Table 4 Treatment, measurement and outcome

1

[33]

Group 1 comprised 58 subjects (mean age 65 years)

Group 2 comprised 50 subjects (mean age 61 years)

Group 3 comprised 54 healthy subjects (mean age 63 years

Radical cystectomy

compared in ileal conduit diversion, modified S-pouch and healthy subjects

Interviews

Erectile dysfunction was worse in groups 1 (who received ileal conduit diversion) (29%) and 2 (modified S-pouch neobladder) (35.5%) compared to group 3 (healthy subjects) (83.2%). The quality of erection (firmness) was similarly affected in groups 1 (17.7%) and 2 (22.2%) compared with group 3 (83.3%)

Sexual dysfunction was also evaluated for women and was not pronounced as in the men. Sexual desire was equally present in all groups and patients in group 1 expressed higher levels of dissatisfaction than the other two groups.

2

[34]

Twenty men in each group (mean age 58 and 59 years)

Radical cystectomy with prostate capsule sparing or nerve sparing and neobladder urinary diversion

Sexual Health Inventory for Men questionnaire (SHIM)

Compared to baseline, sexual function decreased similarly for both groups. 55 and 65% of prostate capsule sparing and nerve sparing patients used aids or medications for erectile function, respectively.

3

[18]

Twenty patients and their spouses/partners (mean age 59 and 58, respectively)

Cystectomy followed by urostomy

Interviews

Participants were found to have frequent erectile dysfunction, ejaculation disorder, fear of hurting spouse/partner and leakage during sexual intercourse.

The participants’ spouse/partner were found to have fear of hurting, decrease in sexual desire, inability to get pleasure/orgasm and avoiding sexual intercourse.

4

[35]

Ninety-one patients and 59 were included in the continent and incontinent group, respectively (mean age 55 and 59.5 years, respectively)

Radical cystectomy with orthopaedic neobladder or uretro-sigmoidostomy (continent group) or uretero-cutanoustomy or had ileal conduit (incontinent group)

Sexual Health Inventory for Men Questionnaire (SHIM)

Regarding sexual function, from 121 patients, 29 (23.9%) underwent nerve-sparing and 59 (48.7%) non nerve- sparing procedure. Erectile dysfunction affected 78.4% of them. There was a significant difference between both groups with lower degrees of erectile dysfunction in nerve-sparing group. After one year postoperatively, 19/29 (65.5%) patients who underwent nerve-sparing radical cystectomy demonstrated spontaneous complete tumescence, 6 (20.7%) achieved erections with the use of oral PDE5 inhibitors while 4 (13.8%) required intra-cavernosal injection therapy. All patients treated with non-nerve sparing RC required intra-cavernosal injection therapy to achieve erections.

5

[36]

Hundred eighty-five men were included (mean age of 57 years)

Prostate sparing cystectomy

Interviews

In total, 136 patients (86.1%) maintained erectile function, of whom 27 (19.9%) successfully used sildenafil, and 6 patients (4.4%) used intra-cavernous injections.

6

[19]

Forty-four men and 6 women (mean age 57.6 years)

Cystoscopy

International Sexual Function Index (IIEF-5) and Female Sexual Function Index (FSFI)

Mild-moderate erectile dysfunction was found in men and sexual dysfunction in women.

7

[37]

Eleven men underwent conventional radical cystoprostatectomy and 14 patients had prostate-sparing cystectomy (mean age 61.55 and 57.5 years, respectively)

Orthotopic neobladder reconstruction after prostate-sparing cystectomy and conventional radical cystoprostatectomy

International Index of Erectile Function-5 (IIEF-5)

After surgery, IIEF-5 scores in conventional radical cystoprostatectomy and prostate-sparing cystectomy groups were 3.7 and 16.0, respectively.

8

[38]

Sixty-three men and 4 women (mean age 63 years)

Robot-assisted radical cystoprostatectomy

Interview

With regard to sexual potency, twenty (43%) patients with neobladder reported spontaneous erections prior to surgery, 14 (29%) erectile dysfunction of some degree, and in 13 (28%) it is unknown. Of the 20 patients with normal sexual function prior to surgery, 90% had spontaneous erections that allowed them to have satisfactory sexual relations; of them, 3 managed it with the help of IPDE-5. Of the 14 patients who already reported some prior erectile dysfunction, 9 achieved satisfactory erections with IPD5.

9

[20]

Hundred and nine patients underwent radical cystectomy and 64 patients underwent trimodality therapy (mean age 66 and 65, respectively)

Radical cystectomy and bladder-sparing trimodality therapy

QoL questionnaire

Male patients who had received trimodality therapy reported less difficulty gaining or maintaining an erection and decreased ejaculation problems compared with those who had undergone radical cystectomy. Patients who had undergone trimodality therapy also reported being less uncomfortable with being sexually intimate and less worried about contaminating their partner during sexual contact.

10

[21]

Twenty-two men and 8 women (mean age 67 years)

Radical cystectomy and urinary diversion

Semi-structured interviews

Overall, 25 and 18.18% of younger and older patients, respectively, reported a discussion with the physician regarding changes in sexual function.

Following surgery, younger patients were more likely to report problems with sexual dysfunction.

11

[39]

Women between 20 and 28 years (mean 24 years) were 30.77%. Women of age range of 32–37 (mean 35 years) were 23.07% Women of age range of 40–54 (mean 49 years) were 48.5%

Radical cystectomy with preservation of genital organs and orthotopic ileal neobladder urinary diversion

Female Sexual Function Index (FSFI) questionnaire

Women who had reported good sexual function had DSFI score ranging from 20 to 32, which was reported by 84.61%. One woman had a score of 15, while another woman was not married and had no partner and she reported a score of zero.

12

[22]

Seventy-one women (mean age of 67 years).

Radical cystectomy

Female Sexual Function Index (FSFI) questionnaire

Only 37% of the patients were sexually active post-surgery and those who were still sexually active tended to have less frequent sexual activity.

A comparison of sexual desire before and after surgery found that 15 patients (37%) reported that this was unchanged, 22 patients (54%) that their desire for sex had decreased and one person that it had increased. Regarding ability to reach orgasm before and after surgery, 16 patients (39%) reported that this was unchanged and 18 (44%) that it was now harder to reach orgasm, while no one reported that it was easier to reach orgasm.

13

[40]

Sixty-eight men and 25 women (mean age 65 years)

Bacillus Calmette–Guérin (BCG) treatment

Semi-structured qualitative interviews

For those individuals who were sexually active, 60.0% of males experienced difficulty gaining or maintaining an erection and 43.1% of males had problems with ejaculation. Among sexually-active females, 62.5% experienced problems including vaginal dryness. Nearly 50% of participants reported that it was very helpful to discuss concerns about sexual function with their partners.

14

[34]

Forty patients (mean age 58 years)

Prostate capsule sparing and nerve sparing cystectomies

Sexual Health Inventory for Men Questionnaire (SHIM)

Average sexual function at 12 months compared with baseline decreased by 1 +/− 11 and 23 +/− 30 points for prostate capsule sparing and nerve sparing, respectively. Of patients with prostate capsule sparing and nerve sparing cystectomy, 55 and 65%, respectively, used aids or medication for erectile function.

15

[23]

Eighteen patients undergoing radical cystectomy and 20 control (mean age 62.3 and 64.9 years, respectively)

Radical cystectomy

International Index of Erectile Function (FSFI) and International Index of Erectile Function (IIEF)

Regarding erectile dysfunction, intercourse satisfaction, orgasmic function, sexual desire and overall satisfaction—the radical cystectomy group started, stayed and ended on a lower level than the case control group throughout the study. No data reported for women.

16

[41]

Fifteen women patients (mean age of 42 years)

Internal genitalia sparing cystectomy

Female Sexual Function Index (FSFI)

Sexual intercourse was regained after 6 weeks, a duration which is significantly shorter than in women without genital preservation. The mean FSFI scores in the study group were significantly higher than in cystectomy women without genital sparing. Similarly, there were significant differences in favour of genital sparing cases in all domains of FSFI.

17

[42]

Seventy-eight men and 8 women (mean age 62 years)

Orthotopic neobladder

International Index of Erectile Function (IIEF-5) and visual analogue scale (VAS).

Most patients (88%) had a score of less than 10 points on IIEF-5, 5.3% of patients showed 10–14 points, 4% showed 15–19, and only 2.7% showed equal to or more than 20 points. Because evaluation by IIEF-5 had not been performed before surgery, we could not determine the precise influence of orthotopic neobladder on sexual function.

18

[43]

Four men (mean age of 45 years)

Radical cystectomy

Interview

All patients reported adequate sexual function with normal erections and satisfactory intercourse similar to that reported before surgery. The erectile activity was regained within the first 5 months after surgery. Two patients (50%) preserved antegrade ejaculation the other two patients reported failure of ejaculation.

19

[44]

Seven men (mean age of 40 years)

Radical cystectomy

Interview

Erectile function is normal in all patients with satisfactory sexual intercourse. Antegrade ejaculation was documented in six cases.

20

[45]

Four men and one woman (mean age 52.4 years)

Nerve sparing laparoscopic radical cystectomy

Female Sexual Function Index (FSFI) and International Index of Erectile Function score

Sexual function was preserved in the female patient and 2 of the 4 male patients.

21

[24]

Eighty-two patients who had undergone radical cystectomy and 177 other therapy (mean age 64.4 years)

Radical cystectomy and other therapy

FACT-BL + additional concerns

Patients with their bladders preserved had more interest in sex when compared with patients who had their bladders removed. Twenty-one percent of respondents who had their bladders preserved were not interested in sex as compared with 39% who underwent radical cystectomy. In the radical cystectomy group, about 89% of the respondents could not have and keep an erection, whereas in the bladder intact group only 32% of respondents could not have and keep an erection.

22

[46]

Thirteen women (mean age 56.7 years)

Nerve sparing cystectomy with urethra and vaginal sparing

Female Sexual Function Index (FSFI

All 6 patients were sexually active 1 year after surgery. There is a significant vaginal dryness, a lack of arousal, and dyspareunia often led to discontinuation of sexual intercourse in the non-nerve-sparing group, with only 1 patient sexually active.

23

[47]

Thirteen women (mean age 56.7 years)

Non nerve sparing and nerve sparing cystectomy

Female Sexual Function Index (FSFI

A reduction occurred in the mean score for desire, arousal, pain, and satisfaction. No change occurred in the mean score for orgasm or lubrication. One patient from the nerve-sparing group reported significant dyspareunia after cystectomy that had resolved. All 6 patients had resumed sexual activity at their 1-year follow-up visit.

24

[48]

Twenty-nine women (mean age of 61 years)

Cystectomy and orthotopic ileal neobladder

Female Sexual Function Index (FSFI)

The 11 of 17 patients who remained sexually active after cystectomy even had slight improvement. Six patients ceased to be sexually active postoperatively due to erectile dysfunction or partner death. One patient with interstitial cystitis became sexually active following cystectomy due to the loss of pelvic pain. Another 12 patients remained sexually inactive postoperatively.

25

(Nieuwenhuijzen, Meinhardt and Horenblas 2005)

Forty men (mean age of 56.9 years)

Prostate sparing cystectomy and neobladder

Interviews on erection and ejaculatory function and the international index of erectile function questionnaire

Erectile function could be determined in 40 patients, and potency was maintained in 77.5%, impaired in 12.5% and absent in 10%.

26

[49]

Forty-nine men (mean age 57.8 years).

Nerve-sparing radical cystectomy, orthotopic diversion, conduit diversion and cutaneous continent diversion

Sexual Health Inventory for Men (SHIM)

Total mean SHIM score decreased after radical cystectomy. Of the 49 patients, 42 (86%) did not have erections sufficient for vaginal penetration. Of these 42 patients, 22 (52%) tried sildenafil citrate. Of these 22 patients, only 2 (9%) responded positively. Only 9 (14%) of 49 sexually active men were potent after surgery. Of these 9 potent patients, 8 (89%) had undergone nerve-sparing radical cystectomy.

27

[50]

Twenty-eight patients (mean age of 51.0 years).

Supra-ampullar cystectomy

Self-administered questionnaire

Potency was preserved in 26 patients (92.8%), reporting satisfactory sexual intercourses; 15 patients (53.5%) also maintained antegrade ejaculation allowing procreation in 3 cases.

28

[51]

Twenty-seven women (mean age 54.79 years)

Radical cystectomy

Female Sexual Function Index (FSFI)

The total mean baseline Index of Female Sexual Function score decreased. The most common symptoms reported by the patients included diminished ability or inability to achieve orgasm in 12 (45%), decreased lubrication in 11 (41%), decreased sexual desire in 10 (37%), and dyspareunia in 6 patients (22%). Only 13 (48%) of the 27 patients were able to have successful vaginal intercourse, with 14 (52%) reporting decreased satisfaction in overall sexual life after radical cystectomy. Eight partners (30%) had a decrease in desire for sexual activity owing to apprehension after cancer diagnosis and treatment.

29

[52]

Ten men and 3 women (mean age 55 years)

Cystectomy and neobladder

Structured interview

Erectile function was insufficient in 3 men. In 5 men ejaculation was antegrade, in 4 it was retrograde and 1 had each experience from time to time. In the women lubrication and orgasmic feeling was reported to be normal after surgery.

30

[53]

Eighteen men (mean age 62.5 years)

Radical radiotherapy

Non-validated questionnaire

Eight out of 17 patients felt that their sex life was a lot worse since radiotherapy and four felt that their sex life was a little. Five patients felt that their sex life was unchanged. No patient felt their sex life had improved. Despite this, seven patients were unconcerned that their sex life had changed. Only eight of those 12 patients whose sex life had deteriorated were concerned about the decline in their sexual function and indeed only two noted great concern over the decline.

31

[54]

Hundred-twelve men (mean age 63 years)

Radical cystectomy

Semi-structured interview

Of the men 20% were sexually inactive before cystectomy and 35% had at least mild erection problems. These percentages increased to 50 and 91, respectively, postoperatively. Most men who tried to reach orgasm after cystectomy could do so but 36% reported that they rarely or never had orgasms. About half of the men who were orgasmic after cystectomy complained that the intensity and pleasure of the sensation were reduced. However, the desire for sexual activity did not change as drastically as the ability to function.

32

[55]

Nine women (mean age 59 years)

Radical cystectomy

Interviews

For most couples postoperative sexual activity included intercourse, although 4 women experienced severe dyspareunia and the other 3 active women had mild discomfort at first. One couple was not able to have intercourse until a session of sexual counselling 20 months postoperatively helped the wife to relax. One woman still has not been able to tolerate vaginal penetration, although she can reach orgasm through noncoital stimulation.

Levels of sexual desire remained normal in 7 women but patient 9 continued to experience low sexual desire and patient 4 lost her desire for sexual activity. Of the 7 women who resumed sexual activity 6 have been able to overcome most or all of the dyspareunia that they experienced at first. The pain and discomfort included a sensation of vaginal tightness in 5 women, including 1 of the 2 whose vagina was repaired by turning the posterior wall downwards. Three women had trouble with vaginal dryness despite use of a water-based lubricant. Only 1 woman produced enough natural vaginal lubrication for comfortable intercourse.

33

(Bergman, Nilson and Peterson 1979)

Forty-two men (mean age 62.3 years)

Cystectomy, prostatectomy and vesiculcctomy

Interviews

Most cases partners were also interviewed.

At the time of the interview, ten men had not attempted to resume sexual activity after the operation.

Only 3 patients were able to have penile erection after cystectomy. Although the remaining 24 patients were sexually active, they did not have a normal erection after the operation. Some of the men who achieved orgasm by masturbation reported a sensation of erection during orgasm.

34

[56]

Seventy-three women (mean age 52.3 years)

Radical cystectomy with urinary diversion

Female Sexual Function Index (FSFI)

Sexual relations had ceased completely in 19 patients (26%), while it was maintained in 54 patients (74%). Among the postoperatively sexually active female various sexual dysfunctions were reported. Overall satisfaction among sexually active females was found to be the same as preoperatively in 14 patients (26%), it had worsened in 32 (59.2%) and was completely lost in eight patients (14.8%).

35

[57]

Seventy-six men (mean age of 57 years)

Cystectomy and bladder substitution

Interview

After cystectomy, only 9% of all patients were still able to have an erection every second time or more often. Thirty-eight percent stated that they were still capable of orgasm, but a rather large proportion (21%) claimed that they did not know. Of the 29 patients with retained orgasmic function, 41% reported no decrease in quality. Only 11% of conduit patients had unchanged or some coital activity post- operatively, as compared to 35% of bladder substitute patients reporting unchanged or some activity.

36

[58]

Twenty-one men (mean age 59.4 years)

Cystectomy with or without urethrectomy

Interview

All had tactile sexual activity and preserved sexual desire. Around the 12 in whom the urethra was preserved, 4 had full and long lasting erection but of short duration. These 5 patients, all had erections that was satisfactory for vaginal penetration and intercourse and four were unable to achieve an erection. Among those whom the urethra was preserved, all but three could experience orgasm. Among the nine patients treated by cystectomy and urethral excision two reported that they had weak erections insufficient for vaginal penetration and intercourse. The remaining seven failed to achieve erection. Three patients in this group experienced orgasm, one patient with a weak erection and two of the seven patients who could not achieve an erection.

37

[59]

18 pre-menopausal women (mean age of 37.8 years)

Radical cystectomy

Female Sexual Function Index (FSFI) questionnaire

Fifteen patients had an unchanged sexual life, practicing sexual intercourse at a once-weekly average rate with normal orgasms. Three patients complained of dyspareunia that was managed with treatment.