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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] By preserving the trigone, the procedure avoids the need for ureteral reimplantation and maintains the native uretero-vesical junction, which reduces the risk of upper tract complications and preserves the potential for spontaneous voiding.[1][2]

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, most commonly in spinal cord injury (SCI) patients. The AUA/SUFU guideline recommends augmentation cystoplasty for select NLUTD patients refractory to or intolerant of less invasive therapies.[4]

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) — may reduce the need for intermittent self-catheterization (ISC) compared to ileum alone.[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. Totally intracorporeal robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RASCAC) is feasible and safe, with median operative time ~250 minutes, EBL ~75 mL, and hospitalization ~12 days. A combined robot-assisted laparoscopy and mini-laparotomy approach has also been described, with a learning curve of approximately five operations.[8][9]

Supratrigonal vs. Subtrigonal Cystectomy​

A key comparative study found that both approaches provide similar symptom relief in IC, but supratrigonal cystectomy offers better functional bladder rehabilitation: all supratrigonal patients voided spontaneously, whereas 41% of subtrigonal patients required self-catheterization due to the need for ureteral reimplantation and more extensive dissection.[1] Subtrigonal cystectomy removes the trigone and requires ureteral reimplantation into the bowel segment.

Outcomes​

IC/BPS​

  • In a 14-year follow-up study (median 171 months), 95.6% of patients reported being "very much better" or "much better" on the PGI-I scale. Persistent pain requiring early revision occurred in 7.7%. Late relapse of ulcerative IC/BPS occurred in 19.2%, and all relapsing patients required ISC.[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 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 are common but generally manageable:

  • Need for intermittent self-catheterization (ISC): 32–41% depending on augmentation material and technique. Ileocecal augmentation may reduce this rate.[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: Theoretical long-term risk at the bowel-bladder anastomosis, though no cases were identified in long-term series.[12][14]
  • Vitamin B₁₂ deficiency: Possible with ileal segment use, requiring long-term monitoring.[15]

In a large series of cystectomy for benign disease (n=139, 53% supratrigonal), 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​

  • IC/BPS subtype matters critically: Supratrigonal cystectomy with augmentation is effective for classic / ulcerative (Hunner lesion) IC but appears unsuitable for nonulcer disease, where trigonal resection and urinary diversion may be needed instead.[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​

  • Regular urodynamic assessment may not be necessary in clinically stable patients with low bladder risk, though close monitoring for urological complications is important.[12]
  • Monitor for metabolic acidosis, B₁₂ deficiency, renal function, and bladder stones.
  • Surveillance for malignancy at the bowel-bladder junction (risk appears very low).

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