“Bladder cancer (BCa) is generally considered as a disease of the elderly with a median age approximately 65 to 70 years at diagnosis. But approximately, one to two per cent of patients will be under 40 years of age. At Bern University in Switzerland, we have had 39 patients under the age of 50 and 16 patients under 40 from 2007 to 2017. ” So stated Prof. Fiona Burkhard (CH) as she kick-started “Plenary Session 01 Bladder cancer in the young patient: Unique aspects”, chaired by herself and Prof. Morgan Rouprêt (FR).
Prof. Burkhard introduced the case of a 34-year-old female presenting with macrohaematuria at a different hospital. The patient had an initial transurethral resection of the bladder (TURB) with a pT1G3, followed by a re-resection when muscle-invasive disease was found. She is a painter with one child, and has a smoking history of 10 pack-years. Prof. Burkhard shared, “The first question the patient asked me was ‘I would like to have second child. Would that be possible?’”
The initial step is preoperative assessment, in which oncological aspects (tumour location) are prioritised over preserving fertility. Following this, specific surgical aspects are considered: nerve-sparing, organ-sparing, and the type of diversion to be offered to the patient. Then, if the patient is pregnant, the focus shifts to care during pregnancy and delivery.
The introduction was followed by the lecture, “Fertility in the young female patient with bladder cancer: Surgical aspects” by Dr. Jo Cresswell (GB). She stated that it is not uncommon to see young female patients wanting to have children; however, for a number of young women who have/will undergo radical cystectomy (RC) or have BCa, sexual function and fertility may also be of importance.
Dr. Cresswell also discussed pelvic organ-sparing cystectomy, which includes uterine-sparing to preserve fertility; ovarian-sparing to avoid early menopause; and vaginal- and nerve-sparing to preserve sexual function. She also cited the EAU Guidelines (2018): “In women, standard RC includes removal of the bladder, entire urethra and adjacent vagina, uterus, distal ureters and regional lymph nodes… Data regarding pelvic organ-preserving radical cystectomy for female patients remains immature.” One of the current Guidelines recommendations – offering sexual-preserving techniques to preserve sexual function since the majority will benefit – was rated “weak”.
However, Dr. Creswell foresees this changing. “I think it’s time to pay attention to vaginal-sparing and ovarian-sparing surgery, and to put more focus on sexual function,” she stated. Careful assessment of the vagina is needed, and bladder-neck urethral biopsies should be considered pre-operatively. For uterine-sparing surgery with the objective of preserving fertility in selected patient cases, improved urinary function should also be taken into account.