Radical Cystectomy and Perioperative Sexual Function: A Cross-Sectional Analysis

Impact of late effects after treatment for bladder cancer with radical cystectomy on Quality of life: a case-control study

BACKGROUND AND PURPOSE

The gold standard when treating muscle-invasive bladder cancer (MIBC) is radical cystectomy (RC), a procedure that holds the potential to affect the function of several pelvic organs, causing an impact on the patient's Quality of Life (QoL). Knowledge of the late effects following bladder cancer and treatment with RC is sparse. The aim is to describe the incidence of late effects and to investigate the impact on QoL.

METHODS

A cross-sectional study using register data in combination with a questionnaire, measuring pelvic organ specific symptoms to treatment and QoL. MIBC patients diagnosed between 2015 and 2020 and able to receive digital mail was invited. For each MIBC patient, 6 age- and gender matched controls were invited. QoL was measured using EORTC-QLQ-C30. The MIBC specific EORTC-QLQ-BLM30 was administered to cases only.

BACKGROUND AND PURPOSE

The gold standard when treating muscle-invasive bladder cancer (MIBC) is radical cystectomy (RC), a procedure that holds the potential to affect the function of several pelvic organs, causing an impact on the patient's Quality of Life (QoL). Knowledge of the late effects following bladder cancer and treatment with RC is sparse. The aim is to describe the incidence of late effects and to investigate the impact on QoL.

METHODS

A cross-sectional study using register data in combination with a questionnaire, measuring pelvic organ specific symptoms to treatment and QoL. MIBC patients diagnosed between 2015 and 2020 and able to receive digital mail was invited. For each MIBC patient, 6 age- and gender matched controls were invited. QoL was measured using EORTC-QLQ-C30. The MIBC specific EORTC-QLQ-BLM30 was administered to cases only.

RESULTS

A total of 628 (54.3%) MIBC patients and their 1,204 (37.3%) matched controls responded. Median age was 73. Mean time since RC was 4.9 (SD 2.1) years. Scoring of the functional items on EORTC-QLQ-C30 and overall QoL were similar for cases and controls. Regarding late effects, similar responses were seen on questionnaire data when comparing cases and controls. On registry data, a higher risk of infections and hydronephrosis were seen for cases. A strong correlation between fatigue and impaired QoL was identified.

INTERPRETATION

MIBC patients were more often diagnosed with late effects such as infections and hydronephrosis, compared to controls. In spite of this, MIBC patients overall QoL was equal to that of the controls.

Female Sexual Function After Radical Cystectomy: A Cross-sectional Study

Background and objective

Radical cystectomy (RC) is the gold-standard treatment for muscle-invasive bladder cancer (MIBC). Approximately 25% of MIBC patients are women. In women, RC includes removal of the ovaries, uterus, and the anterior vaginal wall, during which nerve damage can occur, potentially impacting sexual function. Studies on sexual function among females following RC are sparse. Our aim was to investigate the impact of RC on female sexual function.

Methods

A cross-sectional registry study and a questionnaire survey were used. The Danish Cancer Registry was used to identify all female patients diagnosed with MIBC between 2015 and 2020 who were treated with RC and an ileal conduit. Comorbidity and complications data were obtained from the Danish National Patient Registry. The survey included European Organization for Research and Treatment of Cancer questionnaires on quality of life (EORTC-QLQ-C30) and sexual health (EORTC-SHQ-C22) and eight questions covering female sexual function.

Key findings and limitations

A total of 151 women completed the questionnaires, of whom 30 (21%) reported worries about resuming sexual activity after RC and 51 (34%) about resuming intercourse specifically. An altered perception of vaginal size was reported by 85 (56%) respondents. Prolonged time to experiencing orgasm was reported by 43 (51%) and anorgasmia by 23 (26%) of the sexually active women. Pain during and after penetration in ≥50% of attempts was reported by 29 (54%) and 23 (43%) respondents, respectively. There was moderate correlation between pain and sexual satisfaction (p < 0.001).

Conclusions and clinical implications

RC can result in altered perception of vaginal size and pain on intercourse among female patients with bladder cancer, with potential effects on sexual satisfaction.

Patient summary

We assessed sexual outcomes for women after removal of the bladder for bladder cancer and carried out a survey among Danish women who underwent this treatment between 2015 and 2020. The majority of the women reported changes in sexual function, including pain during intercourse and altered perception of vaginal size.

Urinary function in female patients after traditional, organ-sparing and nerve-sparing radical cystectomy for bladder cancer: a systematic review and pooled analysis

OBJECTIVES

To determine and summarize the available data on urinary, sexual, and health-related quality-of-life (HRQOL) outcomes after traditional radical cystectomy (RC), reproductive organ-preserving RC (ROPRC) and nerve-sparing RC (NSRC) for bladder cancer (BCa) in female patients.

METHODS

The PubMed, SCOPUS and Web of Science databases were searched to identify studies reporting functional outcomes in female patients undergoing RC and urinary diversion for the treatment of BCa. The outcomes of interest were voiding function (for orthotopic neobladder [ONB]), sexual function and HRQOL. The following independent variables were derived and included in the meta-analysis: pooled rate of daytime and nighttime continence/incontinence, and intermittent self-catheterization (ISC) rates. Analyses were performed separately for traditional, organ- and/or nerve-sparing surgical approaches.

RESULTS

Fifty-three studies comprising 2740 female patients (1201 traditional RC and 1539 organ-/nerve-sparing RC, and 264 nerve-sparing-alone RC) were eligible for qualitative synthesis; 44 studies comprising 2418 female patients were included in the quantitative synthesis. In women with ONB diversion, the pooled rates of daytime continence after traditional RC, ROPRC and NSRC were 75.2%, 79.3% and 71.2%, respectively. The pooled rate of nighttime continence after traditional RC was 59.5%; this rate increased to 70.7% and 71.7% in women who underwent ROPRC and NSRC, respectively. The pooled rate of ISC after traditional RC with ONB diversion in female patients was 27.6% and decreased to 20.6% and 16.8% in patients undergoing ROPRC and NSRC, respectively. The use of different definitions and questionnaires in the assessment of postoperative sexual and HRQOL outcomes did not allow a systematic comparison.

CONCLUSIONS

Female organ- and nerve-sparing surgical approaches during RC seem to result in improved voiding function. There is a significant need for well-designed studies exploring sexual and HRQOL outcomes to establish evidence-based management strategies to support a shared decision-making process tailored towards patient expectations and satisfaction. Understanding expected functional, sexual and quality-of-life outcomes is necessary to allow individualized pre- and postoperative counselling and care delivery in female patients planned to undergo RC.

Evaluation of sexual function and vaginal prolapse after radical cystectomy in women: a study to explore an under-evaluated problem

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate sexual function, vaginal prolapse, and quality of life (QoL) in women after radical cystectomy (RC) using validated questionnaires and pelvic organ prolapse quantification (POP-Q) measurement.

METHODS

Female bladder cancer patients who underwent RC at our tertiary care center were included (January 2008 to March 2022). Patients received three validated questionnaires (International Consultation on Incontinence Questionnaire Vaginal Symptoms [ICIQ-VS] Part A, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA revised [PISQ], European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC] C30/BLM30). Patients who consented were examined with vaginal POP-Q measurement.

RESULTS

Out of 322 patients, 193 were still alive, 54 patients were lost to follow-up, and 43 were excluded, resulting in 96 patients who received the questionnaire. Finally, 35 patients were included, of whom 17 patients consented to vaginal examination. Complaints due to vaginal symptoms were low (ICIQ-VS 6.17 + 5.37). Sexual activity was reported by 12 patients (34.3%); 23 patients (65.71%) were not sexually active. No apical prolapse was found in POP-Q measurement; 6 patients (35.3%) had anterior, and 14 patients (82.4%) posterior prolapse; the highest prolapse stage was 2. No significant differences were found regarding POP stages, sexual function, and QoL (all p > 0.05) when comparing continent and incontinent urinary diversions. Comparing the vaginal approach (no sparing vs sparing), significant differences were found in only two PISQ subscales (significantly higher scores after vagina sparing, p = 0.01 and p = 0.02).

CONCLUSIONS

The type of urinary diversion, POP-Q stages, and tumor stages did not show significant differences regarding sexual function, QoL, and prolapse complaints in women after RC, whereas a vagina- sparing approach showed significant differences only in two subscales without clinical relevance.

Utility of Patient-Reported Symptom and Functional Outcomes to Indicate Recovery after First 90 Days of Radical Cystectomy: A Longitudinal Study

This is a longitudinal prospective study that tracked multiple symptom burden and functioning status for bladder cancer (BLC) patients for 3 months post-radical cystectomy at The University of Texas MD Anderson Cancer Center, using a validated disease-specific patient-reported outcome measure (PROM) tool, the MD Anderson Symptom Inventory (the MDASI-PeriOp-BLC). The feasibility of collecting an objective measure for physical functioning, using "Timed Up & Go test" (TUGT) and PRO scores at baseline, discharge and end of study, was tested. Patients (n = 52) received care under an ERAS pathway. The more severe scores of fatigue, sleep disturbance, distress, drowsiness, frequent urination and urinary urgency at baseline predicted poor functional recovery postoperatively (OR = 1.661, 1.039-2.655, p = 0.034); other more severe symptoms at discharge (pain, fatigue, sleep disturbance, lack of appetite, drowsiness, bloating/abdominal tightness) predicted poor functional recovery (OR = 1.697, 1.114-2.584, p = 0.014) postoperatively. Compliance rates at preoperative, discharge and end of study were 100%, 79% and 77%, while TUGT completion rates were 88%, 54% and 13%, respectively. This prospective study found that more severe symptom burden at baseline and discharge is associated with poor functional recovery post-radical cystectomy for BLC. The collection of PROs is more feasible than using performance measures (TUGT) of function following radical cystectomy.

Health-related quality of life after curative treatment for muscle-invasive bladder cancer

Muscle-invasive bladder cancer (MIBC) is an aggressive disease for which the gold-standard treatment is radical cystectomy (RC) in combination with cisplatin-based neoadjuvant chemotherapy. Bladder-sparing strategies such as trimodal therapy (TMT) have also emerged to improve health-related quality of life (HRQoL) of patients. However, an improved understanding of the effect of all these treatment modalities on HRQoL is essential to provide personalized patient care. Different combinations of generic, cancer-specific and bladder cancer-specific questionnaires can be used as instruments for HRQoL evaluation in patients with MIBC before and after curative treatments, which can largely affect multiple domains of HRQoL including general health as well as physical, functional, social and emotional well-being. However, diagnosis of MIBC per se is also likely to affect HRQoL, and the perspective of cure after RC or TMT could induce a return to baseline HRQoL values for most of these domains. A considerable amount of data on HRQoL after RC is available, but conflicting results have been reported regarding the effect of urinary diversion (ileal conduit or orthotopic neobladder) and surgical approach (open or robotic surgery) on patient quality of life. Data on HRQoL after TMT are scarce, and additional comparative studies including patients receiving RC (especially using ileal orthotopic neobladder) are needed.

The current use of the EORTC QLQ-NMIBC24 and QLQ-BLM30 questionnaires for the assessment of health-related quality of life in bladder cancer patients: a systematic review

PURPOSE

Investigating the use of the EORTC bladder cancer (BC) modules by evaluating: (a) study contexts/designs; (b) languages/countries in which the modules were administered; (c) their acceptance by patients/investigators; and (d) their psychometric properties.

METHODS

A systematic review was performed with studies from 1998 until 20/10/2021 in five databases. Articles/conference abstracts using the EORTC-QLQBLM30 (muscle invasive BC) and the EORTC-QLQNMIBC24 (previously referred to as QLQ-BLS24; non-muscle invasive BC) were included. Two authors independently screened titles/abstracts/full-texts and performed data extraction.

RESULTS

A total of 76 eligible studies were identified. Most studies included the BLM30 (n = 53), were in a urological surgery context (n = 41) and were cross-sectional (n = 35) or prospective (n = 30) in design. The BC modules were administered in 14 languages across 19 countries. Missing data were low-moderate for all non-sex related questions (< 1% to 15%). Sex-related questions had higher rates of missing data (ranging from 6.9% to 84%). Most investigators did not use all scales of the questionnaires. One validation study for the original BLS24 led to the development of the NMIBC24, which adopted a new scale structure for which good structural validity was confirmed (n = 3). Good reliability and validity was shown for the NMIBC24 module, except for malaise and bloating/flatulence scales. Psychometric evidence for BLM30 is lacking.

CONCLUSION

These results provide insight into how the EORTC BC quality of life modules could be further improved. Current work is ongoing to update the modules and to determine if the two modules can be combined into a single questionnaire that works well in both the NMIBC and MIBC settings.

Female sexual function in bladder cancer: A review of the evidence

Background

Bladder cancer (BC) treatments are known to be invasive; nevertheless, research into the long-term effects is limited and in the context of sexual function often male focussed. Female sexual dysfunction (FSD) has been reported in up to 75% of female patients. This systematic scoping review examines the literature on sexual consequences of BC in female patients.

Objective

This study aimed to systematically evaluate the evidence on female sexual function in BC to identify areas of unmet need and research priorities.

Evidence Acquisition

We performed a critical review of PubMed, PsychMed, CINAHL, MEDLINE and the Cochrane Library in March 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews statement following Levac et al. methodology. Identified reports were reviewed according to the Critical Appraisal Skills Programme (CASP) criteria. 45 publications were included.

Evidence Synthesis

There was an inconsistent use of patient-reported outcome measures (PROMs), with commonly used PROMs having a narrow symptom focus. However, common symptoms emerged: loss of desire, orgasmic disorders, vaginal dryness, dyspareunia, difficult intromission, reduced clitoral sensation, psychological concerns related to diagnosis, fear of contamination and body image. Sexual activity was reduced in most groups, despite women expressing a motivation to retain sexual function. The degree of symptom distress associated with FSD is underreported. Evidence emerged regarding a gap for women in clinician counselling and follow-up.

Conclusions

The patient's perspective of FSD in BC patients is poorly understood and under-addressed in clinical practice. There have been very few qualitative studies of FSD in BC. Any intervention designed to address the problem must start with greater understanding of both the patients' and clinicians' perspective.

Lay Summary

We examined the evidence on sexual consequences of BC in women. It is apparent that despite common themes of sexual dysfunction emerging, the problem is poorly understood and addressed in clinical practice.

Radical cystectomy and women's sexual health - can we do better?

PURPOSE OF REVIEW

Female sexual function after radical cystectomy is a crucial, but historically overlooked component of bladder cancer survivorship. This review focuses on recent studies, which have investigated pelvic health and sexual function after radical cystectomy. We discuss modifiable factors, which may contribute to decreased sexual function after radical cystectomy and techniques, which may lead to improved outcomes.

RECENT FINDINGS

Sexual function is important to women and there is a significant desire (and unmet need) for more perioperative counseling and discussion regarding sexual function changes and quality of life impacts. Sexual function may be altered due to a combination of hormonal changes from ovarian removal, anatomic changes from vaginal alteration, and sensation changes due to damage to the neurovascular bundle. Techniques to preserve these structures have been developed.

SUMMARY

Sexual function is an important component of survivorship and increasing attention is being focused on this area. Long term studies with objective measures are needed for to compare various techniques and ensure oncologic safety. Ovarian preservation, anterior vaginal wall preservation, and vaginal estrogen replacement should be carefully considered for most patients.

Validation and Application of MD Anderson Symptom Inventory Module for Patients with Bladder Cancer in the Perioperative Setting

Objectives: We developed and validated a disease-specific tool for perioperative patient-reported outcomes assessment for bladder cancer (BLC) patients undergoing radical cystectomy, The MD Anderson Symptom Inventory (the MDASI-PeriOp-BLC). Methods: Patients who underwent radical cystectomy were recruited. We used qualitative interviews and experts’ input to generate disease/treatment-specific items of the MDASI-PeriOp-BLC module; conducted item reduction; examined the psychometric properties of the resultant items for reliability, validity, and clinical interpretability; and conducted cognitive debriefing interviews to assess the tool’s performance. Results: A total of 150 BLC patients contributed to psychometric validation. We identified and defined eight BLC-specific module items (blood in urine, leaking urine, frequent urination, urinary urgency, burning with urination, constipation, changes in sexual function, and stomal problems). We included those 8 items in addition to 13 MDASI core symptoms and 6 interference items to form the MDASI-PeriOp-BLC module. Cronbach alphas were 0.89 and 0.90 for the 21 severity items and the 6 interference items, respectively. Test−retest reliability (intra-class correlation) was 0.92 for the 21 severity items. The MDASI-PeriOp-BLC module significantly differentiated the patients by performance status (p < 0.0001). Conclusions: The MDASI-PeriOp-BLC is a valid, reliable, and concise tool for monitoring symptom burden during perioperative care in BLC patients undergoing radical cystectomy.

What Women Want: Radical Cystectomy and Perioperative Sexual Function Educational Needs

OBJECTIVE

To assess the extent and adequacy of pre-operative sexual function (SF) counseling in females undergoing radical cystectomy (RC) and develop educational material to improve identified deficits.

METHODS

A 10-question survey was electronically delivered to all females who underwent RC at a single institution between 2015 and 2020. 23 of 145 patients responded (15.9%). In addition, women on the Bladder Cancer Advocacy Network (BCAN) patient discussion board were also queried. The primary outcome was the development of a patient educational handout based on patient perception of pre-operative SF counseling and self-reported changes in post-operative SF.

RESULTS

22 women, 84% of whom were sexually active, met the inclusion criteria. More than half (12/22, 54.5%) reported receiving no pre-operative counseling regarding possible SF changes while another 27.3% (6/22) received some counseling but desired more. Most women rated vaginal preservation as moderate to very important (17/22, 77.3%) and nearly all women noted at least one change in SF, most commonly dyspareunia (13/22, 59.1%). Most also desired more information regarding female sexual health. Separately, the BCAN discussion board was queried regarding patient preference for modality of pre-operative counseling. 77.8% (14/18) preferred a discussion with provider and 13/18 (72.2%) also wanted a written handout.

CONCLUSIONS

Sexual dysfunction is prevalent following RC in women and many desire more pre-operative counseling, regardless of disease stage or receipt of chemotherapy. These findings supported our development of interventions to improve pre-operative education as well as strategies to address post-operative SF changes, such as dyspareunia.

Patient-reported outcomes and health-related quality of life after urinary diversions

PURPOSE OF REVIEW

To study the recent literature on health-related quality of life (HRQOL) in patients after radical cystectomy followed by urinary diversion.

RECENT FINDINGS

General consensus regarding, which urinary diversion is superior in terms of HRQOL has not been reached. Although there is an increase in studies favoring the orthotopic neobladder, overall quality of these studies is poor. Other studies suggest that HRQOL outcomes in different types of urinary diversions is similar and that other factors, such as age, comorbidities and sex are more important instead. Patient choice, in consultation with the treating surgeon should be the determinant of which urinary diversion is performed. Furthermore, sexual function can play an important role in HRQOL. However, practice shows that counselling on the option of sexual-preserving techniques is still not implemented in routine clinical practice. Furthermore, studies regarding differences in HRQOL after urinary diversion between male and female individuals are lacking.

SUMMARY

Thorough preoperative counselling on the different types of urinary diversion and options for sexual-preserving techniques decreases decision regret and increases HRQOL in patients after radical cystectomy.