Gynecologic Organ Involvement During Radical Cystectomy for Bladder Cancer: Is It Time to Routinely Spare the Ovaries? - Beyond the Abstract

When women with bladder cancer undergo radical cystectomy, the ovaries are routinely removed as the standard-of-care surgical technique, along with the anterior vaginal wall, uterus, and fallopian tubes.  This practice stems from anecdotal reasoning including potentially lowering the risk of bladder cancer recurrence in the ovaries or development of a de novo primary ovarian malignancy, an assumption that there are minimal health or quality-of-life benefits with ovarian preservation, and the technical ease of removal of the ovaries during surgery.  While robust longitudinal bladder cancer data are lacking, the available urologic and gynecologic evidence more strongly supports the preservation of ovaries.  Removal of ovaries in premenopausal women has been shown to increase all-cause mortality, and in both pre- and postmenopausal women, it may increase cardiovascular disease, worsen bone health, increase sexual dysfunction, and contribute to cognitive decline.1  As most serous ovarian malignancies are now believed to originate from the fallopian tube, continued removal of the fallopian tubes at the time of cystectomy ought to lower the risk of developing a de novo primary ovarian malignancy.2  Ovary-sparing surgery in gynecologic malignancies such as endometrial carcinoma, cervical cancer, and leiomyosarcoma has not shown adverse impacts on oncologic outcomes and is increasingly being performed in select women.3-5  The aim of our study was to challenge the status quo for radical cystectomy and to critically assess our institutional experience for gynecologic organ involvement by bladder cancer.

We reviewed the pathology findings of consecutive radical cystectomies in women performed at our institution over a 20-year period.  After excluding women with non-bladder primary malignancies (e.g. urachal, urethral, other sites of origin) and those with absent reproductive organs at cystectomy, we found that 19 (15%) out of 123 women had reproductive organ (RO) involvement by bladder cancer.  However, only 5 (4%) were specifically found to have ovarian involvement.  Locally advanced disease (≥ pT3) and lymphovascular invasion (LVI) were significantly associated with increased risk of RO involvement.  All women with ovarian involvement had locally advanced disease and lymphovascular invasion (LVI). 

In our study, we found that 41% of women had extravesical disease, at least 24% had nodal metastases, and 15% had at least one reproductive organ involved by bladder cancer, which was predominantly uterine/cervical involvement.  Given these findings, we caution against routinely performing a complete genital-sparing cystectomy outside of the highly select patient.  In contrast, the risk of ovarian involvement in this study was very low and only evident in women with extravesical disease, LVI, and positive margins.  Given the mounting evidence showing functional benefits of ovary-sparing surgery, the low rate of ovarian involvement by organ-confined bladder cancer, and the adaptation of ovary-sparing procedures by gynecologic oncologic surgeons, we recommend having an informed discussion with women of all ages regarding the risks and benefits of sparing the ovaries during radical cystectomy for bladder cancer.  Lastly, our study also indirectly supports standardization of reporting LVI in TUR specimens by pathologists, which recently has been advocated for based on strong evidence for its prognostic value.6

Written by: Benjamin L Taylor, MD, Department of Urology, Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY and Francesca Khani, MD, Assistant Professor of Pathology & Laboratory Medicine, Assistant Professor of Pathology in Urology, Weill Cornell Medicine, Department of Pathology & Laboratory Medicine, New York, NY 10065

References:
  1. Parker WH, Feskanich D, Broder MS, et al: Long-term mortality associated with oophorectomy compared with ovarian conservation in the nurses' health study. Obstet Gynecol 2013; 121: 709–716.
  2. Society of Gynecologic Oncology: SGO Clinical Practice Statement: Salpingectomy for Ovarian Cancer Prevention. https://www.sgo.org/clinical-practice/guidelines/sgo-clinical-practice-statement-salpingectomy-for-ovarian-cancer-prevention/. Accessed March 7, 2018.
  3. Matsuo K, Machida H, Horowitz MP, et al: Risk of metachronous ovarian cancer after ovarian conservation in young women with stage I cervical cancer. Am. J. Obstet. Gynecol. 2017; 217: 580.e1–580.e10.
  4. Lee TS, Lee J-Y, Kim J-W, et al: Outcomes of ovarian preservation in a cohort of premenopausal women with early-stage endometrial cancer: a Korean Gynecologic Oncology Group study. Gynecol. Oncol. 2013; 131: 289–293.
  5. Nasioudis D, Chapman-Davis E, Frey M, et al: Safety of ovarian preservation in premenopausal women with stage I uterine sarcoma. J Gynecol Oncol 2017; 28: e46.
  6. Mari A, Kimura S, Foerster B, et al: A systematic review and meta-analysis of the impact of lymphovascular invasion in bladder cancer transurethral resection specimens. BJU International 2019; 123: 11–21.

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