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

Cancer treatment can have a major impact on sexual function – reports of sexual dysfunction range from 6-96% across all cancer types.1  Among cancer survivors, sexual dysfunction has been reported to profoundly impact the quality of life.  Bladder cancer is the 4th most common malignancy in the United States, and treatment, particularly for invasive disease, can impact sexual function.  Despite this, many urologists do not discuss possible sexual function changes with patients prior to radical cystectomy, particularly with women.2  In a recent publication by Gupta, et al. a lack of information about baseline sexual function was a commonly cited barrier to initiating these conversations.2

The aim of our study was to evaluate perioperative sexual function among patients undergoing radical cystectomy. To do this, the EORTC QLQ – BLM 30, a commonly used quality of life measurement tool was administered to 150 patients in the perioperative period.3 The EORTC QLQ – BLM 30 contains a sexual function subscale which is composed of 8 questions specifically addressing sexual activity.  We included all patients who completed the sexual function subscale in our analysis, giving us a final cohort of 132 patients. 

The data was collected during the perioperative period, which was defined as 30 days before surgery up to 90 days after surgery.  The majority were collected in the 30 days before surgery up to 7 days after surgery.  In our cohort, the median age was 69 years old and 82% of patients were male.  Our most significant finding was that more than half of patients reported at least some interest in having sexual activity and nearly half (40%) had been sexually active within the 4 weeks prior to completing the survey.  We also found that there was a high degree of sexual dysfunction at baseline, greater in women than in men. 

These findings are important because patient age and uncertainty about baseline sexual function have been cited as common barriers to providing adequate pre-operative counseling to patients, particularly females.2 By quantifying baseline sexual function in a prospective, rigorous fashion we demonstrated that more half of patients have an interest in sexual activity in the perioperative period, including women.  This finding provides important information about baseline sexual function and highlights the need for significant improvements in preoperative counseling for patients undergoing radical cystectomy.  Recently, there has been increased attention given to sexual function outcomes and quality of life, and our work supports further efforts to explore this area and develop novel interventions to improve outcomes. 

In addition, the new American Society of Clinical Oncologists (ASCO) guidelines recommend a designated member of the treatment team be responsible for inquiring about the impact of cancer treatments on sexual function at every visit.4 We believe that our study strongly supports the routine use of ASCO recommendations in the radical cystectomy population.

Our study has a few notable strengths compared to prior works.  One is that our data were collected prospectively.  Many prior studies on sexual function have assessed baseline function using questionnaires administered up to two years after surgery.  Additionally, all data were collected in person by a trained interviewer, ensuring consistency and completeness.  We had fewer sexually active men than women in our study, which is a limitation.  In addition, a patient’s report of sexual activity does not necessarily mean that a patient values sexual function preservation.  However, we intend to further explore this area in future studies.  Finally, all data came from a single tertiary referral center and may not be applicable to all radical cystectomy populations.

In conclusion, despite significant illness, a substantial portion of radical cystectomy patients report sexual interest and activity in the perioperative period. Female gender is associated with worse baseline sexual function domain scores. Given this, further studies evaluating the impact of surgery on sexual function and the need for targeted interventions are warranted.

Written by: Mary Beth Westerman, MD, Andrea Kokorovi, MD, Neema Navai, MD, Department of Urology, M.D. Anderson Cancer Center, The University of Texas, Houston, TX, USA

References: 

  1. Management of sexual problems in cancer patients and survivors. Sanchez Varela V, Zhou ES, Bober SL. 2013, Current Problems in Cancer., pp. 37: 319-52.
  2. Comparing Provider-Led Sexual Health Counseling of Male and Female Patients Undergoing Radical Cystectomy. Gupta N, Kucirka LM, Semerjian A, et al. 2020, J Sex Med., pp. 17: 949-56.
  3. The European organization for research and treatment of cancer QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. Aaronson NK, Ahmedzai S, Bergman B, et al. 1993, Journal of the National Cancer Institute., pp. 85: 365-76.
  4. Interventions to address sexual problems in people with cancer: American society of clinical oncology clinical practice guideline adaptation of cancer care Ontario guideline. Carter J, Lacchetti C, Andersen BL, et al. 2018, Journal of Clinical Oncology. , pp. 36: 492-511.
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