Radical Cystectomy and Urinary Diversion in Women

Abstract and Introduction

Abstract

Background and Objective: Standard radical cystectomy (RC) in women includes the removal of the bladder, urethra, uterus with the adnexa, and the anterior vaginal wall, thereby severely affecting the urinary, sexual, and reproductive system. To limit these detrimental effects, organ-sparing, including nerve-sparing approaches, have been developed. Health-related quality of life (HRQOL) and functional outcomes are, indeed, becoming increasingly central to the shared decision-making with the patient. The objectives of this narrative review are: (I) to review the current status of RC in women, including the use of different urinary diversions (UDs); (II) to discuss organ-sparing approaches and their impact on oncological and functional outcomes in women; (III) to discuss the impact of RC on HRQOL and sexual function in women.

Methods: We performed a non-systematic literature review of the available publications in the PubMed database.

Key Content and Findings: Over the past years, gender differences in oncological and functional outcomes after RC have received increased attention. According to the currently available literature, organ-sparing approaches can be safely performed in well-selected women without negatively impacting oncological outcomes. The orthotopic neobladder is feasible and oncologically safe in well-selected and informed women. The choice of the UD should be based on comprehensive counseling and the patient's comorbidities and preferences. There still is a lack of data on sexual recovery after the different surgical approaches aimed to mitigate sexual dysfunction in women undergoing RC.

Conclusions: Pre-and post-operative counseling and support of females undergoing RC regarding their expectations and experiences in terms of quality of life and functional and sexual outcomes are currently insufficient. Well-designed studies in this field are necessary to further improve outcomes of women treated with RC with an overarching aim to close the gender gap in managing women with bladder cancer.

Introduction

Radical cystectomy (RC), including pelvic lymph node dissection with neoadjuvant cisplatin-based therapy when possible, is the standard treatment of localized muscle-invasive bladder cancer (MIBC) and very high-risk non-muscle-invasive bladder cancer.^[1,2] Approximately one-fourth of MIBC patients will undergo RC, which is a complex procedure that differs between genders and is associated with high perioperative morbidity.^[3–5] Counseling women with bladder cancer requires discussion, regarding the surgical approach and its oncological safety, choice of urinary diversion (UD), and expected and desired postoperative functional outcomes. This review aims to discuss the most important aspects of organ sparing RC, the different types of UD, as well as functional and sexual outcomes after RC in females. We present the following article in accordance with the Narrative Review reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-22-463/rc).

Authors and Disclosures

Table 1. The search strategy summary
Items	Specification
Date of search	February 11th, 2022
Databases and other sources searched	PubMed
Search terms used	"radical cystectomy", "female*", "women", "sexual function", "functional outcome", "urinary diversion", "organ sparing radical cystectomy", "nerve sparing radical cystectomy"
Timeframe	1995–2022
Inclusion and exclusion criteria	Inclusion criteria: relevance to the topic; English articles only
Exclusion criteria: editorials/author replies
Selection process	One person assessed the relevance of the articles
Any additional consideration	Additional articles that the authors considered to be of interest to the reader were added

Table 2. Aspects for pre-and intraoperative evaluation of candidates for ROPRC
Functional aspects prior to ROPRC	Oncological contraindications for ROPRC
Age	Bladder neck and trigonum involving bladder cancer
Performance status	Presence of preoperative hydronephrosis
Gynecological examination	Presence of CIS
History of abnormal vaginal bleeding	Clinical tumor stage ≥ cT3
Preoperative continence status	Suspected nodal-positive disease
Preoperative sexual function	Intraoperative positive urethral margins
Menopausal status	Intraoperative positive ureteral margins
Fertility goal	Family history for gynecological malignancies
Previous pelvic surgeries	Genetic predisposition for gynecological malignancies (BRCA1/2 mutations)

Markus von Deimling^1,2, Ekaterina Laukhtina², Benjamin Pradere^2,3, Maximilian Pallauf^2,4, Jakob Klemm¹, Margit Fisch¹, Shahrokh F. Shariat^2,5–9# and Michael Rink^1#

¹Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; ²Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; ³Department of Urology, La Croix Du Sud Hospital, Quint-Fonsegrives, France; ⁴Department of Urology, University Hospital Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria; ⁵Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan; ⁶Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; ⁷Department of Urology, Weill Cornell Medical College, New York, NY, USA; ⁸Department of Urology, University of Texas Southwestern, Dallas, TX, USA; ⁹Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic

Correspondence to
Prof. Shahrokh F. Shariat. Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria. Email: shahrokh.shariat@meduniwien.ac.at.

Contributions
(I) Conception and design: M von Deimling, SF Shariat, M Rink; (II) Administrative support: All authors; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: M von Deimling, SF Shariat, M Rink; (V) Data analysis and interpretation: M von Deimling; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

^#These authors contributed equally to this work.

Conflicts of Interest
All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-22-463/coif). MR serves as an unpaid Associate Editor in Chief of Translational Andrology and Urology from January 2022 to December 2023. MP reports that he has received a research grant from the Austrian Urological Association; support for attending the Austrian Urological Association's yearly meeting; speaker honoraria from Astellas, Janssen, and MedMedia; and an honorarium from Spectra for attending an Advisory Board. MP was a board member of the Austrian Urological Association from 2018 to 2021. The listed content regarding MP were not related to the this study. MF is a member of the Advisory Board of Boston Scientific. MF has received a grant from Boston Scientific as well as support from Astellas/Apogepha for the organization of a scientific meeting. The listed content regarding MF was not related to this study. The other authors have no conflicts of interest to declare.