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

Setup: an 18-Fr preconnected urethral catheter clipped to the drapes, the surgeon on the patient's left, and a lower midline incision from the symphysis to just below/lateral to the umbilicus (to the left if an ileal conduit is planned).

1. Enter the space of Retzius — incise the anterior rectus and transversalis fascia and open the retropubic space bluntly with a sponge stick under direct vision, establishing the plane between bladder and pelvic sidewall/external iliac vessels (upward retraction of the umbilicus aids identification of the linea alba).
2. Peritoneal "wings" and urachus — incise the peritoneum in line with the incision; circumscribe, ligate, and divide the urachus (median umbilical ligament) — a Kocher clamp on it aids traction — and incise the peritoneum in a V-shape to take down the bladder's peritoneal "wings." Explore the abdomen (liver, pre-aortic and pelvic nodes) and release adhesions. Incise the peritoneum lateral to the bladder and ligate/divide the vas deferens.
3. Mobilize the colon and pack the bowel — incise the white line of Toldt to expose the ureters, pack the small bowel into the upper abdomen with radiopaque laparotomy towels, and place a Bookwalter retractor (extensive right-colon mobilization is needed only for orthotopic diversion). Confirm with anaesthesia that the vena cava is not compressed.
4. Dissect the ureters — incise the peritoneum parallel to the common iliac vessels and find the ureter at the crossing; isolate it with a vessel loop and preserve periureteral tissue (never grasp the ureter directly), following it to the bladder. Ligate the superior vesical (obliterated umbilical) artery to gain ureteral length, then divide the ureter at the bladder and send a distal frozen section; a tacking suture aids handling, and clipping-and-tying the stump lets small ureters dilate before diversion.
5. Bring the left ureter across — under the sigmoid, bluntly open a retroperitoneal tunnel just anterior to the sacrum, aorta, and common iliac vessels, and pass the left ureter to the right with a McDougal clamp, ensuring a smooth, untwisted, unkinked course.
6. Posterior plane — sharply divide the posterior peritoneum at the level of the ampulla of the vas and seminal vesicles, developing the plane between the anterior rectal wall and posterior bladder/prostate (blunt or sponge-stick), keeping both lamellae of Denonvilliers' fascia anteriorly and sweeping the rectum down and away (sharp, non-cautery dissection if radiated or locally advanced posteriorly).
7. Lateral pedicles — control and divide the posterolateral pedicles with sequential fires of a GIA stapler or vessel-sealing device, retracting the bladder anteriorly out of the wound (shield the rectum from the instrument tips with a gloved finger — transmitted heat can injure it). If no sealing device is available, clear the internal iliac artery and, distal to the gluteal branch, pass a right-angle behind the vessels and ligate with 2-0 silk, then clip/tie the remaining pedicle down to the endopelvic fascia.
8. Anterior and urethral dissection (analogous to radical retropubic prostatectomy) — sharply incise the endopelvic fascia bilaterally and sweep the levator fibres off; dissect the prostate from the pubis and control the dorsal venous complex by passing a McDougal clamp (suture-ligate or seal). Identify the urethra, clamp it near the prostate with a long Kelly (protecting the rectum), divide it distal to the clamp, and sharply divide the rectourethralis.
9. Nerve-sparing (selected patients) — for good preoperative erections without suspected extravesical spread at the bundle, spare the nerve fibres in the dorsomedial pedicles lateral to the seminal vesicles and the periprostatic neurovascular bundle; avoid any clamping/pinching of the pelvic plexus, take a lateral endopelvic approach bunching the Santorini plexus at (not distal to) the prostate, and avoid cautery at the prostatic apex, dividing the urethra sharply. Unlike radical prostatectomy, functional outcomes remain significantly worse.
10. Orthotopic-diversion prep — preserve urethral length and avoid urethral manipulation; approach the apex laterally along the prostatic capsule without cautery and divide the urethra with a #15 blade for a smooth stump (figure-of-eight sutures for hemostasis). A positive urethral frozen margin precludes orthotopic diversion.
11. Remove the specimen and check — avoid urine spillage; irrigate and pack the pelvis with moist pads. If rectal injury is suspected, fill the pelvis with water and insufflate air per rectum to detect a leak (two-layer closure + antibiotic irrigation, ± proximal colostomy and general-surgery consult, especially after prior radiation). Complete the pelvic lymphadenectomy (after cystectomy when there is no gross adenopathy) and the diversion, then drape the omentum over the anastomoses to guard against fistula and place suction drains.

Female Radical Cystectomy

Position with frog-legged or low-lithotomy access to the vagina and a thorough vaginal prep; a sponge stick for intravaginal manipulation and a Babcock for uterine retraction are the added instruments. The initial mobilization and ureteral dissection mirror the male steps, except that the round ligament is ligated and divided and the ovarian vessels in the infundibulopelvic ligament are ligated and divided (or sealed).

• Classic anterior pelvic exenteration removes the bladder, uterus, both tubes and ovaries, anterior vaginal wall, and urethra. With anterior traction on the uterus and posterosuperior retraction on the rectosigmoid, incise the rectouterine pouch and mobilize the vaginal wall off the rectosigmoid. Place a povidone-iodine–soaked sponge stick in the vagina and push it up and anteriorly to identify the cervix, then incise the vagina just below the cervix with cautery.
• Divide the posterolateral pedicles with a GIA stapler or vessel-sealing device, taking an anterior strip of vaginal wall and proceeding distally as the bladder is retracted anteriorly (if no sealer, ligate the internal-iliac branches distal to the gluteal branch with 2-0 silk — do not ligate the internal iliac artery itself). For a small tumour, avoid resecting a large vaginal segment to spare the pelvic-plexus autonomic innervation running along its lateral aspect.
• Orthotopic neobladder / vaginal-sparing option — for orthotopic diversion or a sexually active patient, spare the vagina: make a circumferential incision at the vaginal apex around the cervix and dissect the posterior bladder off the anterior vaginal wall down to just beyond the palpable Foley balloon (the vesico-urethral junction). Remove only the bladder neck and proximal 1 cm of urethra to preserve sphincter muscularity and innervation (preserve the pubourethral suspensory ligaments and anterior vaginal support). A positive urethral frozen margin mandates urethrectomy and precludes orthotopic diversion.
• Hemostasis — the female pelvis is vascular; separate the lateral pedicles from the lateral vaginal wall before ligation (a vaginal sponge stick/packing helps define the plane), carrying dissection to the bladder neck (identified by the Foley balloon).
• Vaginal closure and NVF — if the anterior wall is taken, close the posterior flap to the introital mucosa in a clamshell fashion (2-0 polyglactin), watertight and interrupted, and interpose an omental flap; vaginal packing to tamponade is removed within a day. Neobladder-vaginal fistula complicates ~3–5% — most from an unrecognized anterior-wall injury at the bladder neck/urethra, so dissect that plane with care.

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.

Operative Technique

Male — perineal urethrectomy. Position in lithotomy (hip flexion 60–90°, exaggerated if more exposure is needed). Over the palpable bulb make a vertical perineal incision (an inverted-U or a midline incision with lateral extension gives more room), place a Scott ring retractor, and divide the bulbospongiosus in the midline to the corpus spongiosum. Isolate the corpus spongiosum and pass a Penrose behind the urethra for retraction; separate the distal urethra from the corpora cavernosa (close any cavernosal nick with Vicryl). Invaginate the penis to the base of the glans and wedge-resect the distal urethra including the fossa navicularis (a penile-base tourniquet controls glandular bleeding). The proximal dissection is the hardest — incise the bulbocavernosus to the perineal membrane, clip the bulbourethral arteries at the 4- and 8-o'clock positions, enter the pelvic floor, and avoid cautery where the stump may be adherent to bowel (especially after cystectomy); excise the entire stump en bloc without avulsing it. Reapproximate the ischiocavernosus and bulbospongiosus in the midline to prevent a perineal hernia.

Prepubic (alternative at cystectomy). Extend the cystectomy incision over the pubis and invert the penis into the prepubic space — no repositioning into lithotomy, ~17 minutes on average, sparing the perineal morbidity and the extra operating hour of the perineal route (Van Poppel).

Female. At cystectomy, make a horseshoe incision around the urethra connected to the vaginal incisions from above, dissect sharply lateral to the urethra and Foley into the pelvic space, and retubularize the vagina (spare the anterior vaginal wall when the bladder floor/neck is uninvolved, especially in young sexually active women). For a distal-third urethral tumour, a distal urethrectomy circumscribes the meatus, amputates the distal urethra, and sutures the proximal urethra to the vaginal mucosa — counsel on a high incontinence risk with extensive resection.

Complications — penile oedema and haematoma are common; incontinence (worse with extensive resection); and a perineal hernia through the urogenital diaphragm (higher after prior infection/radiation).

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

Selection nuances — CIS on cold-cup biopsy of the distant urothelium is a contraindication (the standard resection loop, ~8–10 mm wide, is a handy ruler for the tumour). After resecting the tumour to visual completion, perform an examination under anaesthesia with the bladder empty — a residual palpable mass is clinical T3b and a contraindication. Avoid partial cystectomy when a ureteral reimplant would be needed to obtain the margin (higher recurrence), or when capacity is severely diminished.

Technique

1. Positioning and approach — position as if a radical cystectomy may be needed (perineal/vaginal access available); a midline incision from the pubis to the umbilicus. Choose a transperitoneal approach when the tumour lies near the peritonealized posterior wall, otherwise preperitoneal. Take random bladder biopsies (plus a prostatic urethral biopsy) beforehand to exclude occult CIS, and perform a pelvic lymph node dissection for oncologic cases.
2. Mobilize — control and ligate the urachus (keep the urachus and umbilicus in continuity for an en bloc umbilectomy when oncologically indicated), and ligate the lateral vascular pedicle (anterior hypogastric branches distal to and including the umbilical artery) to expose the posterolateral bladder.
3. Enter away from the tumour — open the bladder at a distant, non-diseased site under direct vision, tenting the wall with Babcock clamps rather than instilling fluid (which risks spillage); concurrent flexible cystoscopy with transillumination helps pick a safe entry away from the orifices. For a small dome tumour, a Satinsky vascular clamp placed below the lesion allows resection without opening the bladder into the field (no spillage).
4. Resect en bloc — take the mass with full-thickness bladder wall, perivesical fat, and overlying peritoneum, keeping a 1–2 cm margin (ideally 2 cm) given the lentiginous growth of urothelial carcinoma; send frozen sections for margin and stage (orientation is unreliable — re-resect circumferentially as needed).
5. Convert to radical cystectomy if frozen shows perivesical-fat invasion, a positive/unobtainable margin, or a tumour too close to the bladder neck for a 1–2 cm margin, or one that would require ureteral resection and reimplantation.
6. Close in two layers — a running full-thickness 3-0 polyglactin, then an imbricating 2-0 polyglactin — and test for extravasation via the Foley (interrupted 2-0 for any leak). Drain with a Foley rarely larger than 18 Fr (upsize or use continuous irrigation if end-of-case haematuria risks clot occlusion and overdistension); never a suprapubic tube — it risks tumour seeding of the extravesical space.
7. Finish — irrigate copiously with warm water to minimize seeding, and place a closed-suction drain laterally, close to but not over the suture line (avoid the inferior epigastric vessels).

Postoperative (ERAS-suited, as the bowel is not violated): discharge around day 2 with a drain-creatinine check to exclude extravasation, and a cystogram at 7–10 days (as early as 3) with antibiotic prophylaxis 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).