments may prevent pelvic organ prolapse and provide posterior support for the neo-vesicourethral anastomosis. This in turn may improve the hypercontinence that occurs from suspected kinking of the neo-vesicourethral anastomosis. Sparing the ovaries, albeit in majority postmenopausal patients, still provides low levels of circulating androgen and estrogen hormones which could impact sexual desire, bone and cardiovascular health.⁵ Sparing the anterior vaginal wall avoids foreshortening the vagina which leads to impenetrable intercourse, or at best dyspareunia from vaginal narrowing and poor vaginal lubrication. Sparing cavernosal nerves can lead to improvement in vaginal wall engorgement and lubrication,⁶ which in turn may lead to less pain with sexual intercourse, improved sexual satisfaction and increase in desire. Sexual activity is known to be associated with emotional well-being, cognition, improved relationships and long-term quality of life.

The nerve-sparing radical cystectomy with uterine preservation was first suggested in 2001 and further described by Bhatta Dar et al in 2007.⁷ The 2 key differences from a traditional radical cystectomy are the location of the peritoneal incision and bladder mobilization in reference to the parametrium. The peritoneal incision is more anterior (fig. 1) which allows for the dissection of the posterior bladder wall from the anterior vaginal wall. This plane may be developed as distally as the posterior bladder neck (fig. 2), with the caveat that any evidence of tumor at the posterior bladder neck should preclude such a dissection and risk positive surgical margins. In the absence of gross tumor involvement at the posterior bladder neck and/or urethra, this allows the entire anterior vaginal wall to be preserved, as well as its urethral support, which is particularly beneficial to patients undergoing an orthotopic reconstruction. In terms of the parametrium, which contains the cavernosal nerves, uterine and vaginal arteries (fig. 3), the bladder can be safely mobilized and dissected from these structures in the same manner as a nerve-sparing radical prostatectomy.

Figure 1. Intra-abdominal view of peritoneal incision in uterine-sparing cystectomy. Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.

Figure 2. Cross-sectional view of female pelvis at level of bladder neck, anterior vaginal wall and cervix. Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.

Figure 3. Sagittal view of parametrium (right) containing pelvic neurovascular plexus. Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.

Figure 4. Biopsychosocial model of sexual health care for patients undergoing radical cystectomy. Used with permission of Urology, 151, Avulova S and Wittmann D, Optimizing Women’s Sexual Function and Sexual Experience After Radical Cystectomy, 138-44, 2020, with permission from Elsevier.

Despite the description of this procedure over a decade and half ago, it remains uncommon in surgical practice. One theory is that as most female bladder cancer patients are older, sexual function is not a priority and therefore it is not the focus of the preoperative discussion. In fact, urologic oncologists routinely omit asking their female patients about sexual activity compared to the male patients.⁸ However, previous studies have shown that even postmenopausal women are sexually active⁹ and most want more preoperative counseling.² Optimizing women’s sexual health as they are undergoing a life-changing surgery can follow a previously published bio-psychosocial model with actionable interventions (fig. 4). Establishing baseline preoperative sexual function and prospectively evaluating functional outcomes with gender specific questions is paramount.¹ Identifying barriers to sexual function recovery among female bladder cancer patients and engagement of multidisciplinary cancer survivorship providers is overdue.¹⁰

Currently, we have a prospective multi-institutional survey study evaluating these very questions among women undergoing radical cystectomy for bladder cancer in the United States sponsored by the Bladder Cancer Advocacy Network (BCAN). To ensure that our survey items were relevant, we engaged BCAN patient advocates early in the process to review the survey questions and performed qualitative interviews with each advocate. One common theme that emerged from this exercise is the expression of relief that someone was finally asking about sexual function and acknowledging that this topic needs further study.

Sporadically, previous publications have outlined the knowledge gap, reviewed the anatomy and urged for more prospective data.¹¹ We hope this prospective study will lay the foundational groundwork on which to base future studies. Surgery is an ever-evolving art form, and to improve care we need to prospectively study outcomes to avoid recall bias and obtain perspective from both surgeon and patient. Furthermore, we need to engage patient research advocates, use a multi-disciplinary approach, and most importantly be open-minded to change in order to improve cancer survivorship.