Podcast Transcript: Gynecologic-Sparing Cystectomy & More: Prioritizing Female Sexual Health

[Dr. Sara Psutka]
Yes. Big issue here, first of all, is prevalence of bladder cancer in women, right? It's considerably less than it is in men, is a substantial predominance of bladder cancer in men. Because of that, I think a lot of urologists actually are less comfortable operating in the female pelvis than in the male pelvis. We do so many more prostates. We do so much more male pelvic surgery. It's really important, I think. I feel like I've spent quite a bit of time these last five years since getting to UW.
We have a couple of really amazing female urologists and urogynecologists and I've actually tried to spend a bunch of time with them, because no one ever taught me how to do a hysterectomy from a gynecologic perspective. We learned to do it as oncologists, which means we take everything out. We go wide, take the ovaries. I really try hard, let's just talk about ovary sparing operations. That all came from this paradigm that presuppose that you take out the ovaries at the time of a radical cystectomy opportunistically, because you're there. It's easy, cuts down on bleeding. There was this thinking that you take it out and you reduce the risk of ovarian cancer in these patients, right?
We know now that that's not true. Actually ACOG, the gynecologic organization has basically come down against opportunistic oophorectomy and debunked a lot of that those preconceptions, because it seems like-- obviously, that the data shows that the risk of ovarian cancer seems to be coming from the fallopian tube. We definitely do opportunistic salpingectomies, but unless the patient is over the age of 75, at which point the androgen production and estrogen production and the ovaries severely attenuated, or there's a really strong reason to do it, I pretty much almost always spare ovaries in these patients.
That's something that really, if you look at any of the old textbooks, a radical cystectomy in a woman always involves taking out the ovaries. I don't think it adds a lot of time to spare them and it doesn't increase bleeding risk. It's just something that if you don't need to take out an organ, why are we doing it? The same thing, I think when it comes now to be thinking about the uterine preserving and preserving the suspensory mechanisms within the female pelvis, especially in someone who's going to have a continent diversion. There's increasing not only a renewed interest, any interest, and also, study about the safety and the feasibility of doing that.
I think as urologic oncologists, I think people are becoming much more comfortable doing these procedures and gaining expertise from our gynae colleagues, our urogyn colleagues and learning from them. I think that's actually really important. It's something that we probably need to invest more as we're training our fellows within urologic oncology. We all need to be really comfortable operating the female pelvis.

[Dr. Aditya Bagrodia]
Yes, definitely quite a few thoughts here. One, I did a month of gynecologic oncology during my fellowship and it was mind blowing how different the approach to similar ultimate operations were, especially preservation of the vaginal cuff. For me, it was largely a lubricated sponge stick in the vagina, make sure that you're posterior to the cervix and then cut down on it and everything anterior to it goes. Just the anatomic fidelity that they approach you with was night and day. I hear you 100% there.
Maybe it would be useful to talk about a patient today, let's say 65-year-old woman, decent sexual health going into it, and maybe has a pretty substantial T3, T4 posterior wall tumor that you're really thinking that a anterior vaginectomy is going to be a good option from a cancer perspective. What does that counseling look like in terms of your sexual function after this operation's over? Listen, your anterior vagina has to go.

[Dr. Sara Psutka]
I will be honest with you, the vast majority of the people that I see actually are still in that camp because we tend to see some pretty bulky, high risk disease. Patients who have gone through neoadjuvant chemotherapy and still have residual disease. We have to remember that at the end of the day, oncologic outcomes are paramount. I tell patients, whether I'm doing it in a male or a female, first order of business is to get all the cancer out because a positive margin in bladder cancer is a lethal disease. There's really nothing good that we can do if we leave disease behind. Pelvic recurrent bladder cancer is awful, right? It's a really hard diagnosis and management of it is awful.
Radiating the pelvis after you've done a urinary diversion is a terrible thing and often still doesn't have long-term durable oncologic benefits. You've got to get it all out. I talk to patients really honestly about what this looks like. We talk about things like the risk of vaginal foreshortening, vaginal stenosis. If you are in that situation, obviously, taking everything locally, there is a high risk of prolapse. In fact, that's something that's a huge risk. Vaginal cuff prolapse, there's a huge risk for that, especially if you remove all the suspensory ligaments. It's something that's very rarely talked about.
We talked earlier about that review of systems. We actually need to talk to make sure we ask our female patients about the degree of pelvic organ prolapse they experienced before going into bladder cancer surgery. That's something that may or may not be traditionally discussed, and that's a really important baseline status to check in on. Then you've got to talk about disruption of the parasympathetic nerves and change in sexual sensation, anorgasmia, dyspareunia, all of those risks afterwards. Then obviously, all the body image changes.
I do think that one thing you can do a really good job of, even if you do have to take the majority of the anterior vagina, is one thing that actually, one of my FPMRS colleagues taught me was that with appropriate mobilization of the posterior vagina, you can still often end up with a vaginal cuff that has a sufficient capacity for penetrative intercourse, even if you're doing a clamshell closure as opposed to wrapping from side to side and doing a vaginoraphy.
I'd be interested to hear what you think. My impression is coronal capacity is really important as opposed to absolute length in terms of maintaining sexual function, because I feel like a lot of times, if you do a vaginal closure, you end up stenosing the vaginal canal and then they have such bad stenosis, it's really painful for a lot of patients and sexual function just doesn't get recovered after that operation. I don't know if that's been your experience, but that's one thing I've noticed.

[Dr. Aditya Bagrodia]
In general, yes. I also remain healthily paranoid anytime I'm doing a vaginal closure about having a dehiscence and having a fistula or basically, having their complete interior continence come out of the vaginal cuff. Thank God it's never happened to me. I've seen it once from a partner over the course of my career. Sounded awful. I say that because when you actually do a virginal closure, as you mentioned, you have three suture lines coming together right there at the distalmost part of the vagina. Just from even bladder, neck reconstructions and prostate, if there's going to be a bit of a dehiscence, I have to imagine it's there.
When an anterior vaginectomy is required, I do go with the clamshell. I think if you cannot insert a penis, and if we're talking about receptive intercourse, that's game over right there. If it's stenotic and you can't, that's challenging. What I'm hearing is, really, across the gamut, libido, vaginal health, ability to receive receptive intercourse, body image, it's a big deal.

[Dr. Sara Psutka]
Yes. A big part of an anterior vaginectomy is you're disrupting all of the nerves, right? Because the nerves wrap around the lateral. If you look at what we know about the neuroanatomy of the female pelvis, and Rachel, you can probably school me on this. Forgive me if I'm speaking out of turn. My understanding from what I've read and what I've learned is the nerve bundles really sit on the lateral aspect of the vagina. If you come down in that tissue, that's where you disrupt it. That totally changes how sex feels, how climax feels, and just all of the neuro innervation of the female pelvis. That's where you mess it up.

[Dr. Rachel Rubin]
This is where we need your data. We need your data and we can't get the data if we don't ask the questions, right? Because what our textbooks say is, oh, pudendal nerve is the only thing that innervates the clitoris. You're not going to screw with the pudendal nerve so their orgasm will be fine. What? Right? The cavernosal nerves to the clitoris should be the same as they are for the penis. We have all that neuroanatomy and it wasn't until Walsh did the dissections and then we said, okay, let's--
That data doesn't actually exist even in the gynecology space. Nobody's talking about it. Nobody's looking at it. No one's doing the dissections or even asking patients before these big surgeries, how do you orgasm? Is it from clitoral stimulation? How do you feel arousal? Our questions aren't good enough to even tease out the data. If you take hysterectomy patients, like in the general gynecology space, oh, hysterectomy is good for sexual function. Why? Because when you take massive amounts of data, most people have hysterectomies because they're bleeding, right? Because they have fibroids, because they have pelvic pain. When you remove it, they feel better.
No one's getting granular to say, well, how do you experience pleasure? Do you have uterine orgasms? Do you have deep enjoyment of the anterior vaginal wall? Which is prostate tissue, actually. It's really important that we ask, what does sex look like and what do you want it to look like, right? What is the goal? What do you actually want? Because for your point, if they have a partner, sometimes you have to say, okay, well, is your partner-- Like, here are dilators? What size dilator is your partner? Because you have someone who has a very large partner, and that's really important to their partnership, we got to go have those conversations, right? Because informed consent is everything.
That doesn't mean you can't take the tissue, but you really got to go have that period where you say, listen, I'm going to do the best I can, but the most important thing here is margins and closure that actually is the right thing. Then when they wake up, they're not like, "Doc, you shortchanged me. Doc, what are you doing," right?

[Dr. Sara Psutka]
To your point also, and Aditya, just talking about like preoperative planning and being able to counsel. I actually really like pelvic MRI to look at burden of disease after chemotherapy and somebody who's got bulky disease to begin with, especially if it's posterior, just to start to understand, just like you would in a prostate, right? Where's the disease at? Where is their extracapsular extension? Is their bulky T4 disease going into the vaginal wall? You know you've got to take a big margin there, if that's the case.
The other thing is, just like you can do unilateral nerve sparing in a man, you can do that in a woman too. I will admit, I'm an open pelvic surgeon. I do my cystectomies open. I oftentimes am really feeling where the disease is. I do a really careful bi-manual at the beginning of the procedure. As I'm resecting, I'm taking cues from what the tissues look like and where the disease is and where I can feel it. You go wide where you have to, and if you don't have to, then you can start to spare some of that lateral tissue. In those cases, I really wrap up on the very, very top of the vagina and take as little as I possibly can so that I actually try to leave most of that lateral tissue undisturbed.
I also think that's actually nice from a bleeding perspective too. If you take that all up really high, you end up getting into less bleeding in the pelvis. At least that's my experience.

[Dr. Aditya Bagrodia]
Yes, I love that. Just from a slightly different perspective, I do most of my pelvic work robotically and I do a substantial volume of prostatectomies. It gets amazing to me when you're doing a gynecologic organ-sparing cystectomy in a female, it's almost indistinguishable, a man from a woman. There's the perirectal fat, the homologies and B, the anterior longitudinal muscle fibers of the vagina. I think early on, I suspect that most people doing these operations have a healthy fear of getting into the bladder, which you obviously don't want to do for tumor spill purposes and so forth.
There is the equivalent of the intrafascial plane where it's just sweeps, and it's so nice and luxurious. If you want to go wider on one side, I think you can get right on the anterior vaginal wall. I've actually gotten within layers of the anterior vaginal wall and imbricated that, just like if you're doing ultra wider section and the rectum's right there on a man. I would agree that really having an understanding of that anatomy, not like here's a bladder, here's a vagina. We got to just either take all of it or some of it, is helpful. I think educating ourselves on that, giving yourself all the cues, for me, it just happens to be that it works a little bit better in my hands robotically.

[Dr. Rachel Rubin]
I have a question.

[Dr. Aditya Bagrodia]
Please.

[Dr. Rachel Rubin]
I haven't looked in a long time. I spend a lot of time helping with the AUA core curriculum in sexual medicine. Is there a section on the AUA core curriculum about specifically doing bladder cancer surgery in women?

[Dr. Sara Psutka]
I've been the senior editor of the core curriculum in oncology for the last couple of years. Now, Will Parker took that job over and I'm the senior consultant, but in our bladder cancer section, we do have that. We added that a couple of years ago, but it still needs to be fleshed out even more. It's a really important part. There is a whole part of the core that is related to-- This must be what you're talking about. There's the gynecologic surgery considerations. There's an evergreen document there that I'm pretty sure-- we link a lot of our stuff too, obviously, because it's highly relevant, but it's probably something that needs to be built out even further.

[Dr. Rachel Rubin]
That's really the problem, is we learn in urology of, well, I was never taught this. I was never taught this. I didn't have any female faculty. I didn't spend any time at urogyn. It's all this excuses, right? I didn't do this. Yet a new laser comes out and you're like, I am the head ThuLEP person of the world. I do all of these things that I never heard of in my residency. When it comes to-- we like to be able to say, oh, I don't see female patients. Oh, I don't take care of those patients. The answer is, well, who does, right? Who does? I'm just so grateful that these conversations are happening because you're really giving permission to people to say, you got this, you can do this.

[Dr. Aditya Bagrodia]
Absolutely.

[Dr. Sara Psutka]
I love that. It's so like, half the world is women.

[Dr. Rachel Rubin]
This isn't a small subset of, ooh, you're never going to see this. This is half the population, right? It's wild.

[Dr. Sara Psutka]
It's been amazing, too, just to-- I think the reconstructive bladder cancer surgery, radical cystectomy is such an intensely morbid operation that we do. There's the onc part of it, the resection. I do think the reconstruction is so important, and what you're talking about Aditya, like doing a really good cuff closure, like a watertight cuff closure. Then I do a spiral flop of the omentum and make sure that I've got nice, healthy, hopefully blood vessel laden tissue surrounding and flop down on that, that's tacked down there to hopefully facilitate healing is really critical because one other thing that I think that women don't often know is the fact that they may have some peritoneal fluid leakage through their cuff as they heal.
If you don't tell them that in advance, that's terribly distressing for women after this operation. Thinking long and hard about making sure you do a really nice closure is actually a pretty critical part of the procedure from, one, avoiding catastrophic complications, like a vaginal cuff dehiscence and evisceration through the vagina. Just from a healing perspective and avoiding pelvic floor fluid collections and abscesses and all of the other things that can happen down there, really washing the area and then doing a nice closure that's off tension. It's a critical quality part of the surgery.

[Dr. Aditya Bagrodia]
Yes, absolutely. Even for some of the retro cancers where you've really got to go wide, really subluxing that introidal skin in to just give you everything under God's green earth to make sure that you're not going to have a dehiscence. The way I think about it is if you don't ask, you're not going to know whether sexual health is prioritized. If it is prioritized, then you've got to, of course, take a look at the disease parameters, bulky tumors that are not fit for either chemo naïve that are going to [unintelligible 00:41:41] for whatever reason or for patients that have bulky posterior tumors. These, I think, we'd all agree that anterior vaginectomy would be a part of it.
I have never done an anterior vaginectomy and spared the uterus and the cervix. Is that something that you've done or is it described, excuse my ignorance?

[Dr. Sara Psutka]
I do have partners who have done that in specific indications or they've taken part of the anterior vagina and spared the uterus. I've personally not done it myself, but I think it's something that you can do, but I think you have to-- Obviously, if you're doing it, you got to make sure that from an oncologic perspective, it makes sense.

[Dr. Aditya Bagrodia]
Yes. The scenario I can think about as a young person that's still of childbearing age, and we see those, and then maybe even if they have some stenosis, as long as they can evacuate their menses and have a C-section and get pregnant.

[Dr. Sara Psutka]
Yes.

[Dr. Aditya Bagrodia]
All right. Maybe those are some of the broad strokes disease characteristics. I think we've talked a little bit about this and I think it's important also, just to remind the listenership that gynecologic sparing is not only a part of the conversation in patients receiving neobladder. I feel like people go in two camps, like female cystectomy, relatively uncommon. Female cystectomy, neobladder, relatively really, really uncommon, but those are people that get a lot more attention, but you can do a gynecologic nerve sparing cystectomy in a woman who's getting a conduit.

[Dr. Sara Psutka]
Absolutely. To some degree, it reduces the risk of pelvic organ prolapse, which can affect up to 13% to 15% of patients, if you look at what's out there and there's not very much, but the poor quality data we have, you can-- and there's no reason not to. I think that again, it all comes down to disease characteristics, and certainly, I'll just again, make the point, you can spare ovaries in everybody. We're talking now about uterus and fallopian tubes.
From a pelvic floor suspensory ligament perspective, maintaining the suspension of the vaginal cuff of the vagina is really important. I think that in somebody who's having a conduit, you can still do a vaginal sparing procedure. It comes down to disease characteristics.