NEUROVASCULAR PRESERVATION IN ORTHOTOPIC CYSTECTOMY: IMPACT ON FEMALE SEXUAL FUNCTION AMIT BHATT, KALYANA NANDIPATI, NIVEDITA DHAR, JAMES ULCHAKER, STEPHEN JONES, RAYMOND RACKLEY, AND CRAIG ZIPPE ABSTRACT Objectives. The published data regarding female orthotopic cystectomy have focused primarily on urethral recurrence and urinary continence. In a new era of sexuality, evaluating postoperative sexual outcome has become a new surgical endpoint. In this study, we focused on the impact of neurovascular preservation after radical cystectomy and neobladder construction. Methods. We assessed female sexuality in 13 patients after orthotopic cystectomy using a standardized questionnaire, Female Sexual Function Index (FSFI). Six patients had undergone nerve-sparing cystectomy and seven had undergone contemporary non-nerve-sparing cystectomy. Intraoperatively, the tumor was deemed oncologically safe for neurovascular preservation. All 13 patients were sexually active preopera- tively, were younger than 65 years old, had recurrence-free follow-up findings after 1 year, and had undergone no pelvic irradiation. The 19-item FSFI questionnaire analyzed six domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) of sexual function. Results. In the nerve-sparing group (mean age 55.9 years), the baseline and 12-month postoperative scores showed a minimal decline in results, with a total mean FSFI score of 24.5 versus 22.3, respectively. In analyzing each of the six domains, no significant decline or difference was observed. Conversely, in the non-nerve-sparing group (mean age 56.7 years), a significant decline or difference was found in the 12-month total mean FSFI scores between the baseline and postoperative FSFI scores (25.0 versus 11.0, respectively). In the non-nerve-sparing group, 6 of 7 patients ultimately discontinued sexual intercourse. Conclusions. Female sexual function was preserved in patients who received neurovascular preservation. In contrast, all domains of sexual function declined in patients who had undergone non-neurovascular preservation. UROLOGY 67: 742–745, 2006. © 2006 Elsevier Inc. W ith urinary monitoring for hematuria, blad- der cancer is being detected with increasing frequency in a younger female population. Younger female patients often prefer orthotopic neobladders to preserve their body image and urinary conti- nence. Female sexual dysfunction is prevalent after radical cystectomy, and in this younger popula- tion, sexual dysfunction is an important concern. With improved detection and oncologic control of bladder cancer, earlier surgical therapy allows preservation of neurovascular bundles and other adjacent structures such as the vagina and cervix. Nerve fibers from the pelvic plexus run beside the lateral walls of the vagina to the bladder neck and urethra. 1 Historically, radical cystectomy removed or damaged the neurovascular bundles on the lat- eral walls of the anterior vagina, causing significant devascularization of the clitoris. Clitoral devascu- larization also occurs with removal of the distal urethra. Urethral sparing and neurovascular pres- ervation potentially saves the nerves and vascula- ture of this region. The purpose of this study was to assess whether neurovascular preservation at cystectomy and or- thotopic diversion could preserve sexual function in a sexually active female population. Using the validated six-domain Female Sexual Function In- dex (FSFI) questionnaire, we compared a subgroup of female patients who underwent neurovascular preservation with orthotopic diversion versus a contemporary series of patients who underwent non-nerve-sparing orthotopic diversion. 2 From the Glickman Urologic Institute, Cleveland Clinic Founda- tion, Cleveland, Ohio Reprint requests: Craig D. Zippe, M.D., Glickman Urological Institute, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: zippec@ccf.org Submitted: May 30, 2005, accepted (with revisions): October 10, 2005 ADULT UROLOGY © 2006 ELSEVIER INC. 0090-4295/06/$32.00 742 ALL RIGHTS RESERVED doi:10.1016/j.urology.2005.10.015