She noted that while small, there is an overlap in bladder cancer incidence and fertility, with live birth rates falling significantly after the age of 40, and a <1% rate of bladder cancer diagnoses in women aged 40-44. Although rare, she acknowledged that higher volume centers will occasionally encounter younger bladder cancer patients who desire preserved fertility. She noted that there has been an increasing interest in pelvic organ-preserving surgery for those women with muscle-invasive or recurrent disease. She broke down the different types of pelvic organ-sparing cystectomy into three categories: uterine-sparing (to preserve fertility potential), ovarian-sparing (to avoid the downsides of early menopause), and vaginal-sparing / nerve-sparing (to improve post-operative sexual function).
Dr. Cresswell presented data regarding uterine-sparing surgery from the last two decades and acknowledged that these are mainly case series and retrospective in nature. A systematic review from Veskimae et. Al from 2017 summarized the outcomes of uterine-sparing cystectomy and found that there appeared to be no significant improvement in post-operative sexual function, urinary function was equivalent as compared to standard anterior exenteration, and that there were no documented pregnancies after uterine-sparing procedures. Another contemporary study from the UK by Gross et. Al suggested that urinary function and continence were superior in patients undergoing uterine-sparing procedures. The study showed equivalent oncologic outcomes for uterine-sparing patients, as well.
Cresswell believes that the potential for better continence is a compelling reason to consider uterine-sparing procedures in appropriately-selected patients. For those being considered for the procedure, she advocates for a careful exam under anesthesia (EUA) and bladder neck biopsies to confirm no adjacent organ involvement or bladder neck involvement. Patients with disease that is ≤ cT2 are also ideal, as there is a decreased likelihood of local recurrence.
Dr. Cresswell then touched on the possibility of pregnancy in women with bladder cancer after radical cystectomy. There are a handful of case reports showing that pregnancy is possible, albeit very rare. She concluded by advocating for the consideration of pelvic-organ sparing radical cystectomy in younger patients, mainly due to the benefits postoperatively including improved urinary function, sexual function, and avoidance of the risks of early menopause. She acknowledges that further studies are needed on the topic of pelvic organ-sparing surgery in women undergoing radical cystectomy to better clarify the potential benefits.
Presented by: Joanne Cresswell, MBBS, MRCS, FRCS(Urol), PhD, South Tees Hospital, Middlesbrough, United Kingdom
Written by: Brian Kadow, MD. Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, Pennsylvania at the 34th European Association of Urology (EAU 2019) #EAU19, conference in Barcelona, Spain from March 15-19, 2019