Gynecologic Complications After Cystectomy: A Retrospective Cohort Study

INTRODUCTION: Bladder cancer is the sixth most common cancer in the United States, with about 23% of cases occurring in women, and most diagnosed in the post-menopausal state. The standard management for muscle-invasive bladder cancer includes en bloc removal of the bladder, urethra, anterior vaginal wall, and gynecologic organs. As cancer survival improves, surgical goals increasingly emphasize survivorship and quality of life. Postoperatively, women may experience vaginal cuff dehiscence, fistula formation, altered anatomy, prolapse, shortened vagina, and dyspareunia; thus, a multidisciplinary collaboration to optimize patient outcomes is needed to deliver the best care. OBJECTIVE: To describe gynecologic complications following bladder cystectomy. METHODS: We performed a retrospective chart review of female patients who underwent cystectomy at our institution from January 1, 2019, to January 1, 2025, for the following indications: cancer of the urinary tract, gynecologic cancer, cancer of the colon/rectum, and benign conditions, including interstitial cystitis and neurogenic bladder. Demographic, clinical, and surgical data were extracted from the electronic medical record. The retrospective study was approved by our institution's review board. The primary outcome was the incidence of vaginal complications, defined as cuff dehiscence, fistula formation, prolapse, and dyspareunia. Secondary outcomes were preoperative predictors of vaginal complications, sexual function before and after cystectomy, and characterization of gynecologist involvement in care. RESULTS: A total of 81 women underwent cystectomy during the study period: 66 (81.4%) for bladder malignancy, 6 (7.4%) for other malignancies, and 9 (11.1%) for benign indications. Gynecologic complications were found in 22.2% (18/81) of patients. Specific vaginal complications included pelvic organ prolapse (8/76 (10.5%)), of which 3 were managed by observation, 3 with pessary, and 2 surgically; vaginal cuff dehiscence/evisceration (4/81 (4.9%)), vaginal fistula (2/79 (2.5%)), and dyspareunia (4/15 (26.7%)). Twenty-four patients had follow-up with a gynecologist (24/81 (29.6%)) (12 with a gynecologist and 12 with a gynecologic oncologist). Specifically, 8 patients had a follow-up with a urogynecologist for complaints of prolapse (6/8 (75%)), vaginal cuff and dehiscence/evisceration (3/8 (37.5%)). Other gynecologic concerns included bleeding, persistent discharge, pain, atrophy, and the ability to have sexual intercourse. 12 (15%) of patients reported being sexually active preoperatively, and 4 (5%) reported dyspareunia. However, the vast majority of records reviewed did not include discussion regarding sexual activity pre- or post-surgery (Table 1). CONCLUSIONS: As survival outcomes for women undergoing cystectomy continue to improve, focus on long-term quality-of-life outcomes becomes essential. Due to the altered anatomy of the vagina, women may face various complications that lead to additional surgical interventions and pose a significant impact on sexual function. Urologists and gynecologists must be aware of potential gynecologic complications after cystectomy. Future work involves a multidisciplinary effort to improve patient counseling and develop novel preventative approaches at the time of the initial surgery that could potentially mitigate the complications.Table 1