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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. Record the actual extent of excision rather than assuming that every operation called “simple cystectomy” removes the entire bladder.[1][2][3]

It is generally combined with urinary diversion. Suspected or established malignancy requires an oncologic assessment and an appropriately planned operation; this benign-disease technique is not a substitute for cancer surgery.[4]

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 permits major surgery, including diversion with or without cystectomy, in carefully selected patients with refractory bladder-centric symptoms or an end-stage small fibrotic bladder. Hunner lesions, small anesthetic bladder capacity and fibrosis support a bladder source of pain. Evaluate pelvic-floor, neuropathic and other extravesical pain sources: pain may persist even after bladder removal.[5]
  • Radiation injury or fistula: anticipate scarred planes, poor healing and adjacent-organ involvement. A benign diagnosis does not make the operation low risk. In one small series, all eight patients with radiation-induced fistula had an early complication; this is a selected cohort, not a universal predicted rate.[7]

The 32% spinal-cord-injury and 18% radiation-damage figures in Osborn's report describe its 139-patient cohort; they are not population-wide frequencies of indications.[8]

Whether to retain the bladder​

Balance the immediate risk of excision against later pyocystis, bleeding, pain and further surgery. The evidence is retrospective and strongly dependent on why the bladder was diverted and whether it can drain.

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; the 80% figure is not a general benign-diversion risk
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
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; does not establish safety in an obstructed or severely diseased retained bladder

Sources: [9][10][11]

AUA/SUFU advises considering cystectomy at diversion and specifically emphasizes concurrent excision in male NLUTD patients. IC/BPS guidance allows diversion alone; neither a small successful bladder-retention series nor a high-complication series determines the choice for every patient.[6][5]

Operative approach​

Rowley technique: supratrigonal excision with mucosectomy​

The original authors' accessible ICS methods describe the following sequence. This is a specific technique, rather than a description of 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.

Do not substitute routine urethral division and deep circumferential pelvic dissection for the published Rowley method. Full excision may be chosen for other indications, but 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. These limited observations do not establish an expected operative time or exclude important risks from cystectomy and diversion.[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. 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 diversionRemaining muscle does not mean a functional augmented bladder has been retained
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. Existing studies do not reliably isolate which component caused each complication.

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, not a pooled Clavien grade II-or-higher rate; coding does not establish identical operative technique
Osborn: 139 benign cystectomies/diversions; 74 were supratrigonal79/139 (57%) had Clavien–Dindo grade II or higher complicationsHeterogeneous procedures and indications
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
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; not a comparison proving robotic superiority

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

Aisen found no statistically significant difference from the malignant-disease cohort's complication frequency (60.4% versus 57.7%, p=0.3). This does not prove equivalence, and the groups differed in age, ASA class and kidney disease. Diabetes and smoking were associated with greater adjusted odds of a complication (OR 1.9 and 1.8). In Osborn's series, longer surgery was associated with more serious complications; the association does not prove that shortening an operation alone removes that risk.[14][8]

IC/BPS symptom outcomes​

Patient selection and the actual reconstruction matter more than a single quoted success rate.

  • 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. The 95.2% figure is not the satisfaction rate for all 35 patients or for simple cystectomy alone.[16]
  • Peters: ten women with ulcerative IC underwent nine conduits and one neobladder. Six required further operations. Nine returned surveys; eight of eight answering the overall-symptom question reported moderate/marked improvement, and eight of nine would choose surgery again.[17]
  • Redmond: 12 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. It does not describe 12 independent diversion-only successes or establish that cystectomy is unnecessary for every patient.[18]

Current EAU guidance emphasizes weak comparative evidence and multidisciplinary specialist selection. Surgery can improve symptoms substantially, but no approach guarantees pain relief.[13][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]

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