Sexual dysfunction after a radical cystectomy Is there an ideal sexual preserving technique for radical cystectomy?
urinary continence and sexual activity. The robotic approach could be of interest for this nerve preservation [43,44]. Additionally, pregnancy after organ-sparing cystectomy with urinary diversion in highly motivated young patients is possible [45]. - Ovaries: According to a recent survey of urologists, reasons for oophorectomy at the time of RC included concern for urothelial carcinoma involvement (54%), development of subsequent ovarian disease (50%) and surgical ease of pelvic node dissection (36%) [46, 47]. Many urologists remain unaware of the risks associated with oophorectomy, believing that there is no effect on health or QOL associated with this procedure. The current understanding of ovarian cancer pathogenesis and the effect of premature oophorectomy has led to a shift in practice within gynecology. Indeed, oophorectomy-induced surgical menopause has been shown to increase the risk of osteoporosis, cognitive impairment, cardiovascular disease and all-cause mortality, and is associated with poorer QOL scores compared to natural menopause [48–50]. This paradigm is now supported by the gynecologic community, but has been slow to translate to other disciplines. Regarding the risk of developing subsequent ovarian disease during the observation period, data on the lifetime risk of ovarian cancer stratified by germline mutations in BRCA1/BRCA2 and mismatch repair genes are emerging. In the absence of strong evidence, being aware of the low incidence of ovarian cancer, which accounts for only 1.3% of all new cancer cases, and the fact that most ovarian cancer cases are sporadic, it does not seem logical to perform systematic concomitant oophorectomy during RC in a patient with no history of hereditary breast or ovarian cancer [47,51]. Finally, the surgical ease of removing the ovarian pedicles, rather than sparing the ovaries, during pelvic node dissection is not an understandable argument. For a skilled surgeon, successful lymph node dissection with organ sparing is feasible by clipping the utero-ovarian pedicle, instead of the lombo-ovarian pedicle, and flipping the ovary out of the pelvis, without compromising oncological outcomes [52]. Thus, with the growing focus on cancer survivorship, preservation of the ovaries at the time of RC has become an increasingly important consideration in urologic oncology. A preoperative agreement must be concluded between the operating surgeon and the patient in all cases in order to avoid the systematic extirpation of the ovaries in not only premenopausal patients, but possibly also in selected postmenopausal patients after a careful evaluation of preoperative sexual function and assessment of putative history of breast and ovarian cancer. Conclusions With a growing focus on QOL in cancer survivorship, further efforts should be directed at reducing the barriers to sexual health pre-operative counseling. Much more work is needed preoperatively, including not only counseling/rehabilitation, improved measurement and consistency of PROMs to assess sexual function in male and female patients, but also specific information about the sexual consequences of surgery and possible options for sex-sparing procedures. In female patients, anterior exenteration “d’office” is no longer acceptable. For well-selected sexually active patients, sex-sparing cystectomy is oncologically safe and may offer functional benefits in preserving pelvic reproductive organs and their nerve structures, with a significant impact on QOL both in terms of sexual health and urinary continence. Sexual health after cystectomy is best co-managed with a multidisciplinary treatment approach, including preoperative counseling, neoadjuvant chemotherapy that may help expand selection criteria and indications, intraoperative nerve and organ preservation, and postoperative interventions to mitigate sexual side effects.
a discussion led by healthcare professionals, but also requested written material to refer to later. Preoperative sexual health assessments should include measurements of erection quality, firmness and desire for men, and dryness, desire, orgasm and dyspareunia for women, ideally using validated questionnaires. However, in a recent survey including 140 urologists, the majority of them did not routinely counsel patients about sexual dysfunction. Moreover, 41.2% of them did not routinely discuss the potential for pelvic organ- sparing RC with sexually active patients [11,13]. While patients varied in the importance they placed on sexual function, with factors such as age, relationship status and oncological concerns affecting prioritisation, both younger and older patients expressed the desire for an option to retain sexual function [14]. In the end, as with the choice of urinary diversion, nerve sparing techniques and postoperative sexual health must be based on comprehensive counseling. Nerve-sparing radical cystectomy for the male: time to optimise techniques Selection of patients According to the guidelines, in a radical cystoprostatectomy, including excision of the prostate and seminal vesicles is recommended [15]. Of course, the preservation of sexuality should in no way compromise the oncological quality of the surgery. However, for selected patients, the surgical technique may be adapted. Sexually active patients with localised disease (cT2) away from the bladder neck, prostate or prostatic urethrawho are properly informed could discuss sexual-sparing techniques. Technical Aspects Several techniques have been proposed to preserve sexual function during cystecomy: preservation of the prostate, seminal vesicles and nerve preservation. - Prostate-sparing procedure: The first iteration of preservation of sexual function in RC proposed the preservation of the prostate through distal transection of the bladder specimen at the level of the bladder neck. This technique carried the risk of violating the bladder tumor and producing positive margins with an increased risk of metastatic recurrence [16]. This risk was reduced by performing prior endoscopic resection of the bladder neck and prostate [17,18]. Another option is en bloc removal of the prostatic parenchyma, bladder neck and bladder, as a “cysto-adenomectomy”, by incising the prostatic capsule transversally until reaching the prostatic parenchyma, and then separating the parenchyma from the prostatic capsule in a maneuver similar to that performed during the enucleation of an adenoma [19]. The urethra is sectioned distally and an anastomosis between the neobladder and the remaining distal prostatic capsule is performed. However, all of these prostate-sparing techniques require that there is no secondary prostatic involvement from urothelial neoplasia and that the presence of a primary prostate cancer has been previously ruled out. Considering that incidental prostate cancer is a relatively common finding during histopathological evaluation of RC specimens [20], these prostate-sparing procedures require appropriate monitoring of the residual prostatic capsule in postoperative follow-up. - Nerve-sparing procedure: Extensive knowledge of pelvic anatomy and nerve-sparing surgical techniques in men is well understood from studies about prostate anatomy and nerve-sparing prostatectomy. In well-selected patients, the preservation of neurovascular bundles has been shown to be oncologically safe, especially for patients with incidental prostate cancer [21], while leading to improved sexual function outcomes and urinary continence in those undergoing orthotopic neobladder [22]. Nerve-sparing procedures have been more widely adopted since the development of the robotic approach, with excellent functional results:up to 75% daytime continence at 1 month postoperatively and recovery of preoperative erectile function up to 77.5% at 12 months [23-25]. The degree of nerve sparing was graded intraoperatively by the surgeon independently on each side and depending on the location of the tumour. Sex-sparing radical cystectomy in females: time to change our point of view Selection of patients Although bladder cancer is more common in men
than in women, it is often more aggressive in female patients, and the proportion of women requiring radical treatment is higher [26]. In female patients, the standard surgical procedure is represented by anterior pelvic exenteration involving en bloc resection of the bladder and adjacent pelvic organs, including the uterus, ovaries, anterior vaginal wall and, in many cases, urethra [15]. However, sexual dysfunction being derived from such a highly demolitive surgery is a key concern [27]. Functional outcomes among women undergoing RC are understudied, with limitations stemming from the use of validated questionnaires, heterogeneous patient populations and small sample sizes [28, 29]. Despite the high risk for sexual dysfunction after cystectomy, there is little data on and attention given to these issues in women, which contrasts with the level of attention paid to the sexual function of men undergoing similar urologic procedures. The consequences of anterior exenteration are numerous. Patients may experience: - Neurovascular bundle damage, since the pelvic sensory fibers of the inferior hypogastric plexus are mainly concentrated in the posterior fornix along lateral sides of the cervix and rectum, and are therefore destroyed by exenteration. Autonomic and nociceptive nerve injuries are often associated with pain disorders, such as dyspareunia, vulvodynia, and vaginismus [30] - Shortening or narrowing of the vagina - Frequent devascularisation and denervation of the clitoris in the case of urethra removal - Voiding issues when performing with an orthotopic neobladder [31,32] According to current guidelines, sexual-sparing cystectomy is an option to consider for women highly motivated to preserve sexual function as soon as strict oncological inclusion criteria are met: localised tumour (cT2) detected on preoperative imaging (ideally MRI) away from the bladder neck, trigone or dorsolateral bladder walls. In these well-selected women, organ-sparing approaches can be performed safely without negatively impacting oncological outcomes [33]. Technical Aspects Various types of pelvic-organ-sparing techniques, usually called “sex-sparing”, have been proposed, aiming at the preservation of neurovascular bundles, vagina, uterus and ovaries. - Vagina: According to a recent survey, vaginal preservation is important, and dyspareunia is the most common post-operative change in sexual function after RC [9, 34]. MRI is the best imaging to confirm the absence of involvement of the trigone or the dorsolateral bladder walls, allowing for full preservation of the anterior vaginal wall. Using a vaginal valve and following the vesico-vaginal dissection plane, as for promontofixation, the midline dissection is anatomical. Then, the neurovascular bundles located on the lateral wall of the vagina can be kept to preserve clitoral function [35]. The endopelvic fascia can be incised very close to the bladder neck to reduce the risk of damage to neurovascular paraurethral structures, which is crucial for both sexual and continence functionality. - Uterus: The risks of uterine invasion have been investigated in preliminary studies to determine which group of patients is suitable for organ- sparing cystectomy. Before the era of MRI, it was proven that uterine involvement in bladder cancer was only 0.3%–12.5% [36,37]. Hydronephrosis on CT, tumor size ≥4.8 cm, positive lymph node status and tumor location at the bladder neck or trigone have been reported as risk factors for sexual organ invasion [38,39]. Now, a patient who shows no uterine invasion on preoperative pelvic MRI meets the necessary criteria and can be considered suitable for preserving the uterus, regardless of clinical stage, tumor location or size [40]. Uterus-sparing surgery would leave the reproductive organs and nerves intact and bring noticeable progression in sexual outcomes. Moreover, in the case of orthotopic bladder substitution, the continence rate was shown to be significantly higher and the clean intermittent catheterisation significantly lower compared to standard radical cystectomy [41,42]. Uterus preservation should therefore be offered to women receiving a neobladder whenever justifiable. Moreover, the meticulous anatomical preservation of utero-vaginal neurovascular hypogastric plexus represents the cornerstone of a rapid and effective recovery of physiological functions in terms of
Dr. Géraldine Pignot Institut Paoli- Calmettes Marseille (FR)
Radical cystectomy (RC) is a major intervention with morbidity rates that should not be disregarded. In addition to the usual post-operative complications, RC also impacts long term functional outcomes, with serious psychological and social drawbacks. Although improvements in perioperative care have decreased complication rates, the side effects during long-term treatment still compromise patients’ quality of life (QOL). As survivorship from bladder cancer improves, appropriate assessment and treatment of these QOL conditions is needed. While standard questionnaires may be offered (IIEF-5 for men, FSFI for women), there is inconsistent use of patient-reported outcome measures (PROMs) after cystectomy. Yet, they are important tools available to understand patient- focused outcomes from care and to accurately assess health-related QOL. Various PROMs have been developed for patients with bladder cancer, although the disease’s heterogeneity makes selection difficult [1]. Regarding sexual heath, it is found that up to 75% of both male and female patients reported sexual dysfunction after RC. Research on the treatment’s impact on sexual health has been widely identified as an unmet need in bladder cancer patients [2]. It is clear that assessment of sexual health needs is largely overlooked for patients undergoing cystectomy compared to those undergoing other cancer treatments [3,4]. Over the past decade, surgical pioneers have adopted minimally invasive RC techniques in an effort to reduce surgical morbidity [5]. Additionally, improvement of imaging modalities, increased knowledge of pelvic structure anatomy and function, the advancement of surgical techniques and emerging technologies have facilitated the development of less destructive methods for treating bladder cancer. In a new era of functional optimisation, evaluating postoperative sexual outcomes has become a new surgical endpoint. Sex-sparing techniques are gaining popularity, with the aim of achieving definitive oncological control while attempting to preserve sexual function [6,7]. Here we summarise the role of pre-operative counseling regarding sexual health needs and the place of organ and nerve-sparing techniques for cystectomy in male and female patients. Importance of pre-operative counseling Preoperative counseling is a major component of the surgical management of bladder cancer, including providing comprehensive information on urinary diversion, nutritional evaluation, and adequate sexual function assessment, in order to identify educational needs and to propose prehabilitation if necessary. Patients reported that in survivorship, unmet informational needs revolved around changes in body image, stomal appliances, incontinence and sexual function, with a significant impact on depression and worries [8]. Indeed, pre-operative sexual health counseling for patients undergoing cystectomy is routine for neither male nor female patients. Between 50 and 80% of patients report having received little or no information on sexual life after RC [9]. Additionally, a well-documented gender bias exists in the assessment of sexual outcomes for women undergoing cystectomy. Recently, gender differences in oncological and functional outcomes after RC have received increased attention [10]. Many women report receiving inadequate preoperative counseling regarding risks of sexual dysfunction, nerve-sparing techniques and post-operative sexual health, regardless of disease stage or receipt of chemotherapy [9]. The main reasons for this gender
References can be requested from the corresponding authors.
disparity have been documented to include advanced patient age, inadequate time and uncertainty of baseline function [11,12].
Saturday 11 March 08:45 - 08:55 Plenary Session: Locally advanced BCa: Misconception of informed consent Yellow Area, eURO Auditorium 1
Regarding patients’ preferences for pre-operative counseling modality, the majority of them preferred
European Urology Today
February/March 2023
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