Female Sexual Function Evaluation and Intraoperative Vaginal Reconstruction in Bladder Cancer - Beyond the Abstract

Treatment for advanced bladder cancer with radical cystectomy (RC) traditionally involves the removal of neighboring reproductive organs, which can cause considerable sexual health issues. The impact of RC on sexual function in men has been studied extensively, however female sexual function before and after RC remains understudied, with a small proportion of women reporting any preoperative counseling.¹

Though bladder cancer is typically diagnosed in older women, females up to age 80 continue to engage in sexual activity.²  Thus, providers evaluating women for RC should place emphasis on sexual health concerns. This review aims to summarize preoperative tools for assessing sexual function in females preparing for RC, and techniques during RC that may preserve sexual function.³

Self-reported questionnaires allow providers to open discussions on baseline sexual activity, desire for fertility, and goals following treatment. The questionnaires with the highest level of evidence for evaluating female sexual function are the Female Sexual Function Index (FSFI), PROMIS Sexual Function and Satisfaction (PROMIS SexFS), and the European Organization on Research and Treatment of Cancer (EORTC) BLM30. The FSFI is comprised of 19 questions and is currently considered the “gold standard” for evaluation of female patients with and without cancer, but does not address other aspects of healthcare related quality of life (HRQoL). The EORTC-BLM30 is specific to cancer patients and incorporates urinary/bowel symptoms as well as urostomy/catheter issues and body image, but cannot be scored completely if the patient is not currently sexually active. The PROMIS SexFS is a comprehensive evaluation of multiple HRQoL domains and is adaptable to patients with diverse sexual orientations, but is much lengthier with 79 questions.

Organ-sparing RC, which preserves reproductive organs including the anterior vagina in women, should be considered especially in young and peri-menopausal women if oncologic outcomes are not compromised. These techniques may reduce postoperative dyspareunia, loss of lubrication, and vaginal shortening. In addition, preservation of nerves between the vaginal wall and bladder neck and minimizing thermal energy in this area are of particular importance to clitoral sensation. Contraindications for organ- and nerve-sparing include patients at high risk of ovarian cancer (cumulative risk > 4% based on genetic predisposition) and bladder cancer involving the anterior vagina. Risk-reducing oophorectomy at the time of RC has been advocated for patients with high risk germline variants such as BRCA1/2, BRIP1, and MLH1/MSH2/MSH6/EPCAM Lynch syndrome genes. Anterior vaginal wall involvement can be diagnosed using transvaginal ultrasound, multi-parametric magnetic resonance imaging (MRI), or conventional computed tomography, though data regarding their use in decision-making for RC is limited. Intravaginal contrast instillation with MRI can improve the sensitivity of detecting vaginal involvement by over 50%.⁴ 

When organ- and nerve-sparing techniques are not feasible, vaginal reconstruction may be performed using a variety of substitution methods. Split-thickness skin grafts, flaps, bowel segments, and biologic scaffolds have been employed to reconstruct the vaginal canal (Figure 1). Skin grafts can be made from a variety of donor sites to create a large surface area, such as the buttock, abdominal wall, or thigh. Skin grafts may be at risk for contraction, however, and rare instances of squamous cell carcinoma of these grafts have been reported. Pedicled flaps carry their own blood supply and have a better rate of graft take, but donor sites are limited and complications are higher in patients with prior pelvic radiotherapy. Bowel substitution also carries a reliable blood supply with less visible donor-site scarring and is also self-lubricating. However, in some cases mucus production can be bothersome and complications such as enteric fistulae may be more significant. Synthetic grafts are typically no longer used due to issues with excessive fibrosis, but more recently biologic scaffolds such as small intestine submucosa have had limited success in vaginal reconstruction. Unfortunately, many of these techniques have not been well-studied in bladder cancer patients, and providers must set expectations with patients preoperatively as the success of vaginal reconstruction is highly dependent on postoperative vaginal dilation and care.

Ultimately, a multimodal approach should be taken with assessment and treatment of post-RC female sexual dysfunction. While urologic surgeons may feel best equipped to handle acute peri-operative care only, sexual dysfunction may significantly impact HRQoL and it is imperative for providers to educate patients on the potential effects of RC and be aware of resources for its management.

1. Urology Institute, University Hospitals of Cleveland, Cleveland, OH, USA
2. Department of Urologic Oncology, Fox Chase Cancer Center, Temple Health Medical Center, Philadelphia, PA, USA

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