The current state of organ-sparing radical cystectomy for women

Women are less likely to be diagnosed with bladder cancer, but that does not make the disease any less fatal for this population of patients. Because radical cystectomy is performed less often on women, organ-sparing techniques are less common and therefore, if patients do survive bladder cancer treatment, they may suffer from worse quality of life as a result of the surgery.

Svetlana Avulova, MD, emphasizes the importance of this topic in a recent interview. As an advocate for patients, she stresses the importance of this population of women with bladder cancer and how their desire to preserve sexual function through organ-sparing treatment should be recognized and validated. Avulova is an assistant professor of surgery in urologic oncology at the Albany Medical Center in Albany, New York.

What are some considerations/challenges unique to women undergoing radical cystectomy?

I think one of the biggest challenges is the fact that bladder cancer doesn't occur as often as it does in men for women. Therefore, the procedure of a radical cystectomy in women is not done as often as in men. So, for example, a high-volume surgeon who treats bladder cancer may do 40 to 50 cystectomies a year in men, but maybe at most 10 or 15 cystectomies a year for women. I see it as one of the biggest challenges—that lower surgical volume leads less interest in improving the techniques of the procedure.

What is the current status of organ-sparing cystectomy? How wide is its applicability?

The current status, as far as I can tell, is that people are talking about it [organ-sparing cystectomy] and some surgeons are routinely counseling women about it and performing it. Now, this is [mostly] being done for younger women. As you may know, bladder cancer occurs in postmenopausal women, and oftentimes, the average age of a woman undergoing a cystectomy is 65 to 70 [years]. And so, organ-sparing for those older women is often not at the forefront of the surgeon's mind, again, because advanced bladder cancer is lethal. When you get to the point of needing a cystectomy, the focus tends to be on oncological cure, and less of a, 'How will this affect their quality of life?" Although procedures describing organ-sparing have been described since, I would say, [the] early 2000s, oftentimes, most high-volume surgeons are not that sure on how to accomplish this. Because the procedures often take a long time—on average, 4 to 5 hours, sometimes 7 or 8—meticulous dissection of ovarian pedicles, uterus, and/or anterior vagina is overlooked and dismissed because you're trying to get the patient off the table quickly.

What can be done to mitigate the adverse events associated with radical cystectomy in women?

Well, for one, I think discussing it and talking about the different techniques out there [is important], and I think we're already heading in the right direction by having this interview today. The second thing, which is what I found when I was researching this topic, is that there really weren't any good resources available, and when I say resources, I mean illustrations or videos. And so, when I was at Mayo Clinic during my fellowship there, I was so impressed by the abundance of illustrations that the Mayo Clinic Media Library contains on anatomical descriptions of procedures. What I noticed is that they had wonderful illustrations for gynecologic oncology procedures, like a nerve-sparing radical hysterectomy, which is removal of the uterus for cervical cancer or uterine cancer. However, the bladder in those illustrations looked very small and not as anatomically to-scale, so I thought that it would be great to use the illustrators from Mayo to see if we can come up with better pictures that could be available to the public. And so, that's what we did when we wrote our AUA update for bladder cancer in women, with Angie Smith [,MD, MS]. We used the Mayo Clinic illustrators to come up with illustrations depicting the female pelvis when encountering organ-sparing radical cystectomy.

Are you currently conducting any research on organ-sparing cystectomy?

Not directly, but peripherally. What I'm doing right now is I'm just trying to get as much information as possible. So, I'm in the gathering-data stage and trying to figure out exactly what we need to know more about. Our current study is looking at sexual function among women who were undergoing radical cystectomy. Part of that study is we're not only trying to figure out the perspective of the patient, but also trying to see what the surgeon actually does. And [what] this entails [is] indicating whether they've done any organ sparing and specifying exactly which organ is being spared. If the vagina is incised, how is it closed? If any preoperative counseling specific to sexual function is performed by the surgeon, [is there] any counseling on what women can expect after the surgery? What I hope to accomplish from the study is to lay the groundwork for future studies where we can hone in on the particular techniques of organ sparing, and to see if we can improve those.

Is there anything else you feel our audience should know about this topic?

I think the most important takeaway I would like the audience to have is that although it seems like this is an insignificant blip in a woman's life who is diagnosed with a major malignancy and is undergoing a life-altering operation, and although it seems not as important as becoming cancer-free, it is important. Unfortunately, whether it's for societal reasons or generational reasons, women are not as comfortable discussing their own sexual function as men [are,] or maybe they don't think that they have a right to it. And so, what I want the audience to take away is that women do want to talk about this, but that perhaps they shy away from it because they don't want to be judged as somebody who values sexual function over becoming cancer-free. I think as providers and as physicians, we really should be advocates for patients, normalize these very sensitive topics, and allow for our patients to express them by querying these questions.