The Cystectomy Option More Women Should Know About

August 21, 2026

Transcript

Voice over:

This is Bladder Cancer Matters, the podcast for bladder cancer patients, caregivers, advocates, and medical and research professionals. It’s brought to you by the Bladder Cancer Advocacy Network, otherwise known as BCAN. BCAN works to increase public awareness about bladder cancer, advances bladder cancer research, and provides educational and support services for bladder cancer patients and their loved ones. To learn more, please visit bcan.org.

Rick Bangs:

Hi, I’m Rick Bangs, the host of Bladder Cancer Matters, a podcast for, by, and about the bladder cancer community. I’m also a survivor of muscle-invasive bladder cancer, the proud owner of a 2006 model year neobladder, and a patient advocate supporting cancer research at the Bladder Cancer Advocacy Network, or as many call it, BCAN, producers of this podcast.

I am pleased to welcome today’s guest, Dr. Rebecca Campbell. Dr. Campbell is a urologic oncologist who specializes in bladder cancer and other urologic cancers. Originally from Cleveland, Ohio, she currently practices at the Cleveland Clinic where she also did her residency and fellowship training. Prior to that, she attended undergraduate and medical school at Case Western Reserve University, also in Cleveland. She is the principal investigator on several bladder cancer and upper tract urothelial cancer clinical trials. Dr. Campbell, thanks for joining our podcast.

Dr. Rebecca Campbell:

Thanks so much for having me.

Rick Bangs:

Oh, it’s a pleasure. So today we’re going to focus on what’s called organ-sparing radical cystectomy. So I thought we could start by defining what is an organ-sparing radical cystectomy and what does it specifically mean if you’re a female?

Dr. Rebecca Campbell:

Great question. So I think first in order to understand what organ sparing is, we need to understand that traditionally cystectomy for bladder cancers in females was called an anterior exenteration. And traditionally it involved removal of the bladder, urethra, uterus, anterior vaginal wall, ovaries, and fallopian tubes. So when we’re talking about organ sparing, we’re referring to sparing or not removing some or all of these reproductive organs. The reason for the traditional surgical approach was because there was concern for undetected or microscopic disease spreading to these female reproductive organs. However, studies have shown that gynecologic organ involvement by bladder cancer is actually only about 5% for patients with muscle-invasive bladder cancer and we have newer data showing that it’s safe to do this in well-selected patients.

Rick Bangs:

Okay. And so now who would qualify for one and who doesn’t qualify?

Dr. Rebecca Campbell:

Well, in order to talk about that, I think it’s important to first define what each type of organ sparing is and why it might be important. So there’s vaginal sparing, there’s uterine sparing, and there’s ovarian sparing, and obviously sometimes patients will qualify for only one or more than one or all of them. So perhaps we can go through each individually.

Rick Bangs:

Yeah, let’s.

Dr. Rebecca Campbell:

I’ll start with vaginal sparing. So this is important for sexual function because as I mentioned before, traditional cystectomy involves removal of the anterior vaginal wall with vaginal reconstruction. This is because the anterior vaginal wall is obviously directly adjacent to the back wall of the bladder and the urethra. So that’s why sometimes it does need to be removed. But if you do have removal of the anterior vaginal wall and reconstruction, this can decrease the depth of the vagina or narrow it, which can make intercourse painful or difficult and have other sexual function implications.

Vaginal sparing, it’s very important for female patients who desire neobladders. So there’s kind of a whole topic we can discuss in regards to that. And I know there’s other podcasts on types of urinary diversions, but specifically relevant to this podcast, we know neobladders are not an option for everyone and that’s something you’d have to discuss with your surgeon. But in order to perform a neoblader, the urethra must be saved so that the pouch can be attached to the urethra. And urethral sparing, which is required for neobladders, is very closely linked to vaginal sparing since they’re directly adjacent to one another.

If your surgeon is performing a neobladder, there’s a few reasons why vaginal sparing in this specific case is important. So the vaginal wall can provide support for the urethra and the nerves, which help the sphincter function and help with continence, and then there’s also a risk with neobladders of developing a fistula between the vagina and the neobladder. So if the vagina is not spared and then thus must be reconstructed, there would be a fresh suture line on the vagina that’s directly next to the suture line of the neobladder and that’s where a fistula could form, and that would present as continuous leakage of urine from the vagina.

Rick Bangs:

So a fistula is like a channel?

Dr. Rebecca Campbell:

Yes. It’s an abnormal connection between two structures. So if you’re able to leave the vagina completely intact and not do any reconstruction on it at all, that’ll decrease the risk of getting a fistula between the neobladder and the vagina. So those are all important considerations when you’re talking to your surgeon about potentially getting a neobladder.

Well, the next type of organ sparing that we can discuss is uterine sparing. This is important to preserve the integrity of the pelvic floor and prevent pelvic organ prolapse. Actually, pelvic organ prolapse can happen in up to 5% of women after cystectomy. But basically the ligaments in the female pelvis that support your organs, they run between the pelvic side walls and the uterus. So if the uterus is removed, then some of these support tissues have to be divided or resected, and that can increase the risk of pelvic organ prolapse. If possible and the uterus can be spared and then the tissue that holds up the uterus will be there and help prevent pelvic organ prolapse.

And finally, the last type of organ sparing we really discuss with cystectomies is ovarian sparing. And as I’m sure many of you know, ovarian sparing is important for hormonal function. If you’re premenopausal, then ovarian sparing can allow a patient to avoid surgical menopause and this helps with long-term outcomes like bone density, cardiovascular effects, and general quality of life. More recently, we’ve also been talking about ovarian sparing even in postmenopausal females and that’s because there is some hormonal benefit that’s not entirely understood, but one mechanism may be that the ovaries can still produce some testosterone, which can be converted to estrogen. So generally if premenopausal and able to, then ovarian sparing is a good way to go. Postmenopausal, it’s a little bit less clear, but there may still be benefits for ovarian sparing in terms of hormonal function.

And then finally, one note when talking about reproductive organ sparing is patients will ask about, “What about the fallopian tubes?” For most female patients with bladder cancer, they’re postmenopausal or at least post-reproductive age, and so the fallopian tubes are usually not providing any useful benefit. And actually studies have shown that removing the fallopian tubes can reduce the risk of some types of ovarian cancer by like 60 to 70%. So there’s actually some guidelines that have been published saying that patients undergoing pelvic surgery for any reason, so not just bladder cancer surgery, but it could be colorectal surgery or a benign hysterectomy, that they get a prophylactic or preventative removal of the fallopian tubes. So when we’re talking about organ sparing, we’re not usually talking about fallopian tubes because those generally can just be safely removed either way.

Rick Bangs:

Okay. I mean, not removing these organs would seem to be the preferred option, not removing any of them, but there are cases where you have to make these decisions, right?

Dr. Rebecca Campbell:

Correct. Yeah. So unfortunately not everyone will qualify for the different types of organ sparing. The most common reason why you may not qualify would be characteristics of your bladder cancer. So, for example, something called T4 disease or bladder cancer that we know is invading into adjacent structures or tissues, that would be a relative contraindication or reason not to do organ sparing. There are certain other bladder tumor characteristics such as very, very large tumors, tumors that are on the trigone or the posterior wall of the bladder that’s directly adjacent to the vagina and cervix, those might not be ideal for organ sparing. Patients with positive lymph nodes, which is a sign of aggressive cancer, that those patients may not unfortunately be a good candidate.

So, in general, I would say for the more aggressive cancers or cancers that have aggressive features or are in certain locations, then organ sparing may not be the best idea, because, as we all know, the number one priority of the surgery should be resecting all cancer and decreasing the chance of recurrence.

Typically, in order to know if one of my patients would qualify for organ sparing, what I do is obviously note the location of the tumor on the resection as well as do an exam in the operating room at the time of diagnosis. So that would be at the original TRBT, or transurethral resection of the bladder tumor. But then also I find that pelvic MRIs are very useful for surgical planning. So these can tell me if there’s any suspicion that any of the reproductive organs may be involved or at risk. I like to get the MRI after systemic therapy if patients got systemic therapy, so I like to get it pretty close to surgery, close to the time of cystectomy so I can have a really good idea about whether or not organ sparing would be safe and I can talk to the patient about it at that time.

Rick Bangs:

Okay. So there’s a lot of factors and the surgeon is going to converse with you and explain what makes sense for you based on all these factors that you’ve brought up, some related to your bladder cancer and some other factors?

Dr. Rebecca Campbell:

Right, exactly. There are some other factors not even related to bladder cancer that can make a difference if a patient has a history of breast cancer or ovarian cancer or a history of BRCA1 or 2 mutation, history of Lynch syndrome. Those are all instances where you probably don’t want to do ovarian sparing because they either have a history of ovarian cancer or are at very high risk for developing ovarian cancer. So in that scenario, the benefit of potentially saving the ovary and the potential hormonal benefits from that would not outweigh the risk. So if you have one of those situations, you have to make sure that your surgeon is aware of it.

Rick Bangs:

Ah. Okay. And they probably would have, I think the word would be “interrogated”. They probably have interrogated you and looked at your record-

Dr. Rebecca Campbell:

Right.

Rick Bangs:

Okay. Got it. So how is this different from nerve sparing?

Dr. Rebecca Campbell:

The nerves that provide continence so that the nerves that go to the urinary sphincter and the nerves that help with sexual outcomes such as lubrication and sensation, those run just lateral to the vagina. So typically the nerves are spared with vaginal sparing, but it is also possible to do nerve sparing even if a portion of the vagina has to be preserved or has to be resected. So they’re not used interchangeably for that reason. You can have nerve sparing without having complete vaginal sparing.

Rick Bangs:

Okay. And so organ sparing, does the availability of this vary by surgeon and institution or is this kind of something that’s generally available, doesn’t need to be asked for? How does it work?

Dr. Rebecca Campbell:

Over the last, I would say, 10 years or so, people are advocating more and more for offering reproductive organ sparing to female patients. So I believe it should be offered everywhere. But given that bladder cancer is three or four times more common in men, I think a lot of surgeons are more used to doing cystectomies in male patients and perhaps are not as comfortable talking to patients about this or doing organ sparing. So I believe it is offered and should be offered everywhere. But if not, if you feel that you qualify for this but are not offered it at a place where you’re receiving care, I would definitely try to seek a second opinion at a higher volume hospital.

Rick Bangs:

I’ve never talked to somebody who regretted getting a second opinion. So …

Dr. Rebecca Campbell:

Definitely.

Rick Bangs:

Yeah. Okay. So now this procedure, does it take longer in the OR because you’re kind of working around things? Is it going to take longer to recovery? What about the complications? How does it compare?

Dr. Rebecca Campbell:

So typically I don’t find that it adds too much time or technical difficulty to the operation. Obviously, every situation is different based on which type of organ sparing you’re doing or if you’re doing all of them, prior surgeries, prior pelvic radiation, these are patient factors that can potentially add more time or difficulty, but usually the complications are not increased with doing organ sparing. The most common complications after this surgery in general, cystectomy, are usually related to the other parts of the surgery, the bladder removal and the urinary diversion parts. So the most common complications are dehydration, UTI, ileus, electrolyte abnormalities, most commonly are not related to the organ-sparing part of the surgery, which generally does not add time or complications. And specifically for the preventative fallopian tube removal that I discussed earlier, that has been shown to not increase complications or bleeding.

Rick Bangs:

Okay, great. So now I think you’ve kind of suggested getting a second opinion, but is there generally a place where I could feel like I’m going to get organ sparing?

Dr. Rebecca Campbell:

I think any hospital that has high volume bladder cancer surgeons is the way to go.

Rick Bangs:

Okay. All right. And is this something I just get or do I have to ask for this? How does that normally work?

Dr. Rebecca Campbell:

I think that’s probably pretty dependent on the specific surgeon and the hospital, but I think if you are interested, you should just go to your appointment and plan on asking. I always think it’s a good idea to bring a list of questions to your appointment. And I actually appreciate when patients do that and I appreciate when they’ve done their homework ahead of time, especially because these appointments can be overwhelming and you may forget to ask these questions, so I think writing it down, bringing that with you is helpful.

If you are not offered it or told you don’t qualify by the surgeon you’re seeing, then definitely get a second opinion. And I know some patients, I’ve been told by my female patients, they feel more comfortable talking to female surgeons about this since we’re discussing sexual function, pelvic organ prolapse, that type of thing. So you may also want to seek out a female surgeon.

Rick Bangs:

I applaud that. I think that’s great advice. Okay. Any final thoughts?

Dr. Rebecca Campbell:

This is something I think that is just becoming more common, more talked about, more recommended, and I hope to continue seeing that trend. And don’t be afraid to ask about it. Don’t be afraid to talk to your surgeon about sexual function and your long-term quality of life concerns is my best advice.

Rick Bangs:

Okay. Thanks. So Dr. Campbell, I want to thank you for explaining organ-sparing cystectomy in women.

Dr. Rebecca Campbell:

Yes. Thank you for having me.

Rick Bangs:

If you’d like more information on bladder cancer, please visit the BCAN website, www.bcan.org. Now, if people want to get in touch with you, they can email info, I-N-F-O, @bcan.org, B-C-A-N dot org. Just a reminder that if you’d like more information about bladder cancer, you can contact the Bladder Cancer Advocacy Network at 1-888-901-2226.

That’s all the time we have today. Please like, comment, and subscribe so we have your feedback. Thank you for listening and we’ll be back soon with another interesting episode of Bladder Cancer Matters. Thanks again, Dr. Campbell.

Dr. Rebecca Campbell:

Thank you.

Voice over:

Thank you for listening to Bladder Cancer Matters, a podcast by the Bladder Cancer Advocacy Network, or BCAN. BCAN works to increase public awareness about bladder cancer, advance bladder cancer research, and provide educational and support services for bladder cancer patients. For more information about this podcast and additional information about bladder cancer, please visit B-C-A-N dot O-R-G.