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Supratrigonal Cystectomy with Augmentation Cystoplasty

Supratrigonal cystectomy is a subtotal bladder resection in which the bladder body (dome and lateral walls) is excised above the level of the trigone, preserving the trigone, ureteral orifices, and bladder neck. It is almost always combined with augmentation cystoplasty using a bowel segment to reconstruct a larger, more compliant reservoir. This procedure is distinct from radical cystectomy, which removes the entire bladder and is used for malignancy.

Definition and Anatomy​

The resection line is placed directly above the ureteral orifices, removing the diseased supratrigonal bladder while leaving the trigone intact.[1] Preserving the trigone usually allows the native ureterovesical junctions to remain intact and may preserve spontaneous voiding. It does not guarantee avoidance of ureteral reimplantation, reflux, obstruction or catheterization; two patients in the long-term IC/BPS cohort underwent concomitant unilateral reimplantation.[1][2][7]

Indications​

Supratrigonal cystectomy with augmentation cystoplasty is reserved for patients who have failed all conservative and less invasive therapies. Two primary indications:

  • Interstitial cystitis / bladder pain syndrome (IC/BPS): Particularly the classic / ulcerative (Hunner lesion) subtype with reduced bladder capacity refractory to conservative treatment. The AUA guideline on IC/BPS states that major surgery (substitution cystoplasty, urinary diversion with or without cystectomy) may be undertaken in carefully selected patients with bladder-centric symptoms for whom all other therapies have failed. The best-documented predictors of success are the presence of Hunner lesions and small bladder capacity under anesthesia.[3]
  • Neurogenic lower urinary tract dysfunction (NLUTD): Refractory neurogenic detrusor overactivity and/or poor bladder compliance, including spinal cord injury (SCI). Supratrigonal resection is particularly relevant to a severely thick, fibrotic bladder wall; it is not mandatory for every augmentation. The AUA/SUFU guideline recommends augmentation cystoplasty for select NLUTD patients refractory to or intolerant of less invasive therapies; EAU identifies the severely fibrotic bladder as an indication for supratrigonal resection.[4][16]

Other benign indications include radiation cystitis and other causes of end-stage small fibrotic bladder.[5]

Surgical Technique​

The procedure has two main components:

  1. Supratrigonal resection: The bladder is mobilized and the dome/body is excised circumferentially just above the ureteral orifices, leaving the trigone as a cuff.[1]
  2. Augmentation cystoplasty: A detubularized segment of bowel is anastomosed to the remaining trigonal remnant to create a low-pressure, high-capacity reservoir. Common bowel segments:
    • Ileum (ileocystoplasty) — the most commonly used segment.[6]
    • Ileocecum (ileocecal augmentation, e.g., Mainz pouch I) — small nonrandomized cohorts suggest better voluntary emptying in some patients; a reduction in catheterization has not been established as a general segment advantage.[1][7]
    • Hautmann pouch (ileal neobladder configuration) — used particularly in SCI patients.[2]

Surgical approaches​

  • Open surgery — the traditional approach.[1][7]
  • Robot-assisted laparoscopic — increasingly reported with favorable perioperative outcomes. A preliminary 10-patient totally intracorporeal RASCAC series reported median operative time 250 minutes, EBL 75 mL and hospitalization 12 days; one patient had a 30-day major complication and two developed late fistulas. A 19-patient combined robotic and mini-laparotomy series described operative-time improvement after about five cases among experienced robotic surgeons. These are feasibility observations, not a validated training threshold or comparative proof of safety.[8][9]

Supratrigonal vs. Subtrigonal Cystectomy​

A retrospective comparison included only 6 supratrigonal and 17 subtrigonal patients, with unequal mean follow-up (31.5 versus 93.9 months). All six supratrigonal patients voided spontaneously; 41% of the subtrigonal group required self-catheterization. The study suggests a possible functional advantage but cannot establish equivalence in pain relief or attribute catheterization causally to ureteral reimplantation.[1] Subtrigonal cystectomy removes the trigone and requires ureteral reimplantation into the bowel segment.

Outcomes​

IC/BPS​

  • In a 27-woman cohort, 26 had postoperative outcome data at median 171 months. 22/23 questionnaire respondents reported being much or very much better; patients with early diversion were not included in that satisfaction assessment. Persistent symptoms led to early diversion in 2/26 and late relapse occurred in 5/26, all of whom required ISC. The satisfaction percentage is not an overall surgical success rate.[7]
  • Classic / ulcerative IC responds significantly better than nonulcer disease. In one series, all 10 patients with classic IC had symptom relief, while all 3 with nonulcer IC had persistent pain.[10]
  • A Korean series of 40 patients with Hunner-lesion IC/BPS showed significant decreases in pain (8.3 → 1.3), frequency, urgency, and nocturia, with significant increases in bladder capacity.[11]

Neurogenic bladder​

  • In SCI patients, a large series (n=77) demonstrated a long-term urodynamic success rate of 93.5% and continence improvement in 76.6% at a median 13 years post-surgery. Bladder lithiasis occurred in 20.5%, and at least one febrile UTI in 55.8% (mostly within the first 2 years). No bladder cancer was diagnosed.[12]
  • Another SCI series (n=61) using the Hautmann pouch showed improved or total continence in 89.7% and 74.1%, respectively, with significant improvements in maximum cystometric capacity (305 → 509 mL), compliance (15 → 42.7 mL/cmH₂O), and detrusor pressure at capacity (54.1 → 19.1 cmH₂O).[2]
  • In a spinal cord injury rehabilitation cohort (n=29), continence improved from 7% to 69%, bladder capacity increased from 240 to 500 mL, and compliance from 13 to 50 mL/cmH₂O.[13]

Complications​

Complications can require further surgery and occasionally be life-threatening. The following observations come from different populations and follow-up periods and should not be pooled:

  • Need for catheterization: Depends on baseline neurologic function, outlet procedures and reconstruction. In the long-term IC/BPS study, 8/26 performed ISC and one had long-term suprapubic drainage; the 41% estimate from Linn concerns subtrigonal reconstruction. These are not universal supratrigonal rates.[1][7]
  • Urinary tract infections / pyelonephritis: 21–56%.[9][12]
  • Bladder stones: 20.5–36.4% in long-term follow-up.[12][14]
  • Bowel dysfunction (diarrhea, fecal incontinence): ~27.5%.[2]
  • Hyperchloremic metabolic acidosis from bowel-segment absorption.[6][13]
  • Urinary fistula: Reported in robot-assisted series, associated with poor ISC compliance.[8]
  • Vesicoureteral reflux: ~17.5% in one IC/BPS series.[11]
  • Paralytic / obstructive ileus: Early postoperative complication.[13]
  • Bladder perforation: Rare but life-threatening.[6][14]
  • Malignancy risk: Malignancy after enterocystoplasty is documented in the broader augmentation literature. No cancers in these two small cohorts does not establish absence of risk; surveillance decisions follow the augmentation guidance.[6][12][14]
  • Vitamin B₁₂ deficiency: Possible with ileal segment use, requiring long-term monitoring.[15]

For separate context, a mixed series of cystectomy with urinary diversion for benign disease (n=139, 53% supratrigonal resection) reported that 57% had Clavien-Dindo grade ≥ II complications — most commonly transfusion, prolonged ileus, and pyelonephritis. Duration of surgery was the only independent predictor of serious complications.[5]

Patient Selection​

  • Select for a bladder source of pain: Historical small cohorts reported better outcomes with Hunner-lesion disease, but AUA does not require Hunner lesions for all major surgery. Carefully selected bladder-centric disease or an end-stage small fibrotic bladder may qualify after other feasible treatments fail. Reassess pelvic-floor and other extravesical pain sources; more extensive resection does not guarantee pain relief in non-Hunner disease.[3][10]
  • Surgery should be performed only by surgeons with extensive experience in IC/BPS or neurogenic bladder, with dedication to long-term follow-up.[3]
  • Patients must be counseled about the potential need for lifelong ISC, metabolic monitoring, and the possibility of persistent or recurrent symptoms.

Long-Term Follow-Up​

  • Maintain lifelong follow-up. For NLUTD with bowel reconstruction, AUA recommends annual history/examination, a basic metabolic panel and urinary-tract imaging; monitor B₁₂ over time when terminal ileum is used.[4][15]
  • Repeat urodynamics according to risk and clinical change. One stable SCI cohort questioned routine repeated testing; this does not override surveillance in high-risk patients or replace reassessment for new incontinence, infection, upper-tract change or impaired emptying.[4][12]
  • Investigate gross hematuria, recurrent symptomatic UTI or unexplained suprapubic pain promptly. Routine annual cystoscopy in an asymptomatic augmented NLUTD patient is not supported by AUA; symptom-directed investigation is essential.[4]

References​

1. Linn JF, Hohenfellner M, Roth S, et al. "Treatment of Interstitial Cystitis: Comparison of Subtrigonal and Supratrigonal Cystectomy Combined With Orthotopic Bladder Substitution." The Journal of Urology. 1998;159(3):774-8. doi:10.1016/s0022-5347(01)63726-1

2. Gobeaux N, Yates DR, Denys P, et al. "Supratrigonal Cystectomy With Hautmann Pouch as Treatment for Neurogenic Bladder in Spinal Cord Injury Patients: Long-Term Functional Results." Neurourology and Urodynamics. 2012;31(5):672-6. doi:10.1002/nau.21239

3. Clemens JQ, Erickson DR, Varela NP, Lai HH. "Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome." The Journal of Urology. 2022;208(1):34-42. doi:10.1097/JU.0000000000002756

4. Ginsberg DA, Boone TB, Cameron AP, et al. "The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-Up." The Journal of Urology. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239

5. Osborn DJ, Dmochowski RR, Kaufman MR, et al. "Cystectomy With Urinary Diversion for Benign Disease: Indications and Outcomes." Urology. 2014;83(6):1433-7. doi:10.1016/j.urology.2014.02.030

6. Cheng PJ, Myers JB. "Augmentation Cystoplasty in the Patient With Neurogenic Bladder." World Journal of Urology. 2020;38(12):3035-3046. doi:10.1007/s00345-019-02919-z

7. Queissert F, Bruecher B, van Ophoven A, Schrader AJ. "Supratrigonal Cystectomy and Augmentation Cystoplasty With Ileum or Ileocecum in the Treatment of Ulcerative Interstitial Cystitis/Bladder Pain Syndrome: A 14-Year Follow-Up." International Urogynecology Journal. 2022;33(5):1267-1272. doi:10.1007/s00192-022-05110-y

8. Grilo N, Chartier-Kastler E, Grande P, et al. "Robot-Assisted Supratrigonal Cystectomy and Augmentation Cystoplasty With Totally Intracorporeal Reconstruction in Neurourological Patients: Technique Description and Preliminary Results." European Urology. 2021;79(6):858-865. doi:10.1016/j.eururo.2020.08.005

9. Madec FX, Hedhli O, Perrouin-Verbe MA, et al. "Feasibility, Morbidity, and Functional Results of Supratrigonal Cystectomy With Augmentation Ileocystoplasty by Combined Robot-Assisted Laparoscopy and Mini-Laparotomy Approach." Journal of Endourology. 2017;31(7):655-660. doi:10.1089/end.2017.0107

10. Peeker R, Aldenborg F, Fall M. "The Treatment of Interstitial Cystitis With Supratrigonal Cystectomy and Ileocystoplasty: Difference in Outcome Between Classic and Nonulcer Disease." The Journal of Urology. 1998;159(5):1479-82. doi:10.1097/00005392-199805000-00018

11. Kim HJ, Lee JS, Cho WJ, et al. "Efficacy and Safety of Augmentation Ileocystoplasty Combined With Supratrigonal Cystectomy for the Treatment of Refractory Bladder Pain Syndrome/Interstitial Cystitis With Hunner's Lesion." International Journal of Urology. 2014;21 Suppl 1:69-73. doi:10.1111/iju.12320

12. Balanca A, Even A, Malot C, et al. "Long-Term Clinical and Urodynamic Effectiveness of Augmentation Ileocystoplasty With Supra-Trigonal Cystectomy in Individuals With Spinal Cord Injury." World Journal of Urology. 2022;40(8):2121-2127. doi:10.1007/s00345-022-04028-w

13. Krebs J, Bartel P, Pannek J. "Functional Outcome of Supratrigonal Cystectomy and Augmentation Ileocystoplasty in Adult Patients With Refractory Neurogenic Lower Urinary Tract Dysfunction." Neurourology and Urodynamics. 2016;35(2):260-6. doi:10.1002/nau.22709

14. Chang JW, Kuo FC, Lin TC, et al. "Long-Term Complications and Outcomes of Augmentation Cystoplasty in Children With Neurogenic Bladder." Scientific Reports. 2024;14(1):4214. doi:10.1038/s41598-024-54431-z

15. Reddy M, Kader K. "Follow-Up Management Of Cystectomy Patients." The Urologic Clinics of North America. 2018;45(2):241-247. doi:10.1016/j.ucl.2018.01.001

16. EAU. Neuro-urology Guidelines. 2026. Bladder augmentation and follow-up. Guideline.