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Simple Cystectomy for Benign Disease

Simple cystectomy is bladder removal for severe benign disease without planned adjacent-organ resection or lymphadenectomy. The extent of removal varies between techniques. Some remove the bladder to its neck; the Rowley technique preserves trigonal muscle and removes its mucosa.[1][2][3]

It is generally combined with urinary diversion.[4] Suspected or established malignancy requires an oncologic assessment and an appropriately planned operation.[4] A contracted, symptomatic bladder after TURBT or intravesical treatment requires evaluation for persistent or recurrent malignancy before a benign-disease reconstruction. When cystectomy is undertaken for cancer, the operation follows oncologic principles.[19] The need for radical cystectomy in persistent or recurrent NMIBC depends on risk and prior treatment; the 2026 EAU guideline gives a Strong recommendation to offer it to patients with BCG-unresponsive tumors.[22]

Indications and selection​

Consider cystectomy and diversion for severe bladder or outlet disease when less invasive options have failed or are inappropriate. Relevant conditions include NLUTD with unsafe storage or a devastated outlet, refractory hemorrhagic or radiation cystitis, complex fistula, and selected bladder-centric IC/BPS.[2][5][6]

  • NLUTD. AUA/SUFU Statement 54 recommends offering diversion when other options have failed or are inappropriate . Assess hand function, drainage feasibility, social support and the patient's home environment. Consider concomitant cystectomy because a retained bladder can cause later problems; this is not a requirement to attempt every other operation first.[6]
  • IC/BPS. AUA Statement 22 states that major surgery, including diversion with or without cystectomy, may be undertaken in carefully selected patients with bladder-centric symptoms, or an end-stage small fibrotic bladder, after all other therapies have failed . Hunner lesions, small anesthetic bladder capacity and fibrosis support a bladder source of pain. Large capacity under anesthesia is among the AUA features indicating an extravesical pain source and a higher risk of surgical failure.[5] Pelvic-floor, neuropathic and other extravesical pain sources are evaluated before surgery, because pain may persist after bladder removal.[5]
  • Radiation injury or fistula. Anticipate scarred planes, poor healing and adjacent-organ involvement. In a patient with prior prostate radiation, suprapubic pain or difficulty walking should prompt evaluation for a urosymphyseal fistula and pubic osteomyelitis; MRI and possible pubic bone debridement may change the operative plan.[20] In one small, selected series, all eight patients with radiation-induced fistula had an early complication.[7]

Whether to retain the bladder​

Balance the immediate risk of excision against later pyocystis, bleeding, pain and further surgery. The evidence is retrospective and depends on the indication and drainage of the retained bladder.[21] In a 97-patient referral-center comparison, concomitant subtrigonal cystectomy was not associated with higher 30-day cumulative morbidity than diversion alone, including in the previously irradiated subgroup.[21] An older US inpatient study of 15,717 benign-indication ileal conduit records found more coded complications during the index admission with concurrent cystectomy (35.0% versus 30.6%; adjusted OR 1.23, 95% CI 1.03–1.48).[23] Its case mix, cystectomy codes and in-hospital endpoint differ from the referral-center study.[23]

Original cohortRetained-bladder outcomesInterpretation
Eigner: 30 adults with mixed benign and malignant conditions24/30 had a complication; nine required reoperation, including four cystectomiesHistoric heterogeneous cohort[9]
Fazili: 24 patients with varied benign conditions, median follow-up 48 months13/24 had retained-bladder problems and six required cystectomySubstantial risk in this selected series[10]
Lawrence: 60 patients diverted for intractable incontinence, mean follow-up 45 monthsFour had pain or pyocystis; none required secondary bladder surgeryExcluded bladder outlet obstruction and active malignancy; safety in obstructed or severely diseased bladders was not assessed[11]

Sources: [9][10][11]

AUA/SUFU advises considering cystectomy at diversion and specifically emphasizes concurrent excision in male NLUTD patients.[6] IC/BPS guidance allows diversion alone; across four retained-bladder series reviewed by AUA, 16/70 patients (23%) later underwent cystectomy (14 for persistent pain and two for pyocystis), and four of the 14 still reported pain afterward.[6][5] The 2026 EAU guideline reports that complete bladder removal is more likely to improve symptoms than leaving part or all of the bladder in situ; its underlying studies were retrospective, observational, and uncontrolled.[13]

Operative approach​

Rowley technique: supratrigonal excision with mucosectomy​

The original authors' accessible ICS methods describe the following sequence. This is a specific technique and does not describe every benign cystectomy:[3]

  1. Divide and protect the ureters for the planned diversion; mobilize the lateral attachments and pedicles toward the trigone.
  2. Fill the bladder and raise peritoneal flaps off the detrusor for later coverage.
  3. Open and inspect the bladder, then bivalve it and remove the lateral bladder segments, leaving the trigonal muscle. Protect adjacent structures, including the vas deferens in men.
  4. Remove the remaining trigonal mucosa, obtain hemostasis and use the peritoneal flaps to cover the base.
  5. Complete the planned urinary diversion.

The published Rowley method does not include routine urethral division or deep circumferential pelvic dissection. Full excision may be chosen for other indications, and its extent and risk differ. The original authors also described situations in which severe fibrosis or a large fistula could make excision inappropriate.[3]

The published Rowley series included 23 patients with mean follow-up eight months. Cystectomy-only time averaged 27.5 minutes in the 19 cases with recorded times; blood loss averaged 46.7 mL in the 12 with separate measurements. No complication was specifically attributed to that component.[1]

Neulander's earlier series comprised 19 patients, including six undergoing delayed cystectomy after prior diversion; its mean cystectomy-only blood loss was 300 mL.[2] Makedon's robotic report involved only two index patients and demonstrates technical feasibility, without establishing comparative safety or a routine blood-loss target.[2][12]

Distinguish the reconstruction being performed​

OperationWhat is preserved or reconstructed?Practical implication
Total/subtrigonal benign cystectomyBladder removed to its neck; urinary tract reconstructed with a selected diversionDiversion may be a conduit, catheterizable reservoir or, in selected patients, orthotopic substitute
Rowley-type simple cystectomyTrigonal muscle retained after mucosal removal; supravesical diversion—
Supratrigonal cystectomy with augmentationTrigone/outlet retained and bowel used to enlarge the reservoirMay preserve urethral emptying, but catheterization and lifelong reservoir surveillance can still be necessary

The terms overlap across publications. State the excision, mucosal treatment, outlet and diversion explicitly when interpreting outcomes or documenting the operation.[3][13]

Morbidity and outcomes​

Perioperative morbidity​

Cystectomy with diversion for benign disease is a major operation.

Study and populationFindingsLimits
Aisen: 389 benign-diagnosis cystectomies in NSQIP, 2005–2014235/389 (60.4%) had a recorded 30-day complication; 150 (38.6%) received a transfusion within 72 hoursAdministrative definitions; no pooled Clavien grade II-or-higher rate or confirmation of identical operative technique[14]
Osborn: 139 benign cystectomies/diversions; 74 were supratrigonal79/139 (57%) had Clavien–Dindo grade II or higher complicationsHeterogeneous procedures and indications[8]
Cohn: 26 patients with refractory benign disease19/26 had a complication within 30 days, including nine with grade III or higher; 19/26 had resolution of the underlying urological problem at 90 daysSmall selected cohort; complication and symptom-resolution outcomes are distinct[7]
Calën: 140 patients undergoing robotic cystectomy and noncontinent diversion for NLUTD58 had an early complication; three early deaths; 57 had late complications and 27 underwent reintervention; median follow-up 29 monthsSingle-center retrospective study[15]

Sources: [14][8][7][15]

Aisen found no statistically significant difference from the malignant-disease cohort's 30-day complication frequency (60.4% versus 57.7%, p=0.3).[14] A later national inpatient analysis of 26,721 cystectomies, including 1,314 for noncancer diagnoses, found higher adjusted in-hospital genitourinary, infectious and wound complications for neurogenic bladder, radiation cystitis or fistula than for cancer cystectomy; neurogenic bladder had 2.4-fold higher adjusted in-hospital mortality. These diagnosis-specific inpatient endpoints differ from Aisen's 30-day aggregate outcome.[24] Age, ASA class and kidney disease differed. Diabetes and smoking were associated with greater adjusted odds of a complication (OR 1.9 and 1.8).[14] In Osborn's series, longer surgery was associated with more serious complications; an effect of shortening surgery was not tested.[14][8]

IC/BPS symptom outcomes​

  • Mateu Arrom. Of 35 patients, 29 underwent supratrigonal cystectomy with enterocystoplasty and six underwent cystectomy with ileal conduit. Pain persisted in two and recurred in one over mean 107-month follow-up. Only 21 completed questionnaires; 20/21 would choose the surgery again.[16]
  • Peters. Ten women with ulcerative IC underwent nine conduits and one neobladder. Four required perioperative transfusion, and six required at least one further operation over mean 3.9-year follow-up. Nine returned surveys; eight of eight answering the overall-symptom question reported moderate or marked improvement, and eight of nine would choose surgery again.[17]
  • Redmond. Twelve patients underwent nine diversions without cystectomy and four augmentations, with one patient progressing from augmentation to diversion. The report found no persistent retained-bladder symptoms after diversion.[18]

The 2026 EAU guideline gives a Strong recommendation to reserve ablative or reconstructive surgery for the last resort and to have it performed by surgeons experienced in primary bladder pain syndrome after multidisciplinary assessment that includes pain management.[13] Across 11 observational series of supratrigonal cystectomy with augmentation, the AUA review found treatment failure in 39/170 patients (23%); 27 underwent secondary cystectomy and diversion for persistent pain.[5]

Counseling and long-term care​

Discuss the irreversible change in urinary drainage, potential persistent pain, bowel and stoma complications, need for catheterization where relevant, sexual and reproductive goals, and the possibility of further surgery. Use outcomes from a population and procedure reasonably similar to the patient's situation, alongside local surgical results.[5][6][13]

Plan lifelong follow-up appropriate to the chosen diversion. If bladder tissue is retained, document the extent and drainage route and provide a plan for new pain, bleeding or infection.[6]

Videos​

Single-Port Robotic Cystectomy for Radiation Complications with Intracorporeal Ileal Conduit
Lee C. Zhao, MD (full length, uncut)

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. doi:10.1016/S0022-5347(05)67134-0

3. Rowley M, Clemens JQ, Cameron AP. "Simple Cystectomy: Outcomes of a New Operative Technique." ICS/IUGA 2010, abstract 717. Original methods and figures. Earlier 17-patient conference report; the later journal series included 23 patients.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. European Association of Urology. EAU Guidelines on Chronic Pelvic Pain. 2026. Management, section 5.3.3: major surgery for primary bladder pain syndrome. Guideline.

14. 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

15. 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

16. 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

17. 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

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

19. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Bladder Cancer. Version 3.2026. August 6, 2026. BL-B 2 of 4. Guideline.

20. Patel N, Mehawed G, Dunglison N, et al. "Uro-symphyseal Fistula: A Systematic Review to Inform a Contemporary, Evidence-based Management Framework." Urology. 2023;178:1-8. doi:10.1016/j.urology.2023.05.002

21. Vetterlein MW, Buhné MJ, Yu H, et al. "Urinary Diversion With or Without Concomitant Cystectomy for Benign Conditions: A Comparative Morbidity Assessment According to the Updated European Association of Urology Guidelines on Reporting and Grading of Complications." Eur Urol Focus. 2022;8(6):1831-1839. doi:10.1016/j.euf.2022.02.008

22. European Association of Urology. "EAU Guidelines on Non-muscle-invasive Bladder Cancer." 2026. Disease management.

23. Brown ET, Osborn D, Mock S, et al. "Perioperative complications of conduit urinary diversion with concomitant cystectomy for benign indications: A population-based analysis." Neurourol Urodyn. 2017;36(5):1411-1416. doi:10.1002/nau.23135

24. Rodriguez Peñaranda N, de Angelis M, Siech C, et al. "Perioperative Complications and In-hospital Mortality After Cystectomy for Nonbladder Cancer Conditions Versus Radical Cystectomy for Bladder Cancer." Ann Surg Oncol. 2025;32(9):6954-6961. doi:10.1245/s10434-025-17456-w