Practical guide to female pelvic organ–sparing radical cystectomy

Smith is director of the Women’s Bladder Cancer Program at Brady Urological Institute of Johns Hopkins University in Baltimore, Maryland, and director of urologic oncology at Sibley Memorial Hospital in Washington, DC. Azari is a urologic oncology fellow and clinical instructor in urology the University of California, San Diego.

Radical cystectomy in women has historically been highly morbid, performed as an anterior exenteration with removal of the bladder, urethra, uterus, ovaries, fallopian tubes, and anterior vaginal wall. Interest in organ preservation emerged in the 1990s, with early reports of female urethral sparing to facilitate neobladder reconstruction.^1,2 Over the past 3 decades, improved understanding of pelvic anatomy and bladder cancer biology,

together with emphasis on quality of life, have expanded opportunities to preserve reproductive organs and nerves when oncologically safe. This evolution is reflected in contemporary guidelines; both the American Urological Association and European Association of Urology now support individualized consideration of organ-sparing approaches for appropriately selected women.^3,4

The rationale for organ preservation is anchored in its functional and long-term health benefits. Even after menopause, ovarian preservation has benefits because the ovaries continue to produce testosterone, which can be converted peripherally to estrogen. Large epidemiologic studies show that women who undergo oophorectomy experience higher rates of all-cause and cardiovascular mortality, with survival advantages persisting beyond menopause.^5-8 When oophorectomy is required in premenopausal women, temporary hormone replacement therapy until the average age of menopause can mitigate cardiovascular and skeletal risks.^9,10

Preserving the uterus and its supporting ligaments contributes to pelvic floor integrity. These structures help maintain support and reduce the risk of postcystectomy pelvic organ prolapse, which is reported in approximately 4.5% of women.¹¹ Although uncommon, prolapse can impair quality of life and is challenging to repair after continent urinary diversion.^12,13 In patients receiving a continent diversion, uterine preservation has been associated with improved continence and reduced hypercontinence.^14-17

Vaginal preservation confers important quality-of-life advantages. Retaining vaginal integrity helps maintain sexual function and reduces complications such as cuff dehiscence and fistula, which can occur in up to 1 in 5 women.¹¹ Protecting pelvic nerves along the lateral vaginal wall preserves autonomic pathways that are essential for sexual arousal and lubrication,^18,19 and it improves continence in women undergoing continent urinary diversion.^14-17

Oncologic safety and patient selection

Cancer control remains the central consideration in any oncologic surgery. Large series show invasion of gynecologic organs by bladder cancer in only 5% to 7% of cases.^20-23 Certain clinical and pathologic features increase the risk of reproductive organ involvement. Bulky tumors, extravesical extension, trigonal involvement, hydronephrosis, lymphovascular invasion, and positive lymph nodes should prompt caution and detailed preoperative counseling.^21,22,24 Nevertheless, organ sparing is not an all-or-none principle; for example, a trigonal tumor requiring partial anterior vaginal resection may still permit preservation of the reproductive organs.

Future gynecologic malignancy risk also warrants attention. Occult malignancy in asymptomatic women is less than 1%^25,26; therefore, a focused preoperative screening strategy is recommended. Cervical cancer screening should be current, and abnormal vaginal bleeding should prompt transvaginal ultrasound and, when appropriate, referral to gynecology for further evaluation. Patients with hereditary cancer syndromes, such as Lynch or BRCA mutations, require individualized counseling, and prophylactic oophorectomy should be considered. Many surgeons offer opportunistic salpingectomy even when preserving ovaries to reduce lifetime ovarian cancer risk by 35%.^27,28 Collaboration with gynecology can further refine risk assessment and operative planning.

Urethral preservation is essential when constructing a neobladder and may also be considered in other patients. Multifocal carcinoma in situ, tumor at the bladder neck or prostatic urethra, and extensive carcinoma in situ elsewhere are established risk factors for urethral involvement.^22,29,30 In the absence of these features, consideration of urethra sparing is appropriate to avoid disrupting autonomic nerve pathways essential for sexual function. Intraoperative frozen section analysis of the urethral margin provides reliable confirmation of oncologic safety; a negative margin is associated with a very low risk of recurrence, supporting safe urethral preservation.³¹

Operative principles

Female pelvic organ–sparing cystectomy requires meticulous, anatomy-driven dissection. A nerve-sparing approach begins by staying close to the bladder pedicles to preserve autonomic fibers of the pelvic plexus. When feasible, the bladder is separated from the anterior vaginal wall, preserving vaginal integrity. If partial resection is required, it should be limited. Wide lateral dissection should be avoided to minimize nerve injury. When a portion of the anterior vaginal wall is removed and there is enough remaining tissue to maintain a functional vagina, or when vaginal preservation is not necessary because of the sexual status, transverse or longitudinal closure can be performed. When significant vaginal loss is unavoidable and functional restoration is important, reconstructive flaps may be used in collaboration with plastic surgery.

Uterine preservation requires careful attention to its supporting ligaments, maintaining pelvic floor stability. During lymphadenectomy and retraction, meticulous technique protects preserved organs and nerves while ensuring adequate oncologic clearance.

Practical implementation

Integrating organ-sparing principles into practice benefits from a structured workflow. Before surgery, tumor characteristics and risk factors should be evaluated to determine the oncologic feasibility of organ preservation; the gynecologic history and screening status should be reviewed; gynecologic consultation should be obtained when indicated; and patients should be counseled about the benefits of preservation and the need for surveillance of retained organs. During the operation, oncologic safety guides all decisions, yet surgeons should remain attentive to opportunities for organ preservation, using intraoperative frozen sections where appropriate. Postoperatively, surveillance must be tailored to the patient’s anatomy and risk profile, with follow-up addressing both cancer control and functional outcomes. Women retaining the uterus and cervix should understand the need for guideline-appropriate gynecologic surveillance and the risk of future malignancy. Premenopausal women undergoing oophorectomy should receive counseling about temporary hormone replacement therapy to protect long-term health. Equally important is proactive discussion of sexual recovery and pelvic function. Setting expectations about continence, lubrication, and arousal and offering referral to pelvic floor physical therapy or sexual medicine can meaningfully improve long-term satisfaction.

Conclusion

Female pelvic organ–sparing radical cystectomy offers a way to reframe what historically has been a morbid operation. By combining rigorous cancer control with attention to pelvic, sexual, hormonal, and functional health, this approach allows many women to retain a sense of normalcy and improved quality of life without compromising oncologic outcomes. Growing evidence encourages urologists to make organ preservation a standard part of patient care rather than an exception.

REFERENCES

1. Stein JP, Stenzl A, Esrig D, et al. Lower urinary tract reconstruction following cystectomy in women using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: initial clinical experience. J Urol. 1994;152(5 Pt 1):1404-1408. doi:10.1016/s0022-5347(17)32431-x

2. Stein JP, Cote RJ, Freeman JA, et al. Indications for lower urinary tract reconstruction in women after cystectomy for bladder cancer: a pathological review of female cystectomy specimens. J Urol. 1995;154(4):1329-1333.

3. Holzbeierlein J, Bixler BR, Buckley DI, et al. Treatment of non-metastatic muscle-invasive bladder cancer: AUA/ASCO/SUO Guideline (2017; Amended 2020, 2024). J Urol. 2024;212(1):3-10. doi:10.1097/JU.0000000000003981

4. van der Heijden AG, Bruins HM, Carrion A, et al. European Association of Urology Guidelines on Muscle-Invasive and Metastatic Bladder Cancer: summary of the 2025 guidelines. Eur Urol. 2025;87(5):582-600. doi:10.1016/j.eururo.2025.02.019

5. Fogle RH, Stanczyk FZ, Zhang X, Paulson RJ. Ovarian androgen production in postmenopausal women. J Clin Endocrinol Metab. 2007;92(8):3040-3043. doi:10.1210/jc.2007-0581

6. Judd HL, Lucas WE, Yen SS. Effect of oophorectomy on circulating testosterone and androstenedione levels in patients with endometrial cancer. Am J Obstet Gynecol. 1974;118(6):793-798. doi:10.1016/0002-9378(74)90490-6

7. Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses’ Health Study. Obstet Gynecol. 2009;113(5):1027-1037. doi:10.1097/AOG.0b013e3181a11c64

8. Smith G. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol. 2005;106(6):1413. doi:10.1097/01.AOG.0000190480.45127.67

9. Sarrel PM, Sullivan SD, Nelson LM. Hormone replacement therapy in young women with surgical primary ovarian insufficiency. Fertil Steril. 2016;106(7):1580-1587. doi:10.1016/j.fertnstert.2016.09.018

10. Hormone therapy in primary ovarian insufficiency. American College of Obstetricians & Gynecologists. May 2017. Accessed September 29, 2025. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/05/hormone-therapy-in-primary-ovarian-insufficiency

11. Richter LA, Osazuwa-Peters OL, Routh JC, Handa VL. Vaginal complications after cystectomy: results from a Medicare sample. J Urol. 2022;207(4):789-796. doi:10.1097/JU.0000000000002336

12. Lee D, Zimmern P. Management of pelvic organ prolapse after radical cystectomy. Curr Urol Rep. 2019;20(11):71. doi:10.1007/s11934-019-0941-1

13. Cruz AP, Chelluri R, Ramchandani P, Guzzo TJ, Smith AL. Post-cystectomy enterocele: a case series and review of the literature. Urology. 2021;150:180-187. doi:10.1016/j.urology.2020.03.063

14. Gross T, Furrer M, Schorno P, et al. Reproductive organ-sparing cystectomy significantly improves continence in women after orthotopic bladder substitution without affecting oncological outcome. BJU Int. 2018;122(2):227-235. doi:10.1111/bju.14191

15. Gross T, Meierhans Ruf SD, Meissner C, Ochsner K, Studer UE. Orthotopic ileal bladder substitution in women: factors influencing urinary incontinence and hypercontinence. Eur Urol. 2015;68(4):664-671. doi:10.1016/j.eururo.2015.05.015

16. Nseyo U, Ginsberg D. Functional outcomes of orthotopic neobladder in women. Curr Urol Rep. 2024;25(11):277-285. doi:10.1007/s11934-024-01223-7

17. Park JS, Yuk HD, Jeong CW, Kwak C, Kim HH, Ku JH. Comparison of functional and oncological outcomes between uterus-sparing radical cystectomy and standard radical cystectomy in females: a retrospective study. Investig Clin Urol. 2022;63(6):612-622. doi:10.4111/icu.20220220

18. Mauroy B, Demondion X, Bizet B, Claret A, Mestdagh P, Hurt C. The female inferior hypogastric (= pelvic) plexus: anatomical and radiological description of the plexus and its afferences—applications to pelvic surgery. Surg Radiol Anat. 2007;29(1):55-66. doi:10.1007/s00276-006-0171-3

19. Modh RA, Mulhall JP, Gilbert SM. Sexual dysfunction following cystectomy and urinary diversion. Nat Rev Urol. 2014;11(8):445-453. doi:10.1038/nrurol.2014.151

20. Bree KK, Hensley PJ, Westerman ME, et al. Contemporary rates of gynecologic organ involvement in females with muscle invasive bladder cancer: a retrospective review of women undergoing radical cystectomy following neoadjuvant chemotherapy. J Urol. 2021;206(3):577-585. doi:10.1097/JU.0000000000001784

21. Lobo N, Uthayanan L, Uribe-Lewis S, et al. Gynaecological organ involvement in females undergoing radical cystectomy: a multicentre study. BJU Int. 2024;133(4):474-479. doi:10.1111/bju.16268

22. Djaladat H, Bruins HM, Miranda G, Cai J, Skinner EC, Daneshmand S. Reproductive organ involvement in female patients undergoing radical cystectomy for urothelial bladder cancer. J Urol. 2012;188(6):2134-2138. doi:10.1016/j.juro.2012.08.024

23. Chang SS, Cole E, Smith JA, Cookson MS. Pathological findings of gynecologic organs obtained at female radical cystectomy. J Urol. 2002;168(1):147-149.

24. Avulova S, Benidir T, Cheville JC, et al. Prevalence, predictors, and oncologic outcomes of pelvic organ involvement in women undergoing radical cystectomy. Arch Pathol Lab Med. 2022;147(2):202-207. doi:10.5858/arpa.2021-0409-OA

25. Ramm O, Gleason JL, Segal S, Antosh DD, Kenton KS. Utility of preoperative endometrial assessment in asymptomatic women undergoing hysterectomy for pelvic floor dysfunction. Int Urogynecol J. 2012;23(7):913-917. doi:10.1007/s00192-012-1694-2

26. Frick AC, Walters MD, Larkin KS, Barber MD. Risk of unanticipated abnormal gynecologic pathology at the time of hysterectomy for uterovaginal prolapse. Am J Obstet Gynecol. 2010;202(5):507.e1-507.e5074. doi:10.1016/j.ajog.2010.01.077

27. Falconer H, Yin L, Grönberg H, Altman D. Ovarian cancer risk after salpingectomy: a nationwide population-based study. J Natl Cancer Inst. 2015;107(2):dju410. doi:10.1093/jnci/dju410

28. Yeguez AC, Talwar R, Smith AL. Optimizing care for women through gynecologic organ considerations during cystectomy: a pre-operative checklist of important considerations. Urology. 2025;197:194-199. doi:10.1016/j.urology.2024.11.044

29. Coloby PJ, Kakizoe T, Tobisu K, Sakamoto M. Urethral involvement in female bladder cancer patients: mapping of 47 consecutive cysto-urethrectomy specimens. J Urol. 1994;152(5 Pt 1):1438-1442. doi:10.1016/s0022-5347(17)32440-0

30. Khanna A, Zganjar A, Lyon T, et al. A contemporary analysis of urethral recurrence following radical cystectomy. J Urol. 2021;206(4):970-977. doi:10.1097/JU.0000000000001842

31. Gakis G, Ali-El-Dein B, Babjuk M, et al. Urethral recurrence in women with orthotopic bladder substitutes: a multi-institutional study. Urol Oncol. 2015;33(5):204.e17-204.e2.04E23. doi:10.1016/j.urolonc.2015.01.020