Armine K. Smith, MD, on sexual health counseling before cystectomy

In this video, Armine K. Smith, MD, of Johns Hopkins Sibley Memorial Hospital in Washington, DC, discusses sexual health and intimacy considerations before radical cystectomy, including differences in counseling and organ-preservation approaches for men and women. Smith recently presented a talk at the Bladder Cancer Advocacy Network (BCAN) Think Tank session on sexual health and intimacy in modern bladder cancer care.

Smith is an associate professor of urology at Johns Hopkins University School of Medicine and codirector for the Women’s Bladder Cancer Program at Sibley Memorial Hospital in Washington, DC.

Smith emphasizes the importance of initiating conversations about sexual health before surgery by asking patients whether they are sexually active, whether sexual function is important to them, and whether they would like a partner involved in the discussion. For men, counseling should distinguish erectile function, orgasm, and fertility, which involve separate mechanisms and may be affected differently by surgery. Removal of the prostate and seminal vesicles and division of the vas deferens typically eliminate ejaculation and natural fertility, even when erectile function is preserved. In carefully selected patients, prostate capsule-sparing and nerve-sparing approaches may help preserve function, provided oncologic outcomes are not compromised.

For women, standard radical cystectomy may involve removal of the bladder, uterus, anterior vaginal wall, ovaries, and urethra, potentially affecting vaginal length and caliber, clitoral and vaginal sensation, hormonal function, and fertility.

“Written out plainly, that's 4 separate injuries at once,” Smith explained. “We shorten and narrow the vagina. We divide the neurovascular supply to [the] clitoris and vaginal wall. We induce surgical menopause, and we end fertility. So my answer to that is not just to counsel better. It's not to do it when we don't have to do it.”

Smith describes organ-preserving approaches, including preservation of the anterior vaginal wall, ovaries, and, when appropriate, uterus, as well as nerve-sparing dissection and attention to vaginal support to reduce the risk of postoperative prolapse. However, these approaches are not suitable for every patient. Tumor location and extent, suspected positive margins, and personal or familial cancer risk may influence which organs can safely be preserved. Counseling should clarify the conditions under which preservation may be considered and acknowledge that final decisions may depend on intraoperative findings.

Smith also highlights a disparity in how clinicians approach sexual function and organ preservation in men and women.

“In men, nerve-sparing surgery is a reflex. In women, the same conversation is available to us, and we don't have it,” she explained. “So 41% of urologists don't routinely raise organ preservation with sexually active women. This isn't a knowledge gap. This is a habit, and I think we have to correct it.”