Nerve-Sparing Cystectomy Preserves Sexual Function in Men With Bladder Cancer

Cystectomy is a major surgery that requires the removal of the bladder and the creation of a urinary diversion. It’s a component of treatment for many patients with bladder cancer and may be an option for patients with other conditions, like neurogenic bladder and fistula repair. Now, surgeons at Cleveland Clinic are increasingly using nerve-sparing techniques for cystectomy that preserve sexual function and quality of life without compromising cancer treatment.

"There's been a shift in the urologic cancer community in terms of prioritizing quality-of-life outcomes without compromising cancer treatment," says Nima Almassi, MD. "Historically, cystectomy has been performed with a wide resection to maximize oncologic treatment and avoid positive margins and cancer recurrence."

Prospective studies have shown that patients generally report positive quality-of-life outcomes across most domains following cystectomy, with a few exceptions. Body image, especially for patients who need a stoma, urinary function, and sexual function tend to be areas where patients report a decreased quality of life. For men undergoing cystectomy, a wide (non-nerve sparing) resection will cause severe erectile dysfunction (ED).

Nerve-sparing cystectomy represents one method of potentially improving quality-of-life outcomes for men undergoing surgery.

Postoperative sexual outcomes in men and women

Urologic oncologists like Dr. Almassi say that many patients don't need to sacrifice their sexual function because of treatment. For male patients undergoing cystectomy, ED is a very common side effect, but nerve-sparing cystectomy can help temper it.

The Cleveland Clinic team has also been focused on improving the bladder cancer experience in women, which includes evaluating similar nerve-sparing and organ-sparing techniques to preserve reproductive anatomy and obviate surgical menopause and sexual dysfunction.

Prospective studies ongoing at Cleveland Clinic have shown that women who undergo vaginal-sparing cystectomy appear to have less prolapse than women, but the data are still early when it comes to sexual function.

Patient selection is key

Patients eligible for this type of surgery have a good baseline ED and are motivated to preserve it. Additionally, they must be free of specific disease characteristics that could complicate oncologic control, such as cancer abutting or involving the neurovascular bundle. Preoperative MRI imaging can guide patient selection.

Similarly, aggressive subtypes of bladder cancer with high risk of being locally advanced may not be suitable for a nerve-sparing surgical approach. "In this case, we would not recommend nerve-sparing out of concern it could compromise cancer control," says Dr. Almassi.

A positive institutional experience

Nerve-sparing cystectomy requires the surgeon to dissect the neurovascular bundles off the bladder and prostate. "We have found that this has yielded much better erectile function in patients after surgery without compromising oncologic outcomes. For all patients who we've deemed eligible for this, we have not had positive surgical margins," notes Dr. Almassi.

Using validated questionnaires, patients report their erectile function about every three months for a year. The team is finding that around six months postoperatively, most patients experience only mild ED, and that remains consistent. Even three months following the surgery, he says, patients typically are recovering well but are often not yet sexually active at this time.

"Most patients' erectile function ends up returning to within three points on a 25-point scale from their preoperative baseline, suggesting erectile function can recover to similar levels to what it was before surgery.”

Part of the center's protocol is starting patients on tadalafil, and they may still be using it when function is assessed postoperatively, Dr. Almassi remarks.

The Cleveland Clinic team opts for a robotic approach, owing to better visualization and access to the neurovascular bundle. However, performing this technique with open surgery is also achievable in experienced hands. "The way the field has transitioned, fewer surgeons in high volume centers perform open cystectomy,” he explains.

A call for screening candidates

"Optimizing quality of life for our patients is a major focus for our group. Studies show that sexual function declines after cystectomy. We have an opportunity to safely personalize a surgical technique in select patients to help preserve functional outcomes,” says Dr. Almassi. "We certainly encourage our colleagues to consider screening patients who may be good candidates."