Cystectomy

Radical cystectomy with bilateral pelvic lymphadenectomy is the standard surgical treatment for muscle-invasive and BCG-unresponsive high-risk non-muscle-invasive bladder cancer. It removes the bladder together with the adjacent organs most likely to harbour extravesical tumour, and is paired with a urinary diversion. Lymph node status is the single most powerful predictor of long-term outcome.

Radical vs Simple Cystectomy

• Simple cystectomy removes the bladder only.
• Radical cystectomy removes the bladder plus perivesical soft tissue and the organs at highest risk of harbouring tumour extending beyond the bladder:
  • Males — prostate and seminal vesicles. A nerve-sparing procedure can be safely offered to selected patients wishing to preserve sexual function.
  • Females — ovaries, fallopian tubes, uterus with cervix, and anterior vagina.

Female organ-sparing cystectomy preserves the uterus, ovaries, and/or vagina. It is an option in selected females with early-stage disease who wish to preserve sexual and/or reproductive function.

Pelvic Lymph Node Dissection

About 25% of patients have pathologic lymph node metastases at cystectomy, and lymph node status is the most powerful surrogate for long-term recurrence-free and overall survival.

Lymphatic drainage of the bladder:

• Primary sites (4): obturator, internal iliac, external iliac, and presacral nodes.
• Secondary sites: common iliac, para-aortic, interaortocaval, and paracaval nodes.

Indication — bilateral pelvic lymph node dissection is performed at any surgery with curative intent (2020 AUA MIBC; absolute).

Template — at minimum, remove the bilateral obturator, internal iliac, and external iliac nodes. Boundaries of the standard dissection:

Boundary	Limit
Superior	Ureter / bifurcation of the common iliac artery
Inferior	Circumflex iliac vein and Cloquet's node / Cooper's ligament at the femoral canal
Lateral	Genitofemoral nerve
Medial	Bladder and internal iliac artery
Posterior	Obturator nerve / fossa

Extended dissection — many retrospective studies suggested a survival benefit from extending boundaries as high as the inferior mesenteric artery, but randomized trials (SWOG S1011 and LEA AUO AB 25/02) showed no significant benefit over a standard template (see the Muscle-Invasive Bladder Cancer tab).

Node count — a standard lymphadenectomy with >12 nodes evaluated is needed for adequate staging (AUA MIBC); observational data support removing >10. The absolute number of nodes removed carries prognostic information and improves staging accuracy in both node-positive and node-negative patients.

Approach

Open and laparoscopic/robotic approaches are both acceptable, with comparable cancer outcomes.

• RAZOR (Parekh 2018, Lancet) — n=360 with cT1–T4 N0–N1 M0 bladder cancer or refractory CIS, randomized to robotic vs open radical cystectomy. Robotic cystectomy was non-inferior to open for 2-year progression-free survival (similar at 3 years). Adverse events (67% vs 69%) and postoperative ileus (22% vs 20%) did not differ significantly.

Preoperative Preparation

• Prostate cancer screening (DRE and PSA) — if there is concern for prostate cancer, plan for complete oncologic removal of the prostate at cystectomy.
• Stoma site marking — mark the ostomy site carefully in both standing and seated positions to maximize appliance fit and minimize stomal irritation. Patients planned for a continent diversion should be counselled about the rare possibility of receiving an ileal conduit instead.
• Bowel preparation — based on colorectal data, routine bowel prep is not recommended, especially when only ileal segments are used.
• Antibiotic prophylaxis — cover both gram-positive skin flora and gram-negative aerobes/anaerobes of the distal small and large bowel. The 2019 AUA Best Practice recommends a single dose of cefazolin within 1 hour of incision; a population study (n=8,351, 353 hospitals) found a penicillin/beta-lactamase-inhibitor regimen (e.g. piperacillin-tazobactam, ampicillin-sulbactam) reduced infectious events and length of stay compared with cefazolin alone.
• Thromboembolic prophylaxis — both mechanical (stockings, pneumatic compression) and pharmacologic prophylaxis before induction of anesthesia.
• Alvimopan (μ-opioid receptor antagonist) — accelerates GI recovery. In a multicenter RCT (Lee 2014, European Urology; n=277, alvimopan vs placebo), alvimopan gave quicker lower-GI recovery, reduced length of stay, and fewer episodes of ileus-related morbidity. Contraindicated in patients who have taken therapeutic-dose opioids for >7 consecutive days immediately before starting it.
• Tranexamic acid infusion — may reduce transfusion risk without increasing venous thromboembolism.

Surgical Technique

Mean operative time is ~6.5 hours.

Positioning and Preparation

• Open radical cystectomy — males supine with the anterior superior iliac spine at or just below the table's flexion point; females in low lithotomy (stirrups or spreader bars) for vaginal access. Table flexion is generally not possible in females.
• Prepare the abdomen from the xiphoid to the upper thighs, and prepare the genital organs (including the vagina in women) and perineum.
• Incision — lower midline, from the symphysis pubis to the umbilicus.

Male Radical Cystectomy

1. Enter the space of Retzius — divide the fascia in the midline (upward retraction of the umbilicus aids identification of the linea alba).
2. Mobilize the bladder off the pelvic sidewall anteriorly and bilaterally by blunt dissection, up to the vas deferens.
3. Make a peritonotomy lateral to either medial umbilical ligament; ligate and divide the urachus.
4. Extend the peritoneal incision lateral to the medial umbilical ligaments to the internal inguinal rings, identifying and dividing the vas deferens.
5. Place a self-retaining retractor (e.g. Bookwalter), retracting bowel cephalad. Confirm with anesthesia that the vena cava is not compressed; protect abdominal contents with moistened laparotomy pads behind the blades.
6. Identify and dissect the ureters from a few cm above the iliac crossing to the detrusor hiatus, preserving adequate adventitia. Ligate and divide the superior vesical artery before completing ureteral dissection to maximize ureteral length, then control and divide the ureter. Send the distal ureteral margin for frozen section (ureteral-margin carcinoma correlates with upper-tract recurrence, though a survival impact is not well established).
7. Ligate the lateral vascular pedicles. When using sealing instruments, shield the rectum from the instrument tips with a gloved finger, as transmitted heat can injure it.
8. Posterior dissection — incise the peritoneum over the seminal vesicles at the rectal cul-de-sac; dissect the rectum free to the level of the prostate, where Denonvilliers' fascia is incised.
9. Anterior dissection (analogous to radical prostatectomy) — incise the endopelvic fascia over the levators, ligate and divide the dorsal venous complex, and incise the anterior urethra. If a continent ileal neobladder is planned, maintain adequate urethral length and send a frozen urethral margin — an orthotopic neobladder is contraindicated with a positive urethral margin because of urethral-recurrence risk.

Nerve-sparing — unlike radical prostatectomy, neurovascular bundle preservation in cystectomy remains controversial; an analogous technique can be used but functional outcomes are significantly worse than after radical prostatectomy.

Female Radical Cystectomy

The initial anterior bladder mobilization and ureteral dissection mirror the male steps, except that the ovarian (gonadal) vessels are identified, ligated, and divided.

• Anterior pelvic exenteration begins by identifying the posterior cervical fornix and incising the vaginal cuff. After entering the vaginal canal, control the lateral and posterior vascular pedicles; the specimen (bladder, uterus, cervix, anterior vaginal cuff) is freed and the urethral meatus incised (antegrade from the pelvis or externally from the introitus). Preserve sufficient vaginal mucosa above the meatus for later closure.
• Orthotopic neobladder option — historically the female operation was a total anterior exenteration, but with no bladder-neck involvement and low-stage disease (≤cT2) an orthotopic neobladder can be considered, requiring urethral sparing with adequate length proximal to the striated sphincter and anterior vaginal-wall sparing for neobladder support. A frozen urethral margin is sent and, as in males, a positive margin contraindicates orthotopic diversion.
• Hemostasis — the female pelvis is vascular; separate the lateral pedicles from the lateral vaginal wall before ligation (vaginal packing helps define the plane). Do not divide the vessels until the midpoint of the lateral vaginal wall is reached, to keep an adequate bladder margin; carry dissection to the bladder neck (identified by the Foley balloon).
• Vaginal closure — release the posterior vaginal wall from the rectum and close the posterior flap to the introital mucosa in a clamshell fashion (2-0 polyglactin), maintaining girth at the cost of some length. Use a watertight interrupted closure to avoid peritoneal-fluid drainage. Place a vaginal packing to distend the vagina and tamponade residual hemorrhage; remove it within two postoperative days.

Intraoperative Decision-Making

• Clinical T4b — biopsy to confirm histology; if positive for urothelial carcinoma, start chemotherapy followed by consideration of radical cystectomy.
• Grossly positive nodes — take a frozen section; if metastasis is confirmed, complete radical cystectomy with extended lymph node dissection when feasible.
• Do not perform cystectomy when lymph node metastases are unresectable (bulk), there is extensive periureteral disease, or the bladder is fixed to the pelvic sidewall.
• Intraoperative ureteral tumour — a papillary lesion at the ureteral margin requires on-table flexible ureteroscopy to map the system. CIS or dysplasia alone does not warrant endoscopy (visual identification is unlikely). If ureteroscopy shows no additional tumours, resect to negative margins; nephroureterectomy or extensive ureteral resection is reserved for more proximal tumours.
• Frozen sections of the ureter — the distal ureter is involved on final pathology in ~6–8% of cystectomies. Routine intraoperative frozen analysis is controversial: ureteral disease increases upper-tract recurrence regardless of margin status, but the risk is partly mitigated by a negative margin. Final ureteral margin is an independent predictor of upper-tract recurrence, though overall upper-tract recurrence is rare (2–8%). Risk factors: bladder CIS, distal ureteral tumour involvement, and high-grade pTa–T1 disease. There is no definitive recommendation for how much distal ureter to remove.

Urethrectomy

Urethral Recurrence — Males

Overall risk of urethral recurrence after cystectomy is ~7% at 5 years and 9% at 10 years, at a median of 2 years (range 0.2–13 years).

• Prostatic urethral involvement is the key risk factor — absolute risk increase ~6% at 5 years (11% with any prostate involvement vs 5% without). The extent of involvement correlates with recurrence: 5-year risk ~18% with pT2 stromal invasion vs ~12% with CIS or pT1 (mucosal/ductal) involvement. Isolated prostatic stromal involvement is unusual without nodal disease. Patients with prostatic stromal invasion are generally counselled to undergo neoadjuvant chemotherapy; if not a candidate or with persistent involvement, concomitant urethrectomy and a cutaneous diversion are recommended.
• Mixed-evidence factors: papillary tumours, multifocality, trigone or bladder-neck involvement, and CIS.
• The presence of bladder CIS or a multifocal tumour should not preclude orthotopic diversion, and some evidence suggests orthotopic diversion may itself protect against urethral recurrence. Close urethral surveillance (periodic urethral wash cytology and urethroscopy as indicated) is mandatory after a neobladder.

Urethral Involvement — Females

Risk factors for urethral involvement (3):

• Tumour involving the bladder neck — in one study ~50% of women with bladder-neck tumours still had a tumour-free proximal urethra, and no woman with a normal bladder neck had urethral involvement; intraoperative frozen section reliably predicted the final urethral margin.
• Tumour invading the anterior vaginal wall — best assessed on bimanual examination under anesthesia at TURBT or cystectomy. Anterior vaginal-wall involvement (or bladder-neck/urethral involvement) contraindicates urethra sparing and orthotopic replacement, as an adequate distal vaginal and urethral margin cannot be obtained.
• Inguinal lymphadenopathy.

Indications for Urethrectomy

Source	Indications
2020 AUA MIBC	Males with invasive cancer at the apical urethral margin; all females not receiving a neobladder (to reduce positive-margin/recurrence risk)
2019 CUA MIBC	Positive urethral margin; males with high-grade or invasive urethral disease distal to the prostatic urethra, or suspected prostatic stromal involvement; females with bladder-neck tumours (CUA does not include anterior vaginal-wall involvement)
Campbell's — males	Absolute: positive urethral margin (a positive frozen contraindicates a neobladder — convert to cutaneous diversion with immediate urethrectomy); CIS or urothelial carcinoma in the prostatic urethra, glands, or stroma. Relative: any non-orthotopic diversion, since urethral-recurrence risk always persists
Campbell's — females	Complete urethrectomy can be omitted unless indicated (allowing orthotopic substitution). Absolute: positive urethral margin (frozen analysis correlates well and should be done in all neobladder candidates); tumour at the bladder neck (~60% will not have urethral tumour on final pathology, so controversy exists); T4 tumours involving the urethra and/or vagina

Preoperative transurethral prostatic biopsy (preferably at the 5- and 7-o'clock positions lateral to the verumontanum at TURBT) can help characterize urethral-recurrence risk and guide diversion choice, but has only moderate sensitivity/specificity and a relatively low positive predictive value versus the final cystoprostatectomy specimen.

Approach — urethrectomy is ideally performed through a prepubic approach.

Delayed urethrectomy — absolute indications (3): urethral wash cytology becomes positive; the patient develops a bloody discharge; or local recurrence is clinically obvious in the perineum or penis.

Partial Cystectomy

For solitary, small lesions without concurrent CIS, partial cystectomy gives results similar to radical cystectomy, and patients can be salvaged with radical cystectomy if needed.

Source	Selection criteria
2020 AUA MIBC (cisplatin-eligible; with bilateral PLND + perioperative chemotherapy)	Accessible tumour location; size <3 cm; no multifocal CIS; no hydronephrosis; adequate bladder function; no residual T1-or-higher disease
2019 CUA MIBC	Dome location; unifocal; small tumour <2 cm; minimal or no CIS; no hydronephrosis; good bladder capacity

Technique — offer perioperative chemotherapy to cisplatin-eligible patients, and perform pelvic lymph node dissection at the time of partial cystectomy. Random bladder biopsies (plus a prostatic urethral biopsy) are taken beforehand to rule out occult CIS. Make the cystotomy away from the tumour, then excise the tumour with the full-thickness bladder wall and perivesical fat with a 1–2 cm mucosal margin, confirming adequacy by frozen section (the ureteral orifice or intramural ureter can be excised and reimplanted if needed). Close the cystotomy in 2–3 layers with 2-0 polyglactin and confirm a watertight closure. Irrigate the field copiously with warm water to minimize pelvic seeding, place a closed-suction drain, and interrogate the closure with a cystogram on postoperative day 7 before removing the Foley.

Urachal Adenocarcinoma

A rare primary adenocarcinoma arising from the urachus, most commonly confined to the bladder dome but able to extend by direct growth. Complete excision includes the umbilicus, the urachus, and the dome of the bladder with a visual tumour-free margin.

Complications

Intraoperative

• Risks of general anesthesia (stroke, myocardial infarction, thrombosis).
• Injury to an adjacent organ (nerves, bowel, rectum).
• Bleeding ± transfusion.

Early Postoperative

Category	Rate	Components
Gastrointestinal	29%	Ileus 16%, small bowel obstruction 5%, constipation 3%, C. difficile colitis 2%, anastomotic bowel leak 1%
Infection	26%	UTI/pyelonephritis 14%, sepsis 4%, pelvic/intra-abdominal abscess 2.4%
Ureteric anastomotic leak	3%	—
Wound	13%	Infection 10%, dehiscence 4%, fascial dehiscence 1.6%

Inpatient mortality is ~2.4% (range 0.9–4.7%) and 90-day mortality ~4.7% (range 0.0–7.0%). Mortality is typically <5% overall but rises substantially with age — 90-day mortality exceeds 10% in patients >75 years and approaches 20% in octogenarians.

Late Postoperative

• Failure to cure; metabolic consequences of diversion; ureteral stricture; hernia; erectile dysfunction; infection.

Postoperative Care

Extended (4-week) venous thromboembolism prophylaxis should be considered in all radical cystectomy cases. Symptomatic VTE occurs in 3–12% in short-term follow-up, and >50% of cases occur after discharge. Extended prophylaxis decreases VTE risk in major abdominal oncologic surgery; although bleeding risk rises slightly, the net benefit clearly favours at least 28 days. Extrarenally-eliminated agents are preferred given the risk of renal insufficiency after cystectomy, with newer oral anticoagulants offering an alternative route (Klaassen 2018).

Self-Test

1. What organs are removed at the time of radical cystectomy? The bladder with perivesical soft tissue. In males, also the prostate and seminal vesicles; in females, also the ovaries, fallopian tubes, uterus with cervix, and anterior vagina (organ-sparing variants exist for selected patients).

2. What are the primary lymphatic drainage sites in bladder cancer? Obturator, internal iliac, external iliac, and presacral nodes (secondary: common iliac, para-aortic, interaortocaval, paracaval).

3. What are the boundaries of lymph node dissection in bladder cancer? Superior — ureter/common iliac bifurcation; inferior — circumflex iliac vein and Cloquet's node/Cooper's ligament at the femoral canal; lateral — genitofemoral nerve; medial — bladder and internal iliac artery; posterior — obturator nerve/fossa.

4. What are the indications for urethrectomy at the time of radical cystectomy? A positive urethral margin; in males, high-grade or invasive urethral disease distal to the prostatic urethra or prostatic stromal/CIS involvement; in females, bladder-neck tumours (and, per AUA, all females not receiving a neobladder). Delayed urethrectomy is indicated for positive urethral wash cytology, bloody discharge, or clinically obvious local recurrence.