Characterizing pelvic organ descent in women after radical cystectomy: an exploratory analysis

The effect of radical cystectomy (RC) on female pelvic floor support remains poorly understood; we aim to characterize the prevalence and severity of pelvic organ descent beyond the pubococcygeal line (PCL) in women who have undergone RC.

We retrospectively reviewed charts of women who underwent RC at our institution from 2017 to 2020. Using cross-sectional static imaging we measured pelvic organ position preoperatively, postoperatively, and throughout the surveillance period, as determined by intestinal position in relation to the PCL on sagittal images obtained in the supine position. Imaging review protocol was developed in collaboration with an expert genitourinary radiologist. We also recorded relevant covariates, including age, race/ethnicity, BMI, vaginal parity, pre-cystectomy prolapse, prior hysterectomy, constipation, and chronic cough.

We identified 48 women with ≥ 1 preoperative and ≥ 1 postoperative scan who underwent RC at our institution out of a total of 80 female cystectomies in the study period. The majority underwent ileal conduit (83%) and non-organ sparing RC (81%). Median pelvic organ proximity to the PCL was significantly closer pre-operatively at 2 mm (IQR: -4, 6) below the PCL versus post-operatively at 14 mm (IQR: 9, 20) (p < 0.001). On scans with maximum organ descent, 96% of patients had increased organ descent from baseline. Median time to maximum descent was 9 months (IQR 3.8, 19.1). Patients undergoing continent diversions had greater post-operative descent than those with incontinent diversions. Vaginal deliveries were independently significantly associated with longer pelvic organ descent beyond the PCL (exp. β = 1.87 [95% CI: 1.21, 2.88; p = 0.009]).

We describe the novel use of pre- and post-operative surveillance cross sectional imaging to characterize the natural history of post-RC pelvic floor descent. In our population, 96% of women demonstrate increased pelvic organ descent after RC on supine static imaging. Descent of pelvic floor support is an underappreciated consequence of RC.