In females, RC involves excision not only of the bladder but also of the uterus, ovaries, and anterior vaginal wall. The decision to concurrently perform bilateral oophorectomy during RC is based on considerations such as the theoretical risk of recurrent BC within ovarian tissues, the potential for de novo primary ovarian malignancy, the assumed minimal health or quality of life (QoL) benefits from ovarian preservation, and perceived procedural simplification through oophorectomy.
Contrary to traditional assumptions, recent data challenges the necessity of oophorectomy during cystectomy by revealing tangible health and QoL benefits associated with ovarian preservation, even in postmenopausal women.2
Earlier skepticism by Liedberg et al. challenged the rationale for synchronous oophorectomy, emphasizing the minimal risk of subsequent ovarian malignancy in the absence of a germline mutation and the lack of empirical evidence regarding BC recurrence within the ovaries.3 However, the frequency of Ovarian Cancer (OC) germline mutations in women with BC is not well-established, and the concurrent incidence and timing of OC and BC remain poorly characterized. Our study was published in European Urology Focus by Bukavina et al aims to characterize the prevalence of pathogenic OC germline mutations in females who have been diagnosed with BC. Furthermore, our study aims to elucidate the chronological sequence of OC and BC occurrences in patients with and without OC germline variants.4
Briefly, our study utilized data from 501,387 UK Biobank participants, including 1346 female patients with BC.5 The study found that 3.4% of the females diagnosed with BC possessed distinct germline variants linked to a range of susceptibilities for developing OC. The most common mutations included CHEK2, ATM, PALB2, and BRCA1. The study revealed that women with OC germline variants were more susceptible to developing additional cancers, such as breast, melanoma, and uterine/endometrial cancers, and often experienced the onset of these diseases, including BC, at a younger age. Importantly, our findings demonstrate that OC diagnoses typically occurred 11-15 years before BC across the entire cohort, even in patients with OC germline variants. Additionally, there were no subsequent cases of OC detected following the diagnosis of BC.
The published study calls into question the conventional practice of risk-reducing oophorectomy during radical cystectomy in women with BC, even in highest risk group, further underscoring the very low probability of subsequent OC development in residual ovarian tissue. The study does emphasize that while OC invariably precedes BC diagnosis due to its higher penetrance and earlier onset, there remains a risk for endometrial and uterine cancers. Therefore, the decision to preserve organs in patients at high risk should be guided by a personalized oncological strategy. This approach should include Pap smears and high-risk HPV testing, assessment of genetic predisposition and cancer susceptibility, and taking into account the specific quality of life considerations for each patient.
Written by:
- Sneha Parekh, MD, Urology PGY2, Larkin Palm Springs Hospital, Miami, FL
- Laura Davis, MD, Urology PGY3, University Hospitals Cleveland Medical Center, Cleveland, OH
- Laura Bukavina, MD, MPH, MSc, Urologic Oncologist, Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, OH; Department of Urology, Fox Chase Cancer Center, Philadelphia, PA
- Davis L, Isali I, Prunty M, Calaway A, Mishra K, Miller A, et al. Female Sexual Function Following Radical Cystectomy in Bladder Cancer. Sex Med Rev. 2022;10(2):231-9.
- Bukavina L, Mishra K, Mahran A, Shekar A, Sheyn D, Slopnick E, et al. Gender Disparity in Cystectomy Postoperative Outcomes: Propensity Score Analysis of the National Surgical Quality Improvement Program Database. Eur Urol Oncol. 2021;4(1):84-92.
- Liedberg F, Jancke G, Sörenby A, Kannisto P. Should we Refrain from Performing Oophorectomy in Conjunction with Radical Cystectomy for Bladder Cancer? Eur Urol. 2017;71(6):851-3.
- Bukavina L, Davis L, Helstrom E, Magee D, Ponsky L, Uzzo R, et al. Population Estimates of Ovarian Cancer Risk in a Cohort of Patients with Bladder Cancer. Eur Urol Focus. 2024.
- Sudlow C, Gallacher J, Allen N, Beral V, Burton P, Danesh J, et al. UK biobank: an open access resource for identifying the causes of a wide range of complex diseases of middle and old age. PLoS Med. 2015;12(3):e1001779.