The Feasibility and Safety of Reproductive Organ Preserving Radical Cystectomy for Elderly Female Patients With Muscle-Invasive Bladder Cancer: A Retrospective Propensity Score-matched Study

Association between bladder cancer treatment and female sexual function

INTRODUCTION

Bladder cancer ranks 17th in prevalence of cancer types among women, and the trend is rising. The increased risk of female sexual dysfunction (FSD) after radical cystectomy (RC) underscores the need for greater focus on preserving and mitigating FSD.

OBJECTIVES

To place greater emphasis on the importance of female sexual function (FSF) in the treatment of bladder cancer and stimulate additional research to discover more effective solutions for enhancing the overall quality of life.

METHODS

This review used a narrative approach. Previous reviews on FSF after RC have provided limited and 1-sided solutions due to the lack of research. What makes this review unique is its innovative approach: it includes all available measures curing FSD as well as comparative analyses based on experimental data, thus making the findings more comprehensive. A detailed perspective of treatments for female bladder cancer is provided, including nerve- and organ-sparing RC, robot-assisted RC, and radiotherapy. We also analyze the impact of treatments for female bladder cancer on postoperative FSD. Additionally, solutions for addressing or alleviating postoperative FSD are summarized, such as urinary diversion, vaginal reconstruction, and drug and nondrug treatment.

RESULTS

Research has suggested that robot-assisted nerve- and organ-sparing RC is promising. Moreover, orthotopic neobladder among urinary diversions without a stoma helps to maintain a positive female body image. If part of the anterior vaginal wall must be removed during RC, vaginal reconstruction can restore the dimensions with synthetic grafts and biologic scaffolds. Additionally, postoperative measures, such as vaginal laser and hormone therapy, and use of vaginal dilators and lubricants have a significant role in reducing distress caused by FSD to provide maximum relief.

CONCLUSIONS

To support FSF after RC, various interventions are needed, and urologists must focus on patient recovery while minimizing treatment impact on FSF as much as possible.

Comparative evaluation of reproductive organ-preserving versus standard radical cystectomy in female: a meta-analysis and systematic review of perioperative, oncological, and functional outcomes

BACKGROUND

To evaluate the perioperative, oncological, and functional outcomes of reproductive organ-preserving radical cystectomy (ROPRC) compared to standard radical cystectomy (SRC) in the treatment of female bladder cancer.

METHODS

A systematic search was conducted in November 2023 across several scientific databases. We executed a systematic review and cumulative meta-analysis of the primary outcomes of interest, adhering to the PRISMA and AMSTAR guidelines. The study was registered in PROSPERO (CRD42024501522).

RESULTS

The meta-analysis included 10 studies with a total of 2015 participants. ROPRC showed a significant reduction in operative time and postoperative fasting period compared to SRC (MD - 45.69, 95% CI - 78.91 ~ - 12.47, p = 0.007, and MD - 0.69, 95% CI - 1.25 ~ - 0.13, p = 0.02, respectively). Functional outcomes, both daytime continence rate (OR 4.94, 95% CI 1.53 ~ 15.91, p = 0.008) and nighttime continence rate (OR 5.91, 95% CI 1.94 ~ 18.01, p = 0.002), and sexual function measured by the Female Sexual Function Index (MD 5.72, 95% CI 0.19 ~ 11.26, p = 0.04), were significantly improved in the ROPRC group. There were no significant differences between ROPRC and SRC in terms of estimated blood loss, length of hospital stay, overall postoperative complications, minor complications or major complications. Oncologically, both procedures showed comparable outcomes with no significant differences in positive surgical margins, tumor recurrence rates, overall survival, cancer-specific survival, recurrence-free survival, or progression-free survival.

CONCLUSIONS

ROPRC is a viable and effective alternative to SRC in female bladder cancer patients, offering enhanced functional outcomes and similar oncological safety. These findings suggest that ROPRC can improve the quality of life in female bladder cancer patients without compromising the efficacy of cancer treatment.

Long-term survival after female pelvic organ-sparing radical cystectomy versus standard radical cystectomy: a multi-institutional propensity score-matched analysis

BACKGROUND

The application of pelvic organ preserving-radical cystectomy (POPRC) in female patients with bladder cancer has attracted more and more attention in recent years. In the current study, the authors aim to compare the long-term oncological outcomes of POPRC versus standard radical cystectomy (SRC) in a large multicenter retrospective cohort.

PATIENTS AND METHODS

Data on female patients with bladder cancer who underwent POPRC or SRC in January 2006 and April 2018 were included from three Chinese urological centers. The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival and recurrence-free survival. To decrease the effect of unmeasured confounders associated with treatment selection, 1:1 propensity score matching was performed.

RESULTS

Among the 273 enrolled patients, 158 underwent POPRC (57.9%), and 115 underwent SRC (42.1%). The median follow-up time was 38.6 (15.9-62.5) months. After propensity score matching, each cohort included 99 matched patients. The OS ( P =0.940), cancer-specific survival ( P =0.957), and recurrence-free survival ( P =0.476) did not differ significantly from the two matched cohorts. Subgroup analysis confirmed that the OS was similar between the patients treated with POPRC and SRC across all subgroups examined (all P > 0.05). In multivariable analysis, the surgical method (SRC vs. POPRC) was not an independent risk factor for OS (Hazard ratio 0.874, 95% CI 0.592-1.290; P =0.498).

CONCLUSIONS

The results showed that no significant difference in long-term survival was determined between female patients undergoing SRC and those undergoing POPRC.

Oncological and functional outcomes of female reproductive organ-sparing radical cystectomy and ileal neobladder construction

OBJECTIVES

To examine the oncological and urinary functional outcomes of reproductive organ-sparing radical cystectomy (ROS-RC) and U-shaped ileal neobladder construction in females compared with male patients.

METHODS

We retrospectively examined 357 patients (281 male and 76 female) with muscle-invasive bladder cancer who were treated with RC plus U-shaped ileal neobladder construction between May 1996 and July 2021. All female patients were treated with ROS-RC. We compared disease-free survival (DFS), cancer-specific survival (CSS), overall survival (OS), and urinary functional outcomes between male and female patients. We evaluated the effect of gender on DFS, CSS, and OS. Furthermore, urinary functional outcomes were evaluated in 140 males and 48 females using a pressure-flow study at 3, 6, 9, and 12 months postoperatively.

RESULTS

Female patients were considerably older than male patients at the time of radical cystectomy. No significant difference was noted in the tumor stage preoperatively. The multivariable Cox regression analysis with an inverse probability treatment weighted model revealed that the female gender was not significantly related to DFS, CSS, and OS. Moreover, urinary functions at 12 months were not markedly different between males and females, except for the capacity of the neobladder, detrusor pressure, and maximum urethral closure pressure.

CONCLUSIONS

This study demonstrates that female patients with ROS-RC and U-shaped ileal neobladder construction did not significantly correlate with worse oncological outcomes. The combination of ROS-RC and U-shaped ileal neobladder construction might attain adequate urinary function without sacrificing oncologic outcomes.

Oncological and functional outcomes of organ-preserving cystectomy versus standard radical cystectomy: A systematic review and meta-analysis

Introduction

Radical cystectomy (RC) is historically considered the gold standard treatment for muscle invasive and high-risk non-muscle invasive bladder cancer. However, this technique leaves the majority of patients of both sexes with poor sexual and urinary function. Organ-sparing cystectomy (OSC) techniques are emerging as an alternative to the standard procedure to preserve these functions, without compromising the oncological outcomes. We present a systematic review and meta-analysis of the published literature.

Methods

MEDLINE, Embase and Web of Science were systematically searched for eligible studies on 6 April 2021. Primary outcomes studied were both oncological outcomes, specifically overall recurrence, and functional outcomes, specifically sexual function, and daytime and nighttime continence. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated. The PROSPERO registration reference number was CRD42018118897.

Results

From 13 894 identified abstracts, 19 studies (1886 male and 305 female patients) were eligible for inclusion in this review. These studies included patients who underwent either whole prostate, prostate capsule, seminal vesicle, nerve, uterus, ovary, vagina and fallopian tube sparing techniques. Four studies included only female patients.Thirteen studies reported oncological outcomes, and overall recurrence rate was similar between the two groups (five studies; OR 0.73; 95% CI 0.38-1.40, p = 0.34). Thirteen studies reported on male sexual function. In men, OSC had significantly greater odds of retaining potency (five studies; OR 9.05; 95% CI 5.07-16.16, p < 0.00001). Fourteen studies (13 on males and 1 female) reported urinary outcomes. In men, OSC demonstrated greater odds of daytime (seven studies; OR 2.61; 95% CI 1.74 to 3.92, p < 0.00001) and nighttime continence (seven studies; OR 2.62; 95% CI 1.76 to 3.89, p < 0.00001).

Conclusion

In carefully selected patients, OSC allows the potential to provide better sexual and urinary function without compromising oncological outcomes. There remains, however, a paucity of OSC studies in females. Further studies are required to make recommendations based on robust clinical evidence.

Female Sexual Function Following Radical Cystectomy in Bladder Cancer

INTRODUCTION

A clear and well-documented gender bias exists in the evaluation of sexual outcomes for women undergoing urologic surgery. Due to the anatomic template of anterior exenteration, women are commonly left with side effects that include sexual dysfunction and the perpetuated effects of surgical menopause.

OBJECTIVES

To present evaluation and treatment recommendations for female sexual dysfunction treatment and evaluation, in addition to surgical templates during radical cystectomy (RC).

METHODS

This article reviews current literature regarding sexual function and RC with urinary diversion in female bladder cancer patients. Furthermore, this review will provide a review of techniques for organ and neurovascular preservation, along with novel vaginal reconstruction templates. Our review will further focus on emerging technology, including minimally invasive surgery and organ and nerve preservation, directed at preservation of female sexual function.

RESULTS

Clinically, studies have demonstrated that females who have undergone genitalia-sparing and neurovascular preservation during RC regained sexual activity earlier than patients undergoing traditional RC. If organ and nerve preservation is not feasible due to involvement of trigone or bladder neck, vaginal reconstruction can mitigate the sexual dysfunction that results from a loss of the anterior vagina during a standard RC.

CONCLUSION

Female sexual dysfunction is associated with high levels of patient distress and is best comanaged with a multidisciplinary treatment approach, including preoperative counseling, intraoperative nerve, and organ preservation, and postoperative interventions to mitigate sexual side effects. Davis L, Isali I, Prunty M, et al. Female Sexual Function Following Radical Cystectomy in Bladder Cancer. Sex Med Rev 2021;XX:XXX-XXX.

Dysuria therapeutic agents as an independent prognostic factor for the primary recurrence of non-muscle invasive bladder cancer: a propensity score matching study

OBJECTIVE

To investigate if the use of therapeutic agents for dysuria is a risk factor for the primary recurrence of non-muscle invasive bladder cancer (NMIBC).

METHODS

First, patients with NMIBC were divided into two groups: the non-recurrence group and the recurrence group. Patient characteristics were compared between both groups. The risk factors of recurrence that were statistically different between the two groups were identified by multivariate analysis. Second, we divided the patients into risk and non-risk groups, and differences in the recurrence-free survival (RFS) between the two groups were analyzed before and after propensity score matching (PSM).

RESULTS

A total of 162 patients were included, with 84 patients in the non-recurrence group and 78 patients in the recurrence group. In the multivariate analysis, the intake of dysuria agents and bacillus Calmette-Guérin (BCG) therapy were independent factors. The RFS results in terms of the intake of dysuria agents were statistically significant before and after PSM analysis, but no factors were significantly different between the BCG and non-BCG groups after PSM.

CONCLUSIONS

Therapeutic agents for dysuria might be at an independent risk factor for NMIBC recurrence. This trial is registered with the UMIN Clinical Trials Registry under the number UMIN000036097 (https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno = R000041122).

Sexual-Sparing Robot Assisted Radical Cystectomy in Female: A Step-By-Step Guide

OBJECTIVE

To show different approaches for sexual-sparing robot assisted radical cystectomy in women.

MATERIALS AND METHODS

Radical cystectomy (RC) is a mainstay treatment for localized muscle invasive bladder cancer and high-risk non muscle invasive bladder cancer not responding to adequate endovesical therapy.¹ In women traditionally RC is performed with hystero-adnexectomy and resection of the anterior vaginal wall, but this technique often brings sexual disorders. With time, vaginal sparing techniques have been developed to improve functional outcomes in women motivated to preserve their sexual function.^2-4 The indications for vaginal-sparing RC are absence of tumor in bladder neck or urethra and no sign of infiltration of anterior vaginal wall and parametria at preoperative staging.

RESULTS

Procedure steps as follows. Step 1: Bilateral adnexectomy and ureteral isolation until their distal portion. Step 2: Vesico-vaginal dissection. Step 3: Bilateral pelvic and common iliac node dissection. Step 4: Ureteral clamping and section. Step5: Posterolateral bladder pedicle dissection. Step 6: Anterior dissection of the bladder towards the urethra. In women, this should be achieved without injuring the Santorini plexus and innervation of the clitoris. Step 7: Bladder neck identification and urethral dissection. Cystectomy is completed. Step 8: En bloc hystero-adnexectomy with anterior vaginal wall preservation; the vaginal pedicles are spared too. Step 9: Specimen extraction from the vagina and vaginal suture.It is also possible to perform a fully sexual-sparing robotic RC by following the vesico-vaginal plan without dissecting the vaginal dome and leaving internal genitalia intact. This technique is typically carried out in case of young women with no pathological uterine and ovarian findings.Vesico-vaginal plan can also be developed after opening the vaginal dome. This approach gives the possibility to subsequently dissect the cervix, to identify and spare the vaginal pedicles and to perform an "en bloc" radical cystectomy, with preservation of the anterior vaginal wall.In case of neobladder, diversion is carried out intracorporeally following the principles of the Saint Augustin neobladder.⁵ CONCLUSIONS: Robot assisted anterior pelvectomy with anterior vaginal wall preservation is a feasible and mini-invasive technique. For a satisfying functional result, it is crucial to preserve the vaginal neurovascular pedicles. This sexual-sparing approach must be carried out after a correct patient selection: women motivated to preserve their sexual function and ideally in the neobladder setting, when a posterior support for the urinary diversion is needed. Absence of tumor in bladder neck and urethra at magnetic resonance imaging could help patient selection.

Genitalia Preserving Robotic Radical Cystectomy with Intracorporeal Studer Pouch Formation in the Female: Experience in 5 Cases

We present operative, postoperative, oncologic and functional outcomes of genital tract sparing robot-assisted laparoscopic radical cystectomy, bilateral extended pelvic lymph node (LN) dissection and intracorporeal Studer pouch construction on five female patients with bladder cancer. One of the cases had concomitant nephroureterectomy performed due to a non-functioning kidney. Median patient age, mean operation time, median estimated blood loss and mean duration of hospital stay were 59 (39–78), 462 ± 25, 400 (50–970), 8.8 ± 2.5, respectively. Pathologic stages were pTis (n=1), pT1 (n=1), pT3 (n=1), pT4a (n=1) and pT4b (n=1). Mean LN yield was 32.4 ± 8.9. Positive surgical margins were detected in 2 patients with pT4 diseases. Only minor complications developed that were resolved with medical treatment. Two patients had no, 1 patient had mild, and 2 patients had moderate daytime incontinence. One patient had good, 3 patients had fair, and 1 had poor night-time incontinence. This complex robotic surgery can be performed safely with acceptable short-term surgical, oncological and functional outcomes.

Impairment and Longitudinal Recovery of Older Adults Treated with Radical Cystectomy for Muscle Invasive Bladder Cancer

PURPOSE

Treatment for muscle invasive bladder cancer includes radical cystectomy, a major surgery that can be associated with significant toxicity. Limited data exist related to changes in patient global health status and recovery following radical cystectomy. We used geriatric assessment to longitudinally compare health related impairments in older and younger patients with muscle invasive bladder cancer who undergo radical cystectomy.

MATERIALS AND METHODS

Older and younger patients (70 or older and younger than 70 years) with muscle invasive bladder cancer undergoing radical cystectomy at an academic institution were enrolled between 2012 and 2019. Patients completed the geriatric assessment before radical cystectomy, and 1, 3 and 12 months after radical cystectomy. For each geriatric assessment measure the Wilcoxon rank sum test was used to compare score distribution between age groups at each time point. The Wilcoxon signed rank test was used to compare distributions between time points within each age group.

RESULTS

A total of 80 patients (42 younger and 38 older) were enrolled. Before radical cystectomy 78% of patients were impaired on at least 1 geriatric assessment measure. Both age groups had worsening physical function and nutrition at 1 month after radical cystectomy, with older patients having a greater decline in function than younger patients. Both groups recovered to baseline at 3 months after radical cystectomy and maintained this status at 1 year.

CONCLUSIONS

High rates of impairments were found across age groups in the short term after radical cystectomy, followed by recovery to baseline.

Gender Disparity in Cystectomy Postoperative Outcomes: Propensity Score Analysis of the National Surgical Quality Improvement Program Database

BACKGROUND

While female gender is considered a protective determinant in the majority of cancers, outcomes in women diagnosed with bladder cancer have continued to show disproportional mortality when compared with men.

OBJECTIVE

The aim of this retrospective propensity score-matched analysis was to evaluate the intra- and postoperative differences among genders, as well as to evaluate reproductive organ-preserving radical cystectomy (ROPRC) as compared with radical cystectomy (RC) as a potential confounder in female cystectomy patients.

DESIGN, SETTING, AND PARTICIPANTS

Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), men and women undergoing a cystectomy between 2011 and 2017 were analyzed. In addition, females undergoing ROPRC and RC were analyzed for immediate postoperative outcomes.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Men and women undergoing a cystectomy were evaluated through propensity score matching (PSM) for baseline differences using a 1:1 caliper width of 0.2 to the nearest neighbor. Using multivariable logistic regression analysis, we evaluated differences in the risk of readmission, complications, and reoperation in the immediate postsurgical period in males and females. Similarly, differences were assessed in ROPRC and RC groups.

RESULTS AND LIMITATIONS

We achieved a balance between males and females after PSM: 1263 males and 1263 females treated with cystectomy. The risks of readmission (adjusted odds ratio [aOR] 1.228 [1.005-1.510], p=0.045), superficial surgical site infection (aOR 1.507 [1.095-2.086], p=0.012), and transfusion (aOR 2.031 [1.713-2.411], p<0.001) were increased in females undergoing a cystectomy compared with males. No differences were observed in surgical outcomes in ovarian sparing/RC cohort.

CONCLUSIONS

Using the 2011-2017 NSQIP database, we were able to demonstrate an increased rate of postoperative transfusion, readmission rate, and surgical site infection in females who underwent cystectomy. Our findings suggest that females experience an increased rate of complications in the immediate postoperative period. This may ultimately lead to worse oncologic outcomes in females after an RC. Lastly, we did not find any increased rate of complications in ROPRC as compared with RC.

PATIENT SUMMARY

This study highlights differences in immediate postoperative outcomes between males and females undergoing cystectomy for bladder cancer. Some of these potential differences include higher risk of infection, transfusion, and readmission. These differences may predispose females to worse long-term outcomes. In addition, due to potential benefits of ovarian preservation in the recent literature, we also evaluated the risks and complications of ovarian sparing cystectomy. We found ovarian preservation to be a safe and feasible procedure in a highly selected group of patients.