Introduction:

Standard radical cystectomy (RC) in women with bladder cancer involves removal of the bladder, as well as the uterus, fallopian tubes, ovaries, and anterior vaginal wall. While the rationale is removal of adjacent organs at risk for local tumor extension, this en bloc approach induces a number of physical changes such as disruption of the clitoral vascular supply, alterations in vaginal anatomy, damage to the neurovascular bundle, weakening of the pelvic floor, and—in some cases—induction of surgical menopause that can have a significant impact on female patients’ sexual and overall health. Alternatively, pelvic-organ-preserving (POP) RC techniques in women, which aim to preserve some or all of the gynecologic organs and neurovascular bundle, have been shown to be both oncologically safe in select patients and to improve postoperative functional outcomes. However, practice patterns regarding POP RC and factors impacting surgical decision-making among urologists performing RC are not known.

Methods:

We conducted a cross-sectional survey of members of the Society of Urologic Oncology who performed female RC to assess national practice patterns regarding performance of POP RC in premenopausal and postmenopausal women with organ-confined disease, as well as factors associated with operative decision-making. Frequency of sparing the uterus/cervix, neurovascular bundle, ovaries, and a portion of the vagina when performing RC in a premenopausal woman with clinically-localized disease was quantified on a 5-point scale (never, rarely [<25%], sometimes [25-50%], mostly [51-99%], always). Routine resection was defined as sparing <50% of the time. Changes in operative technique for a postmenopausal patient with similar disease burden were quantified on a 3-point scale (less likely to spare, no change, and more likely to spare). Modified Poisson regression was used to examine univariate associations between provider characteristics and routine resection of each female pelvic organ.

Results:

Overall, 140 of 723 members responded to our survey and met inclusion criteria. The median age was 42 years (interquartile range [IQR]: 38-51), 9.3% were female, 81.4% had completed an oncology fellowship, and 77.9% were in academic practice. The median number of female RC’s performed in the preceding 12 months was 5 (IQR: 3-10). In premenopausal women, 79.2% routinely resected the uterus/cervix, 67.3% the neurovascular bundle, 48.5% the ovaries, and 18.8% a portion of the vagina (Figure 1). In postmenopausal women, 72.0% were less likely to spare the uterus/cervix, 44.4% were less likely to perform nerve-sparing, 74.7% were less likely to spare the ovaries, and 25.3% were less likely to perform vaginal preservation (Figure 2). Provider sex, age, practice setting, fellowship training, years in practice, and female RC volume were not predictive of routine resection of the uterus/ cervix, neurovascular bundle, ovaries, or vagina in premenopausal women.

Conclusion:

Although the American Urological Association guidelines for treatment of non-metastatic muscle-invasive bladder cancer state that providers should consider organ-preservation for patients with organ-confined disease, urologists in this study reported that they do not routinely perform POP RC or nerve-sparing RC in premenopausal women with clinically-localized bladder cancer. Additionally, this practice appears to be widespread among urologists of varying backgrounds and clinical experience. Future efforts should aim to identify clinician barriers to performing POP and nerve-sparing female RC when oncologically feasible to improve functional outcomes among female patients. 

Funding: Greenberg Bladder Cancer Institute