With the discovery of immunotherapeutics, advances in multidisciplinary care, and refinement of surgical approaches, patient outcomes in muscle-invasive bladder cancer are improving.¹ These improvements have allowed for increased focus on cancer survivorship, which emphasizes the health, well-being, and quality of life (QOL) of people living with cancer, as well as urinary and sexual function. In female patients, it is important to understand the QOL concerns women face after radical cystectomy (RC) for bladder cancer (BC). While previously understudied, recent data suggest that women after RC experience postoperative pelvic and vaginal complications that significantly impact QOL. With this understanding, urologists can plausibly improve their perioperative evaluation and counseling to better establish realistic goals for patients while modifying surgical techniques to help reduce complications and improve functional outcomes.

Traditionally, RC in women has included removal of the bladder/urethra, in addition to the anterior vagina, uterus, fallopian tubes, and ovaries. This Halsted-esque approach stemmed from surgical principles in the 1950s suggesting high death rates after cystectomy alone were likely due to understaging of unknown locally advanced disease. With modern-day imaging, organ-confined disease can be better predicted prior to surgery and neoadjuvant therapies can downstage locally advanced cancers, which can provide opportunity for adjacent organ sparing. Bree et al demonstrated that involvement of the gynecologic organs, particularly the ovaries, is exceedingly rare in BC patients undergoing RC.² Statistics like these have allowed for a paradigm shift in the surgical treatment of BC that allows sparing of uninvolved organs. Shifting to a modified surgical approach in appropriately selected patients can have additional benefits that maximize QOL in BC survivors.

The earliest surgical modification for female RC was the adoption of urethral sparing for creation of an orthotopic neobladder in appropriately selected women. While male orthotopic neobladders became a standard diversion option in the mid-1990s, it was not until 2001 that this approach was demonstrated for women.³ Since then, additional surgical modifications have included vaginal-sparing cystectomy with preservation of the anterior vaginal wall, as well as genital organ–sparing cystectomy with preservation of the anterior vaginal wall in addition to the uterus/cervix and sometimes fallopian tubes/ovaries if present. The latter approach was first described by Bhatta Dar et al in 2007.⁴ Such modifications preserve autonomic nerves by reducing dissection around the uterus and vagina, which may reduce the risk of postoperative sexual dysfunction, prolapse, and fistula.

Although female organ-sparing techniques have been reported, there has not been unanimous adoption of these modifications. Moreover, there are recent data to suggest that pelvic and vaginal complication rates with traditional RC techniques are higher than expected. In a retrospective cohort study of Medicare patients undergoing RC, Richter et al found that approximately 20% of the cohort had a postoperative vaginal complication (Figure 1).⁵ The most common complication was vaginal cuff dehiscence, which occurred in about 10% of the cohort and can lead to bowel evisceration with need for urgent reoperation.⁵ In appropriately selected patients, a complete vaginal-sparing cystectomy eliminates risk of cuff dehiscence. In this approach, the entire anterior vaginal wall is preserved by dissecting the posterior bladder wall off this plane, obviating the need for vaginal closure and thereby eliminating risk of dehiscence. Patient risk factors, such as vaginal atrophy in the postmenopausal population, additionally increase the risk of cuff dehiscence. Consideration of local vaginal estrogen pre- and postoperatively can help with tissue strength and integrity to potentially reduce this modifiable risk factor.

Postcystectomy vaginal fistula is another relatively common and concerning complication. Most fistulas occur in the setting of neobladder reconstruction and form between the vagina and neobladder at the site of the neobladder-urethral anastomosis. Other types of fistulas include connection between the vaginal cuff and peritoneal cavity, often with continuous leakage of peritoneal fluid. In the Medicare study, the rate of vaginal fistula was found to be 7%, which is similar to the 3% to 6% fistula rate found in a systematic review of vaginal complications after RC for BC.⁶ Genital organ–sparing cystectomy is a surgical modification thought to reduce the risk of neobladder vaginal fistula by preserving blood supply to the anterior vagina and avoiding overlapping suture lines (Figure 2).

The true incidence of pelvic organ prolapse (POP) after RC is not well reported. Few studies report using objective measurements or validated instruments, and those that do often describe only the post-RC findings, without comparison to preoperative exams. The Medicare data would suggest a 4.5% incidence of POP after RC; however, this is likely underreported as diagnosis was reliant on coding data.⁵ Beyond causing symptoms of bulge, prolapse that occurs in the setting of urinary diversion with neobladder risks chronic urinary retention due to the acute angulation of the urethra that results from descent of the posterior neobladder wall into the vagina. Strategies for prevention of POP have focused on preserving the anterior vaginal wall and pubourethral ligaments, as well as limiting dissection of uterosacral ligaments, considered to be responsible for apical vaginal support (Figure 2).

Information on sexual function and dyspareunia following RC is best captured in prospective patient-centered studies, of which there are few. The rates of dyspareunia in the Medicare cohort were much lower than seen in systematic review and likely related to reporting bias and the method of data collection using a coding database. Systematic review evaluating sexual function in women after RC was similarly limited by the lack of high-quality data, but we do know that postmenopausal women are sexually active and that they often receive no preoperative counseling regarding the possible sexual function changes that may occur after RC. When sexual health counseling does occur preoperatively, there are notable gender disparities, with providers less likely to discuss baseline sexual function and postoperative sexual health with women than men.⁷

As the field evolves to accept surgical modifications that improve functional outcomes in women undergoing RC, we propose several considerations. Patients should be evaluated for baseline POP symptoms and urologists should capture information about baseline sexual function and postoperative goals. Genital organ–sparing cystectomy should be considered and concrete selection criteria defined so that functional outcomes can be optimized while maintaining oncologic standards. Modifiable risk factors, such as vaginal atrophy, can be addressed perioperatively with vaginal estrogen to optimize tissue quality. Prospective studies using standardized instruments and subjective outcome measures are needed to better understand the true incidence of these complications and their impact on QOL.