Approximately 1 in 5 women undergoing cystectomy experience vaginal complications, a new study finds.

This complication rate is higher than expected, Lee A. Richter, MD, of MedStar/Georgetown University Medical Center in Washington, DC, and colleagues reported in The Journal of Urology. Cystectomy in women has traditionally included removal of the anterior vagina, uterus, fallopian tubes, and ovaries, in addition to the bladder and urethra. Modifications have been made to the standard technique to help preserve reproductive and sexual function.

Among 481 women aged 65 years or older who had a cystectomy from 2011 to 2017 in the Medicare 5% sample, a vaginal complication developed in 102 (21.2%), and 26 (5.4%) received an intervention after the index surgery. The risk of vaginal complications was 2.3-fold higher among women undergoing cystectomy for non-urologic cancers vs bladder cancer. Of the cohort, 378 patients (79%) had bladder cancer and 401 (83.4%) underwent an incontinent conduit or catheterizable channel diversion.

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“Given that our Medicare cohort was an older group, it makes sense that they were less likely to have a continent diversion, as this is often reserved for younger, healthy patients,” the authors explained. “Understanding that most fistula occur in the setting of neobladder reconstruction, it is plausible that the incidence of vaginal fistula in the general population is even higher than what we found in an older cohort with very few neobladder diversions.”

The risk of a vaginal complication significantly decreased by 3% for each 1-year decrease in age at diagnosis. More than a third of patients (37.2%) were younger than 70 years old.

Vaginal cuff dehiscence was the most common vaginal complication within 2 years of cystectomy, occurring in 49 patients (10.2%) at a median 25 days, the investigators reported. Vaginal fistula developed in 33 women (6.9%) and pelvic organ prolapse in 21 (4.5%). Fewer than 11 women had a formal diagnosis of dyspareunia. Twelve women (2.5%) had a surgical intervention for vaginal prolapse. Few patients had interventions for vaginal fistula or vaginal cuff dehiscence.

According to Dr Richter’s team, vaginal cuff dehiscence is of particular concern because it can involve bowel evisceration and the need for emergent reoperation.

“Urologic oncologists should discuss these potential complications with patients preoperatively, and should provide them with information about possible postoperative symptoms.”


Richter LA, Osazuwa-Peters O, Routh J, and Handa V. Vaginal complications after bladder cystectomy: Results from a Medicare sample. J Urol. Published online December 2, 2021. doi:10.1097/JU.0000000000002336