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Simple Cystectomy for Benign Disease

Simple cystectomy is the removal of the bladder without excision of adjacent organs (prostate, seminal vesicles, uterus, vagina, or pelvic lymph nodes), performed exclusively for benign disease and designed to avoid the morbidity of deep pelvic dissection associated with radical cystectomy.[1][2] It is almost always paired with urinary diversion (ileal conduit or continent diversion) and represents a critical distinction from radical cystectomy, which is an oncologic procedure.

Definition and Key Distinction from Radical Cystectomy​

Simple cystectomy removes only the bladder itself, deliberately avoiding dissection of adjacent structures. In contrast, radical cystectomy involves removal of the bladder plus the prostate and seminal vesicles in men, and potentially the uterus, cervix, fallopian tubes, ovaries, and anterior vaginal wall in women, along with bilateral pelvic lymph node dissection.[3][4] Simple cystectomy is not appropriate for malignancy, as it does not address potential extravesical tumor extension or lymph node metastases.

Indications​

Simple cystectomy is reserved for patients with treatment-refractory benign bladder disease who have exhausted all conservative therapies. Common indications:

The AUA guideline on IC/BPS states that major surgery (including cystectomy with or without urinary diversion) may be undertaken in carefully selected patients with bladder-centric symptoms for whom all other therapies have failed; the best predictors of success are Hunner lesions and small bladder capacity under anesthesia.[7] The AUA/SUFU guideline on NLUTD recommends urinary diversion for end-stage bladder dysfunction when all other options have failed, and notes that cystectomy should be considered at the time of diversion given the delayed complication rate of 21–50% for patients with a retained bladder.[10]

Rationale: Why Remove the Bladder at All?​

The primary rationale for performing simple cystectomy at the time of urinary diversion is to prevent complications of the retained defunctionalized bladder:

  • 54–80% of patients with a retained bladder experience complications including pyocystis, hemorrhage, pain, spasms, and rarely secondary urothelial carcinoma.[9][11][12]
  • 20–25% ultimately require a secondary (completion) cystectomy.[2][9][11]
  • In one series, 80% experienced at least one complication, with pyocystis in 67%, hemorrhage in 23%, and 30% requiring reoperation.[12]
  • Another series found 54% had problems with the retained bladder, with 25% requiring cystectomy.[11]

The data are not entirely uniform. One study of 60 patients diverted for intractable incontinence found only a 7% complication rate from the defunctionalized bladder, with no patient requiring secondary cystectomy, suggesting that concomitant cystectomy may not always be necessary.[13]

Surgical Technique​

The technique, as described by Rowley et al. (University of Michigan), emphasizes efficiency and avoidance of deep pelvic dissection:[1]

  1. Mobilization: The bladder is mobilized from its peritoneal attachments. The urachus is divided.
  2. Vascular control: The lateral pedicles are controlled and divided, staying close to the bladder wall to avoid injury to surrounding structures.
  3. Ureter management: The ureters are identified and divided (they will be reimplanted into the diversion conduit).
  4. Bladder excision: The bladder is dissected off the surrounding structures (rectum posteriorly, prostate/vagina inferiorly) without removing these organs. The dissection plane stays on the bladder wall, avoiding deep pelvic dissection.
  5. Urethral division: The urethra is divided and the bladder is removed.
  6. Urinary diversion: An ileal conduit or continent diversion is constructed using a bowel segment.

The simple cystectomy portion alone averages only 27.5–30 minutes of operative time with minimal blood loss (47–300 mL).[1][2] The entire procedure including diversion averages ~318 minutes with total blood loss of ~232 mL.[1]

Robot-assisted approach: A robotic-assisted simple cystectomy technique completes the cystectomy portion in 35–48 minutes with blood loss of ≤10 mL, recapitulating the principles of open surgery with the benefits of minimally invasive technique.[9]

Outcomes​

Symptom resolution​

  • In long-term follow-up (mean 107 months) of 35 patients who underwent cystectomy for BPS, pain persisted in only 5.7% and recurred in 2.8%. Satisfaction with surgery was 8.8/10, and 95.2% would undergo the same surgery again.[14]
  • In a series of 10 women with ulcerative IC who underwent cystectomy with ileal conduit, IC pain resolved in all patients except one, and 8/9 reported moderate/marked improvement in overall symptoms.[15]
  • Resolution of underlying urological pathology was achieved in 73% of patients at 90 days in one series.[8]

Perioperative safety of the cystectomy component​

In the University of Michigan series, no complications were specifically attributed to the simple cystectomy portion of the procedure. All pathology specimens revealed no evidence of malignancy.[1]

Complications​

Despite the relative simplicity of the cystectomy itself, the overall procedure (cystectomy + urinary diversion) carries significant morbidity, largely attributable to the diversion component:

  • Overall complication rate: 57–73% (Clavien-Dindo ≥ II).[5][8][16]
  • Bleeding requiring transfusion: 38.6%.[16]
  • Wound infection: 16.2%.[16]
  • Urinary tract infection: 23%.[8]
  • Respiratory complications: 7.5%.[16]
  • Wound dehiscence: 2.1%.[16]
  • DVT: 2.1%.[16]
  • Renal complications: 2.3%.[16]

On multivariate analysis, diabetes (OR 1.9) and smoking (OR 1.8) were independently associated with increased complication risk.[16] Duration of surgery was the only independent predictor of serious complications in another large series (OR 1.07 per 10-minute increment).[5]

The complication rate for simple cystectomy for benign disease is comparable to radical cystectomy for malignancy (60.4% vs 57.7%, p = 0.3), despite the benign cohort being younger. This reflects the higher comorbidity burden (higher ASA scores, more chronic kidney disease) in the benign disease population.[16]

Simple Cystectomy vs. Supratrigonal Cystectomy​

FeatureSimple CystectomySupratrigonal Cystectomy
Bladder removedEntire bladderDome / body only (trigone preserved)
Adjacent organs removedNoneNone
ReconstructionIleal conduit or continent diversionAugmentation cystoplasty (bowel patch)
Voiding mechanismStoma or catheterizable channelPotential for spontaneous voiding
Primary goalRemove diseased bladder + divert urineIncrease capacity while preserving voiding
Typical indicationsEnd-stage bladder, inability to self-catheterizeRefractory detrusor overactivity, small-capacity IC

References: [1][2][3][4]

Special Considerations by Indication​

  • Neurogenic bladder: Robot-assisted cystectomy with non-continent urinary diversion in NLUTD patients (n=140) showed early complication rates of 41% (72% minor), late complications in 41%, and most patients reported improved quality of life. The main indication was inability to perform intermittent self-catheterization (89%).[6]
  • IC/BPS: Whether cystectomy is necessary at all (vs diversion alone) remains debated. One series of 12 IC/BPS patients found that urinary diversion without cystectomy provided symptomatic cure in all patients, with no persistent symptoms from the retained bladder.[18] The AUA guideline and most experts recommend cystectomy when diversion is performed to prevent long-term retained-bladder complications.[7][10]
  • Radiation cystitis: Patients with radiation-induced fistula have the highest complication rates — 100% experienced a complication within 30 days vs 44% of neurogenic bladder patients (p = 0.03).[8]

Patient Counseling​

  • Simple cystectomy with diversion is irreversible and life-altering.[7]
  • The overall complication rate is high (~60%), comparable to radical cystectomy.[16]
  • Long-term stoma care or catheterizable-channel management will be required.
  • Despite complications, patient satisfaction is generally high (>95% would choose surgery again).[14][15]
  • Surgery should only be performed after exhausting all conservative options, by surgeons experienced in complex reconstruction.[7]

References​

1. Rowley MW, Clemens JQ, Latini JM, Cameron AP. "Simple Cystectomy: Outcomes of a New Operative Technique." Urology. 2011;78(4):942-5. doi:10.1016/j.urology.2011.05.046

2. Neulander EZ, Rivera I, Eisenbrown N, Wajsman Z. "Simple Cystectomy in Patients Requiring Urinary Diversion." The Journal of Urology. 2000;164(4):1169-72.

3. Holzbeierlein J, Bixler BR, Buckley DI, et al. "Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/SUO Guideline (2017; Amended 2020, 2024)." The Journal of Urology. 2024;212(1):3-10. doi:10.1097/JU.0000000000003981

4. Lenis AT, Lec PM, Chamie K, Mshs MD. "Bladder Cancer: A Review." JAMA. 2020;324(19):1980-1991. doi:10.1001/jama.2020.17598

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. Calën L, Mesnard B, Hedhli O, et al. "Robot-Assisted Laparoscopic Cystectomy With Non-Continent Urinary Diversion for Neurogenic Lower Urinary Tract Dysfunction: Midterm Outcomes." Neurourology and Urodynamics. 2023;42(3):586-596. doi:10.1002/nau.25134

7. 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

8. Cohn JA, Large MC, Richards KA, Steinberg GD, Bales GT. "Cystectomy and Urinary Diversion as Management of Treatment-Refractory Benign Disease: The Impact of Preoperative Urological Conditions on Perioperative Outcomes." International Journal of Urology. 2014;21(4):382-6. doi:10.1111/iju.12284

9. Makedon AM, Sadowsky A, Johnson BA, Walker DT, Lloyd GL. "A Novel Technique of Robotic-Assisted Simple Cystectomy During Urinary Diversion for Benign Indications." Urology. 2023;172:234. doi:10.1016/j.urology.2022.11.013

10. 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

11. Fazili T, Bhat TR, Masood S, Palmer JH, Mufti GR. "Fate of the Leftover Bladder After Supravesical Urinary Diversion for Benign Disease." The Journal of Urology. 2006;176(2):620-1. doi:10.1016/j.juro.2006.03.056

12. Eigner EB, Freiha FS. "The Fate of the Remaining Bladder Following Supravesical Diversion." The Journal of Urology. 1990;144(1):31-3. doi:10.1016/s0022-5347(17)39358-8

13. Lawrence A, Hu B, Lee O, Stone A. "Pyocystis After Urinary Diversion for Incontinence — Is a Concomitant Cystectomy Necessary?" Urology. 2013;82(5):1161-5. doi:10.1016/j.urology.2013.06.037

14. Mateu Arrom L, Gutiérrez Ruiz C, Mayordomo Ferrer O, et al. "Long-Term Follow-Up After Cystectomy for Bladder Pain Syndrome: Pain Status, Sexual Function and Quality of Life." World Journal of Urology. 2019;37(8):1597-1603. doi:10.1007/s00345-018-2554-6

15. Peters KM, Jaeger C, Killinger KA, Rosenberg B, Boura JA. "Cystectomy for Ulcerative Interstitial Cystitis: Sequelae and Patients' Perceptions of Improvement." Urology. 2013;82(4):829-33. doi:10.1016/j.urology.2013.06.043

16. Aisen CM, Lipsky MJ, Tran H, Chung DE. "Understanding Simple Cystectomy for Benign Disease: A Unique Patient Cohort With Significant Risks." Urology. 2017;110:239-243. doi:10.1016/j.urology.2017.07.002

17. 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

18. Redmond EJ, Flood HD. "The Role of Reconstructive Surgery in Patients With End-Stage Interstitial Cystitis/Bladder Pain Syndrome: Is Cystectomy Necessary?" International Urogynecology Journal. 2017;28(10):1551-1556. doi:10.1007/s00192-017-3307-6