Empowering Choices: Discussing Urologic Care, Sexual Health for Women

In this exploration of urologic care for women, Christopher Wallis, MD, PhD, FRCSC, an assistant professor at the University of Toronto and urologic oncologist at Mount Sinai Hospital and University Health Network, and Ariana L. Smith, MD, professor of urology and director of pelvic medicine and reconstructive surgery at University of Pennsylvania Medicine, navigate the considerations surrounding ovarian, uterine, and cervical health, shedding light on how urologists can contribute to reducing risks and improving the overall well-being of their female patients.

Dr. Smith presented on these topics during a State-of-the-Art Lecture at the Society of Urologic Oncology (SUO) Annual Meeting 2023.

Dr. Wallis: In urologic oncology, there has been a growing focus on incorporating women’s pelvic health into the care of urologic malignancies. Your recent talk at the SUO Annual Meeting touched on factors that we may not have considered since medical school. Could you provide an overview of competing risks and other considerations that urologic oncologists should address before proceeding with urologic care?

Dr. Smith: When optimizing care for women in urology, we can draw parallels to the progress made in optimizing care for men. Preserving sexual function, continence, and self-image, critical to care for men, are equally relevant to women. Decision-making about gynecologic organs during urologic surgery should factor in these concerns.

Some women may not mention these topics, assuming the urologist will make the right decisions for their health, but some decisions are not simply right or wrong, they require thoughtful discussion and shared decision making. Urologic oncologists, focused on survivorship and improving long-term quality of life, should have these discussions to optimize the care women who are now living longer with their cancer.

Dr. Wallis: The focus often centers around cystectomy for bladder cancer. Concerning organ sparing, especially regarding the uterus and ovaries, what considerations should urologic oncologists bear in mind when determining whether these organs should be retained or removed?

Dr. Smith: The shift toward organ-sparing surgery in urologic oncology is notable and can be beneficial for many women, but safety is paramount. For ovaries, data from the Nurses’ Health Study suggest benefits in cardio and bone health as well as overall survival if the ovaries are retained until at least 65 years of age. Evaluating individual risks however—including genetic factors, Lynch syndrome, and family history of breast or ovarian cancer—informs this decision and can identify women who are not optimal candidates for ovarian sparing surgery and may benefit from risk reducing oophorectomy. All women who are beyond childbearing, can benefit from risk reduction of ovarian cancer by undergoing salpingectomy alone (without oophorectomy). We have now learned that the majority of ovarian cancers originate in the fallopian tubes, allowing for salpingectomy alone to reduce ovarian cancer risk without the hormonal impact of oophorectomy.

Dr. Wallis: How should urologists approach counseling for cervical cancer screening and the potential impact on organ-sparing decisions?

Dr. Smith: Understanding a patients prior cervical cancer screening history is critical to the discussion and safety of uterine sparing surgery. While the uterus is not routinely screened, the cervix is, providing valuable information, recognizing that women who are following current guidelines with screening every 3-5 years will not need additional testing prior to urologic surgery. In addition, the American College of Obstetricians and Gynecologists guidelines recommend stopping cervical cancer screening after age 65 if prior screenings were negative, further reducing the need for additional testing. Identifying abnormal cervical cytology and/or presence of high-risk HPV necessitates additional testing of the cervix with colposcopy and biopsy to risk stratify and inform the best management of the cervix and uterus at the time of cystectomy.

Dr. Wallis: Balancing the benefits of organ sparing, particularly for sexual function, is crucial. How can urologists approach counseling on sexual function for women with bladder cancer?

Dr. Smith: Initiating a conversation with women that bladder cancer surgery generally removes more than just the bladder, is a start. Discussing the other organs planned for removal and their impact on sexual activity and sexual function is important. Like male patients, women value preserving their sexual function and their vaginal anatomy. Addressing the impact of hysterectomy, pelvic nerve involvement, and anterior vaginectomy, particularly in cases of pelvic exenteration, is paramount. Preoperative discussions on cancer-specific risks and postoperative care, including the use of topical vaginal estrogen for healing, can optimize outcomes.

Dr. Wallis: For women requiring anterior vaginal wall resection, are there technical tips or postoperative care strategies that can help optimize sexual function?

Dr. Smith: In cases necessitating anterior vaginal wall resection, optimizing healing with topical vaginal estrogen started preoperatively may be beneficial in reducing wound dehiscence, peritoneal leak, and pelvic prolapse. Postoperatively, after adequate healing has occurred, the use of vaginal dilators in conjunction with vaginal estrogen may allow more women to resume sexual activity after cystectomy. Open discussions and tailored care plans are essential.

Dr. Wallis: Thank you for sharing your insights, Dr. Smith. We hope to see continued progress in integrating these considerations into routine care for women with bladder cancer.