It is estimated that about 83,190 new cases of bladder cancer were diagnosed in the US in 2024, with a male:female ratio of 3:1.¹ One in 4 patients will present with muscle-invasive bladder cancer (MIBC), and up to half of the patients initially presenting with high-risk nonmuscle-invasive bladder cancer will progress to MIBC. For nonmetastatic MIBC, and in some cases of high-risk nonmuscle-invasive bladder cancer, radical cystectomy (RC) is considered the standard treatment. RC has considerable short- and long-term consequences, in particular, notable negative impact on sexual function, among other health-related quality of life (HRQoL) factors.

In men, erectile dysfunction (ED) is a highly prevalent sexual complaint following RC, although rates of ED vary greatly in the literature. As with post-RC patients, iatrogenic ED following RC is largely attributed to injury of the periprostatic neurovascular bundles.² Functional outcomes following RC may also be influenced by the use of neoadjuvant chemotherapy, the psychosocial impact of urinary diversion, and the older and less healthy population in which RC is often performed.

While numerous studies have attempted to describe HRQoL outcomes following RC, erectile function (EF) outcomes are often left as secondary or tertiary end points of broader assessments. Standardized tools have been developed to assess HRQoL in the post-RC patient, including the Functional Assessment of Cancer Therapy–Bladder questionnaire, the Bladder Cancer Index, and the EORTC-QLQ-BLM30 questionnaire (European Organization for Research and Treatment of Cancer health-related quality of life questionnaire to assess patients with muscle-invasive bladder cancer, 30-item). Assessment of EF with these metrics is limited, with some tools utilizing just a single question. Operative advancements,³ plus the more ready utilization of post-RC phosphodiesterase type 5 inhibitors, have limited the interpretation of EF assessment in noncontemporary studies.

Attempts to improve EF outcomes have been ongoing for decades, with Dr Walsh demonstrating more than 40 years ago that preserving the neurovascular bundles during RC could help restore EF. In his initial study, 9 of 11 patients (82%) who underwent nerve-sparing (NS) RC regained EF within 1 year.² EF recovery in these studies was based on interviews with patients and their spouses. The recovery rates were remarkably high, suggesting possible biases, as is often seen with nonstandardized interview-based assessments. Small sample sizes and highly selected patients also likely contributed to this figure.

Subsequent studies have shown mixed results, possibly due to the varied methods that authors have used in assessing EF. This is best seen in a study published by Hekal et al⁴ in 2009, which included an assessment of 21 patients with pre-RC functional erections who underwent NS-RC. EF was assessed in different ways, comparing a single-question assessment and the International Index of Erectile Function–Erectile Function Domain score. Using the single-question assessment, 58% reported complete restoration of EF, while Erectile Function Domain score indicated that 33% had mild ED or normal function. In 2013, Tyritzis et al reported a remarkable EF recovery rate of 81% following NS-RC, with EF being assessed by yet another metric, a proprietary nonvalidated questionnaire.⁵ The authors of a recent meta-analysis reported that they could only identify 4 published studies with comparable EF data looking at NS vs non-NS-RC. EF rates with NS-RC in these studies ranged from 26% to 100%.⁶

More recently, prostate- and prostate-capsule–sparing RC have been developed, with guidelines recommending consideration for patients with high motivation to preserve fertility and sexual function.¹ Despite early concerns regarding oncologic outcomes with this approach, sexual function appears better preserved based on the limited data available. Clay et al published a meta-analysis reporting EF recovery rates that ranged from 50% to 92%⁶; however, the AUA Guidelines note that NS procedures may offer similar outcomes.¹ The type of urinary diversion may also influence EF, but again, data in this regard are mixed.

While still a topic of debate, penile rehabilitation has shown potential benefits following radical pelvic surgery, particularly when started early.⁷ Therapeutic approaches include phosphodiesterase type 5 inhibitors, vacuum erectile devices, and intracavernosal injections. While these modalities are generally considered safe, their efficacy can vary, and long-term compliance is often suboptimal. For patients with persistent ED who fail to respond to more conservative treatments, implantation of a penile implant offers a more definitive solution. Altered anatomy and urinary diversion do introduce some added technical complexities to implantation, particularly for reservoir placement. Prosthetic surgeons treating this population should be prepared to encounter difficulties such as penile fibrosis and loss of the extraperitoneal space with RC and must have familiarity with reservoir placement in ectopic locations.⁸ Patients with orthotopic neobladders have the added concern of postoperative urinary retention, potentially requiring prolonged urethral catheterization, which increases the risk of urethral erosion.

Beyond ED, men undergoing RC may experience a range of additional sexual health concerns, including orgasmic dysfunction, sexual incontinence, Peyronie’s disease, low sex drive, and low testosterone. In a review of literature regarding orgasmic dysfunction following RC, Haney et al⁹ reported 33% to 62% of patients complained of anorgasmia, while 5% to 45% of men reported climacturia, although the authors did note that data regarding orgasmic function are sparse in general and difficult to quantify. They also note they were unable to identify studies reporting rates of dysorgasmia.⁹ Similarly, data on testosterone levels and low sex drive are also relatively lacking, with just 1 study reporting androgen profiles in post-RC patients. That study reported hormone profiles in 25 patients, with 38% having low testosterone (<300 ng/dL) on 90-day postoperative assessment.¹⁰ In contrast, a study looking at a large claims database revealed only 6% of patients being diagnosed with testosterone deficiency before RC.¹¹ The discrepancy in the 2 figures suggests many RC patients may have undiagnosed low testosterone, which could impact sexual health outcomes following surgery. More work is needed to better elucidate these issues.

In summary, sexual health issues are common following RC. As the emphasis in managing bladder cancer increasingly moves toward survivorship and quality of life, it is essential to address sexual dysfunction following the procedure as a core component of comprehensive care.