Vaginal Complications after Radical Cystectomy for Bladder Cancer: A Systematic Review

Due to advances in multimodal treatment for pelvic malignancies, life expectancy after radical cystectomy for bladder cancer is increasing. As life expectancy improves, there is an increasing focus on issues related to cancer survivorship. This shift in focus has come with radical cystectomy using a vaginal sparing approach in properly selected female patients, with a goal of preserving sexual function, and in those undergoing orthotopic diversions, potentially improving rates of urinary continence. However, radical cystectomy with a vaginal sparing approach brings unique complications specific to the female population: pelvic organ prolapse, vaginal dehiscence or evisceration, vaginal fistula, and dyspareunia. While several case series of these individual complications have been reported, the actual incidence remains unknown.

More importantly, while urologists now commonly offer vaginal sparing procedures for women undergoing radical cystectomy, there is no comprehensive review to describe all the potential outcomes unique to this procedure. We recognized that vaginal complications are not generally considered as a potential long-term risk of cystectomy, however, we hypothesize that they may occur at rates higher than expected in this population.

We performed a systematic review according to PRISMA guidelines. Our findings confirmed that there are relatively few high-quality studies reporting on these complications. Neobladder vaginal fistula (NVF) was the most common type complication reported, often presenting within the first 3 months after cystectomy surgery. The incidence of NVF following RC varies from 3-6% at higher volume centers and most often occurs along the anterior vaginal wall at the location of the neobladder-urethral anastomosis. Studies reviewed repeatedly noted that maintaining the anterior vaginal wall (with neovascular preservation) and the distal urethra (with clitoral neuro vasculature preservation) appeared to be associated with improved sexual function, but small study numbers and potential confounders prevented any definitive conclusions.

This is an important area of study, as we think about how we can enhance quality of life in the post-cystectomy population. Further studies, utilizing standardized instruments and subjective outcome measures are needed to better define the incidence of vaginal complications after radical cystectomy for bladder cancer, and importantly, to understand their impact on quality of life measures.

Written by: Lee Ann Richter, MD, MedStar National Center for Advanced Pelvic Surgery

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