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Cystectomy

A cystectomy is a surgical procedure to remove all or part of the urinary bladder, most commonly performed to treat bladder cancer but also for certain benign conditions affecting bladder function. There are three main types: partial cystectomy, which removes only the portion of the bladder containing a tumor; simple cystectomy, which removes the bladder for noncancerous issues such as severe infections or neurological disorders; and radical cystectomy, the most extensive form that removes the entire bladder along with nearby lymph nodes and, in men, the prostate and seminal vesicles, or in women, the uterus, ovaries, and part of the vagina. Radical cystectomy is the standard treatment for muscle-invasive bladder cancer (stages T2-T4) and high-risk non-muscle-invasive cases unresponsive to other therapies like Bacillus Calmette-Guérin (BCG) instillation. The procedure typically lasts about six hours and can be performed via open through a lower abdominal incision or minimally invasively using laparoscopic or robotic techniques, which may reduce blood loss and recovery time. Because the stores , cystectomy requires , such as an ileal conduit (a on the connected to the intestines) or a continent reservoir like a neobladder reconstructed from intestinal to allow internal storage. Indications beyond cancer include neurogenic bladder, interstitial cystitis, or complications from , though these are less common. Risks associated with cystectomy include , , blood clots, damage to nearby organs, bowel complications, and long-term issues like or , with complication rates potentially exceeding 50% in radical cases. Recovery involves a stay of 1 to 7 days, depending on the approach, followed by weeks to months of gradual return to normal activities, often with lifelong monitoring for cancer recurrence or diversion-related problems. Advances like enhanced protocols and robotic assistance have improved outcomes, with studies showing comparable survival rates to open but shorter stays.

Indications

Bladder malignancy

Cystectomy represents the primary surgical intervention for muscle-invasive (MIBC), encompassing clinical stages T2 to T4a without distant , where it is endorsed as the by the (NCCN) guidelines to achieve local control and improve survival outcomes. For cisplatin-eligible patients, this procedure is typically preceded by neoadjuvant to address micrometastatic disease, with regimens such as , , , and (MVAC) showing a 5-year overall survival benefit of approximately 5% compared to cystectomy alone in landmark randomized trials. Dose-dense MVAC variants have further enhanced response rates, downstaging up to 40% of tumors to non-invasive states at cystectomy, thereby optimizing oncologic efficacy. In high-risk non-muscle-invasive (NMIBC), cystectomy is reserved for cases refractory to intravesical Calmette-Guérin (BCG) , particularly () with multifocal, recurrent, or high-grade features that confer a substantial risk of progression to MIBC. According to American Urological Association (AUA) guidelines, radical cystectomy offers the best chance for cure in BCG-unresponsive disease, with 5-year cancer-specific survival rates exceeding 70% in appropriately selected patients, surpassing outcomes from alternative intravesical or systemic therapies alone. While radical cystectomy offers the best chance for cure, systemic immunotherapies such as are approved for BCG-unresponsive in patients ineligible for cystectomy, per AUA guidelines (as of 2024). Salvage cystectomy plays a critical role in managing local failure after trimodality therapy (TMT)—a bladder-preserving involving maximal transurethral resection followed by concurrent chemoradiation—for patients initially unsuitable for or declining upfront cystectomy. This approach is indicated for persistent invasive recurrence or high-grade NMIBC post-TMT, with studies reporting 5-year overall survival rates of 50-60% in salvage settings, comparable to primary cystectomy when performed promptly. Additionally, in upper tract urothelial with synchronous tumors, cystectomy integrated with nephroureterectomy addresses the multifocal nature of urothelial malignancy and prevents recurrence related to synchronous bladder involvement. The evolution of cystectomy for MIBC reflects a historical from partial cystectomy, prevalent in the for localized tumors, to radical cystectomy as the dominant paradigm by the 1980s, supported by observational and comparative studies demonstrating improved local control and reduced pelvic recurrence rates with the latter. This shift was influenced by accumulating evidence of multifocal and lymphatic spread, prompting randomized evaluations that underscored the oncologic superiority of en bloc bladder removal over in achieving durable remission.

Benign conditions

Cystectomy for benign conditions is infrequently performed, accounting for less than 5% of all procedures annually in high-volume centers, primarily reserved for cases where conservative and less invasive interventions fail to alleviate symptoms or prevent life-threatening complications. These indications contrast with malignant cases by focusing on symptom relief and organ preservation efforts rather than oncologic control, often involving simple cystectomy with to manage , recurrent infections, or upper urinary tract deterioration. Severe interstitial cystitis, also known as bladder pain syndrome, represents a key benign indication for cystectomy when patients experience debilitating , urgency, and frequency unresponsive to multimodal therapies including oral medications, intravesical instillations, fulguration of Hunner's lesions, or even augmentation cystoplasty. In such refractory cases, supratrigonal cystectomy—removing the above the trigone while preserving the —combined with neobladder reconstruction has demonstrated symptomatic improvement in over 80% of patients, though persistent may occur in a subset due to central sensitization. Long-term outcomes emphasize enhanced , with high satisfaction rates despite potential need for adjunctive . Neurogenic bladder dysfunction, particularly in patients with or , warrants cystectomy when high bladder pressures lead to , recurrent intractable urinary tract infections, or progressive renal deterioration despite optimized antimuscarinics, clean intermittent catheterization, or injections. In cohorts, this procedure eliminates risks of pyocystis and while preserving upper tract function, with studies reporting substantial improvements in urinary quality-of-life metrics and low recurrence of infections post-diversion. For patients, indications similarly prioritize prevention of , though careful preoperative urodynamic assessment is essential to confirm irreversibility. Radiation- or chemotherapy-induced , often manifesting as , reduced capacity, or formation following pelvic treatments, necessitates cystectomy in severe, non-responsive cases to avert hemorrhage, , or . accounts for approximately 18% of benign cystectomies in specialized series, with resulting from endarteritis and ischemia leading to irreversible submucosal scarring; diversion post-removal typically resolves these sequelae effectively. Chemotherapy-related , though less common, follows similar in high-dose regimens and is managed analogously when conservative measures like hyperbaric oxygen fail. Congenital anomalies such as or severe bladder trauma with irreparable damage also justify cystectomy, particularly when primary reconstructions fail to achieve functional capacity or continence. In exstrophy, cystectomy is indicated for intrinsically small or diseased bladder templates post-interval growth attempts, often in pediatric or adolescent populations, to facilitate and prevent chronic infections or risk. Severe trauma, including penetrating injuries or blunt ruptures causing extensive tissue loss, similarly prompts removal if repair would yield a non-compliant, high-risk reservoir, prioritizing hemodynamic stability and long-term renal protection.

Preoperative preparation

Patient assessment

Patient assessment for cystectomy involves a thorough by a multidisciplinary team, typically including urologists, oncologists, and radiologists, to facilitate shared and determine surgical candidacy based on extent and overall status. Diagnostic evaluation begins with , often performed as an outpatient flexible procedure to visualize the , followed by rigid under for detailed inspection and documentation of tumor characteristics using a diagram. Transurethral resection of the tumor (TURBT) is essential for histopathological confirmation and initial , ensuring is included in the sample; prostatic urethral may be added in cases of neck involvement or . A bimanual under , conducted before and after TURBT, assesses local tumor extent and mobility to aid clinical . Upper urinary tract via urography or MRI evaluates for synchronous lesions, while chest screens for pulmonary metastases as part of systemic . Cross-sectional of the and with intravenous contrast, if not contraindicated, further delineates local and nodal involvement. Staging follows the American Joint Committee on Cancer (AJCC) TNM system, 8th edition, which categorizes (T) depth, regional (N) involvement, and distant (M) to guide cystectomy indications, particularly for muscle-invasive (T2-T4a, N0, M0). MRI using the Vesical Imaging-Reporting and Data System (VI-RADS) enhances T-stage accuracy, with sensitivity of 83% and specificity of 90% for distinguishing T1 from T2 disease. Functional assessments evaluate organ systems to predict perioperative risks and suitability for urinary diversion. Renal function is assessed via (GFR), with a of >40 mL/min/1.73 m² often required for continent diversions to minimize metabolic complications; comprehensive metabolic panels guide this evaluation. Pulmonary function tests, including , diagnose underlying lung disease but have limited predictive value for postoperative complications in cystectomy patients. Nutritional status is gauged by levels, where preoperative (<3.5 g/dL) independently predicts higher complication rates and prolonged recovery. Psychosocial evaluation addresses quality-of-life implications, particularly stoma acceptance following incontinent diversion, using tools like the Clinical Frailty Scale or mini-COG for frail or older patients to support and adjustment. This comprehensive approach ensures alignment with indications such as bladder malignancy while optimizing outcomes.

Preoperative management

Preoperative management for cystectomy focuses on optimizing patient physiology and logistics to enhance surgical safety and outcomes, particularly for those with muscle-invasive bladder cancer (MIBC). For eligible patients with cT2-T4aN0M0 MIBC, neoadjuvant chemotherapy combined with immunotherapy is recommended to improve survival rates prior to radical cystectomy, per 2025 guidelines; standard protocols involve 3-4 cycles of cisplatin-based regimens such as gemcitabine-cisplatin (GC) plus a PD-L1 inhibitor (e.g., durvalumab), or chemotherapy alone (e.g., GC, methotrexate-vinblastine-doxorubicin-cisplatin (MVAC), or dose-dense MVAC (dd-MVAC)) if immunotherapy is unsuitable. Response is assessed through clinical restaging, including imaging (e.g., multiparametric MRI or CT), cystoscopy, and biopsy, typically 4-6 weeks after completion, with pathological complete response (ypT0N0) rates ranging from 12-42% across trials. Patients ineligible for cisplatin due to renal impairment or comorbidities may proceed directly to surgery, alternative neoadjuvant therapies like enfortumab vedotin plus pembrolizumab, or carboplatin-based regimens in select cases. Bowel preparation remains a traditional component for radical cystectomy involving , despite evolving evidence questioning its necessity in enhanced recovery protocols. Mechanical cleansing typically uses oral (PEG) electrolyte solutions (e.g., 4 liters over 1-2 days) to clear the colon, reducing intraoperative contamination risk. This is often combined with oral antibiotics such as neomycin (1 g) and erythromycin base (1 g) administered in three doses the day before to minimize bacterial load, mirroring standards adapted for ileal or colonic segments. However, randomized trials in cystectomy patients show no significant reduction in infectious complications with routine mechanical bowel preparation, leading some centers to omit it in favor of targeted antibiotic prophylaxis. Informed consent is a critical step, involving detailed discussions of procedure risks, alternatives, and lifestyle impacts to ensure understanding and shared . receive counseling on options (e.g., ileal conduit vs. neobladder), including long-term effects on such as incontinence or care. For reproductive-age individuals, fertility preservation is addressed, particularly in women where oocyte or can be offered preoperatively via ovarian stimulation and retrieval, preserving future options despite potential ovarian transposition during surgery. In men, radical cystectomy typically renders irreversible due to removal, but banking is recommended. Consent also covers oncologic risks like recurrence and the multidisciplinary team's role in tailoring the approach. Prophylactic measures emphasize modifiable risk factors to mitigate complications. counseling is initiated at least 4 weeks preoperatively, as quitting reduces postoperative pulmonary and wound issues by up to 41%, with even brief abstinence showing benefits. Vaccination status is updated per general guidelines, including and pneumococcal vaccines for at-risk patients to prevent respiratory s. Comorbidities are optimized, such as achieving HbA1c below 8% in diabetics through adjustment and glucose , as poor elevates and risks. Nutritional ensures levels above 3.0 g/dL, with supplementation if needed. Enhanced recovery after surgery () protocols are initiated preoperatively to streamline recovery and reduce morbidity. These include minimal —allowing clear fluids up to 2 hours and solids up to 6 hours before —combined with via a 400 mL drink (e.g., 12.5% solution) 2-3 hours preoperatively to maintain stores and attenuate . also incorporates on expectations, early mobilization plans, and strategies to foster compliance and psychological preparation. has been shown to shorten hospital stays by 2-3 days in cystectomy cohorts without increasing readmissions.

Types

Simple cystectomy

Simple cystectomy involves the complete removal of the urinary without excision of adjacent organs or lymph nodes. This procedure is primarily indicated for benign conditions that severely impair bladder function, such as intractable , neurogenic bladder, cystitis, or radiation-induced damage, where cancer is not present. Unlike radical cystectomy, it avoids extensive pelvic , reducing operative time and risks to surrounding structures like the in men or reproductive organs in women. Urinary diversion is still required post-procedure, similar to other total cystectomies.

Partial cystectomy

Partial cystectomy involves the surgical removal of a portion of the containing the tumor while preserving the remainder of the organ to maintain urinary function. This bladder-sparing approach is suitable for a select subset of patients with muscle-invasive (MIBC), typically comprising 5-10% of cases, where the tumor's location and characteristics allow for complete resection without compromising oncologic safety. Strict selection criteria are essential to ensure efficacy and minimize recurrence risk. The tumor must be solitary, located in the dome or anterior wall of the , and measure less than 5 cm in diameter to facilitate adequate resection. There should be no evidence of () elsewhere in the , confirmed by random biopsies, and the residual must retain sufficient capacity post-resection to support continence and voiding. Additionally, the procedure requires that the bladder neck and trigone remain uninvolved to preserve natural continence mechanisms and ureteral function, avoiding the need for reimplantation. During the procedure, a minimum 2 cm clear surgical margin around the tumor is mandated, with intraoperative frozen section analysis to verify negativity and guide resection. This margin helps achieve local control while maximizing preserved volume. In appropriately selected patients with tumors, partial cystectomy demonstrates oncologic outcomes comparable to radical cystectomy, including a 5-year recurrence-free of approximately 70% based on retrospective series. Local recurrence rates range from 8-41%, often manageable with transurethral resection or salvage therapy. Contraindications specific to partial cystectomy include multifocal disease, involvement of the trigone or neck, associated , or tumors not amenable to 2 cm margins, in which cases progression to radical cystectomy is recommended. Compared to radical cystectomy, partial cystectomy preserves native function but requires vigilant surveillance due to higher intravesical recurrence potential in non-ideal candidates.

Radical cystectomy

Radical cystectomy involves the en bloc resection of the entire along with adjacent structures to achieve oncologic control in muscle-invasive . In men, this typically includes cystoprostatectomy, encompassing removal of the , , and , as well as the distal ureters (which are reimplanted), and surrounding perivesical fat. In women, the removes the , , ovaries, fallopian tubes, anterior vaginal wall, and distal ureters to ensure clear margins, though organ-sparing approaches may be considered in select cases based on disease extent and desires. Bilateral pelvic is an integral component, with the standard template dissecting nodes in the obturator , external iliac, and internal iliac regions up to the common iliac bifurcation; an extended template extends to the , including presacral and presciatic nodes. While extended increases detection of node-positive disease (26% vs. 13% in standard templates), recent SWOG S1011 trial data indicate no overall survival benefit compared to standard dissection, though it may provide therapeutic value in confirmed node-positive cases from earlier studies. The procedure's historical evolution traces back to the 1940s, when partial cystectomies were common for localized disease, but staging systems like Jewett-Strong (introduced in 1946) highlighted the prognostic importance of muscle invasion depth, prompting a shift toward more radical approaches for deeper tumors. By the 1970s, radical cystectomy emerged as the standard for muscle-invasive (T2-T4a), incorporating extended resections and based on refined staging that correlated local extension with metastatic risk, marking a departure from conservative surgeries. In the open approach, operative times average 4-6 hours, with median blood loss of 500-1000 mL, though these vary by patient factors and diversion type. Integration with neoadjuvant chemotherapy, particularly cisplatin-based regimens like dose-dense MVAC, achieves pathologic downstaging in approximately 30-40% of cases (e.g., to ≤pT1N0), enhancing survival by addressing micrometastases prior to . Adjuvant therapies may follow based on pathologic findings, though their role remains adjunctive to the surgical resection. This procedure necessitates , as detailed elsewhere.

Surgical techniques

Open approach

The open approach to cystectomy involves a traditional surgical method utilizing a large incision to provide direct visualization and manual access to the pelvic organs, allowing for precise and removal of the . This technique is particularly employed in radical cystectomy for muscle-invasive , where complete excision of the and surrounding structures is required, often combined with pelvic . Common incision types include a lower midline extending from the to the umbilicus, which offers broad exposure to the , or a positioned just above the for more limited lower abdominal access in select cases. The midline approach facilitates entry into the , while the Pfannenstiel variant involves detaching the rectus muscles from the sheath without separating them, preserving vascular supply and enabling extraperitoneal extension if needed. The procedure begins with general and ureteral catheterization to identify and protect the ureters. Early vascular control is achieved by ligating the superior and inferior vesical arteries and the anterior division of the to minimize blood loss. Dissection proceeds posteriorly along the in males or the in females, incising Denonvilliers' to separate the from the , followed by mobilization of the laterally and superiorly. Pelvic is performed en bloc, encompassing nodes from the laterally to the medially, and up to the ureteral crossing of the superiorly. The is then removed en bloc with adjacent organs (such as the , , , and ovaries) while maintaining peritoneal integrity to reduce spillage risk. The specimen is extracted through the incision, and is constructed as indicated. Advantages of the open approach include superior tactile feedback for assessing surgical margins in locally advanced tumors, enhanced control during extensive , and greater ease in managing complex anatomies such as adhesions or bulky disease. It remains the preferred method for cases requiring robust manual manipulation where minimally invasive techniques may falter. Historically, the open approach has been the gold standard for radical cystectomy since the mid-20th century, with the Bricker procedure in 1950 establishing ileal conduit diversion as a standard complement to removal. Oncologic outcomes with open cystectomy are equivalent to robotic-assisted methods, as demonstrated by the RAZOR trial, which showed non-inferior 2-year recurrence-free survival rates between the two. Conversion from minimally invasive to open cystectomy occurs in approximately 4-6% of cases, primarily due to intraoperative challenges like adhesions, , or .

Minimally invasive approach

Minimally invasive approaches to cystectomy, including laparoscopic and robotic-assisted techniques, aim to replicate the oncologic efficacy of open surgery while minimizing incision size, reducing postoperative , and accelerating . These methods involve small ports for instrument insertion, allowing for precise in the confined pelvic space. Laparoscopic cystectomy typically employs a transperitoneal route, beginning with the creation of using insufflation to a of 12-15 mmHg, followed by placement of 3-5 trocars for access to the . Key steps include mobilization of the bowel, of the ureters and vascular pedicles, and intracorporeal pelvic to assess and remove potential metastatic sites. Robotic-assisted radical cystectomy (RARC) has emerged as the predominant minimally invasive variant, leveraging systems like the da Vinci platform to enhance surgeon control. This involves 5-6 ports: typically an 8-mm supraumbilical camera port, additional 8-mm robotic ports for instruments, and a 12-mm assistant port, positioned cephalad to accommodate pelvic . The system's high-definition magnification (up to 10x) and wristed instruments with 7 enable tremor filtration and precise handling of delicate structures, such as the neurovascular bundles and pedicles, reducing inadvertent injury. Clinical evidence supports the noninferiority of RARC compared to open cystectomy in oncologic outcomes. The iROC trial (2022), a multicenter randomized controlled study of 317 patients, demonstrated comparable 90-day morbidity and benefits in recovery, with estimated blood loss averaging 200-500 mL and median stays of 5-7 days versus higher volumes (up to 800 mL) and longer stays (7-10 days) in open approaches. Long-term data from the RAZOR trial and subsequent analyses indicate similar 5-year overall survival rates of approximately 56% (57% robotic vs. 55% open) between robotic and open groups, with no significant differences in recurrence-free survival. Adoption of robotic techniques has surged , with robotic procedures increasingly comprising a significant portion of radical cystectomies as of 2024, driven by American Urological Association (AUA) endorsements and availability in high-volume centers. This shift reflects improved perioperative metrics, including lower transfusion rates (under 25%) and enhanced yields (median 15-20 nodes). However, limitations persist, including a steep requiring 20-30 cases for proficiency in operative time and complication reduction, as well as higher upfront costs (up to $2,000 more per procedure due to equipment and maintenance).

Urinary diversion

Incontinent diversions

Incontinent urinary diversions, such as the , provide a passive drainage pathway for urine following cystectomy, directing it continuously to an external collection appliance via an abdominal . The , also known as the Bricker procedure, remains the most common form of incontinent diversion, historically serving as the gold standard for over 30 years due to its relative simplicity and reliability.00116-8/fulltext) In this technique, the ureters are anastomosed to an isolated segment of , with the proximal end of the segment brought to the skin surface as a , allowing gravity-dependent urine flow without voluntary control. The surgical steps begin with the isolation of a 15- to 20-cm segment of , typically harvested 15 cm proximal to the ileocecal junction to preserve bowel function and minimize metabolic disturbances. The ureters are mobilized while preserving their blood supply, then anastomosed to the distal end of the ileal segment using techniques such as the Bricker end-to-side method or anti-reflux approaches like the (where ureters are combined and implanted directly) or LeDuc (involving a submucosal tunnel to prevent reflux). The proximal ileal end is exteriorized through a incision in the , matured to skin level, and the bowel continuity is restored with an ileoileostomy. This diversion is particularly preferred for patients with compromised manual dexterity, as it eliminates the need for intermittent self-catheterization required in continent alternatives; those with renal impairment, to limit exposure to more absorptive bowel segments; or individuals with , given the procedure's shorter operative time and lower risk profile. It is often indicated after cystectomy for invasive but suits cases with significant comorbidities where minimizing surgical complexity is prioritized. Long-term patency of the ileal conduit is favorable, with functional success in over 90% of cases at extended follow-up when strictures are managed, though vigilant monitoring for ureterointestinal obstruction is required. A key metabolic risk arises from absorption across the ileal mucosa, leading to hyperchloremic in approximately 15% of patients; regular assessment of serum levels (below 21 mmol/L signaling ) and supplementation with oral if needed are essential for management. Appliance management is crucial for quality of life, involving a secure pouching system with a skin barrier to protect the peristomal area from urine exposure and prevent irritation. Comprehensive stoma education, typically provided by specialized nurses, covers pouch emptying every 4-6 hours, gentle skin cleansing with warm water (avoiding soaps with oils), and application of barriers or protective powders for minor irritations, ensuring long-term skin integrity and patient independence.

Continent diversions

Continent urinary diversions are surgical reconstructions that enable internal storage of in a created from intestinal segments, allowing for controlled emptying either through the or via intermittent self-catheterization, thereby eliminating the need for external appliances. These methods are particularly valued for their potential to preserve by mimicking natural voiding patterns more closely than incontinent options. The orthotopic neobladder represents the most physiologic form of continent diversion, where an ileal or ileocecal pouch is fashioned and anastomosed directly to the , permitting near-normal voiding via abdominal straining without a . The pouch technique, introduced in 1989, is a widely adopted approach that utilizes 40 to 60 cm of to construct a low-pressure with an afferent tubular segment to minimize . In contrast, the continent cutaneous , such as the pouch, involves creating a pouch from the and that is accessed via a catheterizable abdominal , with continence maintained by a valve mechanism often achieved through ileal intussusception or reinforcement of the . This method is suitable when urethral preservation is not feasible. Candidacy for continent diversions requires adequate renal function to handle potential metabolic changes, absence of urethral involvement by tumor or prior radiation to ensure safe reconstruction, and patient motivation to perform self-catheterization four to six times daily for cutaneous reservoirs. Orthotopic options are generally preferred for motivated patients without urethral , while cutaneous reservoirs serve as alternatives for those with contraindications to urethro-intestinal . Functional outcomes demonstrate high success rates, with daytime continence achieved in 80% to 90% of patients and nighttime continence in 60% to 70%, alongside typical voided volumes of 300 to 500 mL that support adequate reservoir capacity. These rates improve over time, often reaching 92% daytime continence by one year post-surgery. The evolution of these techniques began in the 1980s with the Mainz pouch, an ileocecal reservoir introduced in 1983 that established continent cutaneous diversion using intussuscepted ileal valves for continence. Advancements have progressed to modern robotic intracorporeal diversions, where 2025 trials report reduced operative times and blood loss compared to methods, enhancing feasibility and recovery.

Contraindications

Absolute contraindications

Absolute contraindications to cystectomy represent clinical scenarios where the is deemed futile for curative or carries prohibitive risks that preclude performance, typically determined through multidisciplinary evaluation involving urologists, oncologists, and anesthesiologists. These conditions prevent proceeding with , shifting management toward palliative or alternative therapies such as systemic or . Bleeding diathesis, such as uncorrectable , is an absolute due to the high risk of intraoperative and postoperative hemorrhage. Distant metastases, classified as disease (e.g., involvement of distant organs like the liver or lungs confirmed by such as or scans), constitute an absolute because local surgical control does not confer survival benefit in the presence of widespread dissemination. Extensive local invasion, such as T4b staging where the tumor encroaches on unresectable structures like the pelvic sidewall or encases major vessels as evidenced by preoperative , renders the tumor non-resectable and prohibits cystectomy for curative purposes. Severe comorbidities that preclude safe and major pelvic also serve as absolute barriers; examples include uncompensated (New York Heart Association class IV), where exhibit symptoms at rest and cannot tolerate operative stress.

Relative contraindications

Relative contraindications to cystectomy encompass factors that elevate risks but do not preclude outright, allowing for individualized assessment and potential optimization strategies. Advanced age, particularly over 80 years combined with frailty, represents a significant relative , as it correlates with higher complication rates and reduced survival probabilities. Frailty in this context is often evaluated using tools such as the (CCI), where a score greater than 3 indicates substantial comorbidity burden and increased vulnerability to adverse outcomes following radical cystectomy. Despite these risks, age alone should not bar intervention if performance status is adequate, emphasizing the need for comprehensive preoperative evaluation. Obesity, defined as a body mass index () greater than 35 kg/m², complicates surgical access and heightens the likelihood of wound-related issues and other complications in cystectomy patients. However, this factor is manageable through enhanced recovery after surgery () protocols, which mitigate risks by optimizing , , and to reduce overall morbidity. A history of prior pelvic introduces adhesions and , which can prolong operative time and elevate complication risks during cystectomy, though these challenges can often be addressed with experienced surgical teams and meticulous planning. Compromised renal function, such as end-stage renal disease requiring or a (GFR) of 30-45 mL/min, poses a relative contraindication by predisposing patients to further renal decline post-surgery and influencing choices, potentially necessitating alternatives like tubes to preserve kidney function. Ultimately, shared decision-making is essential for high-risk patients, incorporating risk-benefit analyses via nomograms that predict perioperative mortality rates of approximately 5-10% in frail or comorbid individuals to guide whether cystectomy aligns with overall goals of care. Patient assessment metrics, such as frailty indices, further inform these discussions without overriding clinical judgment.

Risks and complications

Perioperative risks

Cystectomy, particularly radical cystectomy for , carries substantial risks of intraoperative and immediate postoperative hemorrhage due to the extensive in the involving major vascular structures. Estimated blood loss typically ranges from 500 to 1500 mL, with medians around 600 mL in open procedures, though lower volumes (300-500 mL) are reported in robotic-assisted approaches. Transfusion rates vary from 20% to 40%, influenced by surgical technique, patient comorbidities, and use of hemostatic agents like , which can reduce both blood loss and transfusion needs. Management focuses on meticulous vascular control during to ligate and clamp major vessels such as the iliac arteries and veins, alongside intraoperative cell salvage techniques that reinfuse autologous blood after processing to minimize allogeneic transfusions without increasing oncologic risks. Infections represent another key perioperative hazard, with surgical site infections (SSI) occurring in 5-10% of cases and urinary tract infections (UTI) more frequent at 20-30% due to indwelling catheters and . Prophylaxis typically involves a single preoperative dose of , often combined with for coverage, administered within 60 minutes of incision, with evidence supporting discontinuation after 24 hours to reduce resistance risks while effectively preventing SSI. Catheter-associated UTIs are mitigated through strict sterile insertion protocols, early removal when feasible (typically 7-14 days postop), and surveillance cultures to guide if infection develops. Anesthetic complications, including deep vein thrombosis (DVT), arise from prolonged immobility, pelvic , and hypercoagulability in cancer patients, with overall VTE incidence estimated at 10-15% in the period. Prevention relies on mechanical measures such as sequential compression devices applied to the lower starting preoperatively and continued until full ambulation, often supplemented by pharmacologic prophylaxis like in moderate- to high-risk patients per guidelines. Cardiopulmonary events are particularly concerning in elderly patients with comorbidities, where () occurs in 2-5% of cases, often within the first few postoperative days due to fluid shifts, , and response. involves serial levels starting postoperatively to detect subclinical injury, with thresholds guiding or if elevations exceed 0.04 ng/mL. Operative mortality for cystectomy is 1-3% within 30 days, rising to 3-7% at 90 days (higher in patients aged ≥75 years, up to 11% for ≥80 years), with lower rates in robotic-assisted procedures (e.g., 2.7% 90-day) compared to open (4.2%) as per studies from 2011-2025 evaluating over 1000 patients. Risk factors include advanced age, score ≥3, and preoperative frailty, underscoring the need for multidisciplinary preoperative optimization. Enhanced recovery after surgery () protocols have reduced overall perioperative morbidity in recent implementations.

Gastrointestinal complications

Gastrointestinal complications are among the most frequent adverse events following cystectomy, primarily due to the and resection of bowel segments required for procedures. These issues can prolong hospital stays and necessitate additional interventions, with being the predominant early concern. Postoperative , characterized by temporary impairment of bowel motility, occurs in 20-30% of patients after radical cystectomy. It typically manifests within the first few postoperative days with symptoms such as , , and , often resolving within 3-5 days. Management is conservative, involving nasogastric tube decompression for gastric decompression and early enteral feeding to stimulate gastrointestinal recovery, as part of enhanced recovery protocols. Recent studies show reducing rates to 15-25%. Anastomotic leaks at the ureterointestinal junction arise in 3-5% of cases, potentially leading to urine extravasation into the and subsequent with fever, , and . Diagnosis relies on computed imaging with oral and intravenous contrast to identify extraluminal fluid collections or contrast leakage. Prompt recognition allows for with drainage or, in severe cases, surgical repair to prevent formation. Intraoperative bowel injury, occurring in 2-5% of procedures (higher for rectal injuries at up to 10% in patients with prior ), often results from adhesiolysis in patients with prior surgeries or during harvest of ileal segments for diversion. These injuries are usually serosal tears or enterotomies, which are identified and repaired primarily with sutures under direct visualization to avoid postoperative leaks. Long-term gastrointestinal effects include due to resection of the terminal , affecting up to 17% of patients with ileal diversions; annual monitoring of serum levels is recommended, with supplementation as needed to prevent . Additionally, from ileal loss can cause chronic , managed through dietary modifications or bile acid sequestrants like cholestyramine. Prior doubles the risk of these gastrointestinal complications, primarily by promoting adhesions that complicate bowel handling and increase or injury likelihood.

Urinary complications

Urinary complications following cystectomy primarily arise from the surgical of the urinary tract, including issues with flow, storage, and metabolic balance in urinary diversions such as ileal conduits or orthotopic neobladders. These complications can occur early in the postoperative period or develop long-term, impacting renal function and . Common manifestations include obstructions, leaks, infections, and imbalances, often necessitating interventions like stenting, , or medical therapy. Ureteral obstruction or stricture at the ureterointestinal is a frequent issue, occurring in 3-10% of patients after radical cystectomy, particularly at the ureterointestinal junction due to ischemia, , or technical factors. This complication can lead to and impaired urine drainage if untreated. Management typically involves initial endoscopic dilatation and stenting, with open or robotic revision reserved for recurrent or refractory cases, achieving success rates of 78-87%. Early urine leaks from anastomotic sites affect 2-4% of patients, often within the first few weeks post-cystectomy, resulting from poor , tension, or at the ureteroenteric or urethroneal junctions. These leaks may present as urinary or fistulas, detectable via imaging or . Most cases resolve with conservative measures, including prolonged drainage and antibiotics, while persistent leaks require percutaneous or tube placement to divert urine and promote . Metabolic disturbances, such as hyperchloremic , are prevalent in patients with ileal conduit diversions, affecting up to 15% and resulting from absorption and loss across the intestinal mucosa, often manifesting as serum pH below 7.3. This condition is usually subclinical but can cause , , or renal strain in symptomatic cases. Treatment involves alkali supplementation, such as oral (1-2 g three times daily), alongside monitoring of electrolytes and hydration status, particularly in the first 6-12 months postoperatively. In orthotopic neobladders, —characterized by inflammation and recurrent infections of the reservoir—occurs in 10-20% of patients, driven by bacterial , mucus stasis, or incomplete emptying. Symptoms include , , and fever, with higher rates in continent diversions compared to conduits. Management relies on regimens tailored to culture results, often or amoxicillin-clavulanate for 2-4 weeks, combined with regular irrigations to prevent recurrence. Long-term renal deterioration affects approximately 15% of patients after , attributed to chronic obstruction, recurrent infections, or leading to progressive decline in . This risk is higher in incontinent diversions like ileal conduits due to potential upper tract changes. Monitoring involves serial creatinine measurements, estimated calculations, and periodic imaging such as or to detect early and intervene as needed.

Neurological and sexual complications

Neurological complications following cystectomy primarily arise from disruption of pelvic autonomic and peripheral during extensive , particularly in procedures. In men, occurs in up to 80% of cases due to injury to the cavernosal , which are vulnerable during removal and pelvic . This dysfunction stems from the anatomical proximity of these to the surgical field, leading to impaired neurovascular supply essential for penile . Nerve-sparing techniques, which aim to preserve these structures, are feasible in patients with disease limited to non-muscle-invasive or organ-confined stages (less than T3), potentially restoring potency in 40-50% of suitable candidates postoperatively. Autonomic neuropathy is another key concern, especially in patients receiving orthotopic neobladders, where loss of bladder sensation results from denervation of the detrusor muscle and urethral sphincter. This absence of neurofeedback impairs the ability to sense fullness, contributing to overflow incontinence, particularly at night, as patients fail to awaken for voluntary voiding. The condition arises from severance of parasympathetic and sympathetic fibers in the pelvic plexus, disrupting the tonus-regulating mechanisms necessary for coordinated bladder emptying. Peripheral neuropathies affecting the lower extremities occur in approximately 1-2% of cases, attributed to prolonged positioning during surgery, which compresses nerves such as the peroneal or femoral at pressure points like the fibular head or . These typically manifest as neuropraxia, presenting with weakness, numbness, or postoperatively, but most resolve spontaneously within 3-6 months as nerve conduction recovers. In women, is prevalent, with pelvic often causing anatomical changes that reduce vaginal and , leading to in a majority of patients. Vaginal shortening or contributes to this, affecting comfort during intercourse, though specific incidence varies; management includes vaginal lubricants for symptom relief and reconstructive procedures like in select cases to restore length and function. Robotic-assisted approaches may mitigate some through enhanced visualization and precision, potentially improving potency rates in nerve-sparing scenarios compared to open surgery.

Recovery

Immediate postoperative care

Immediate postoperative care following cystectomy focuses on stabilizing the patient, managing , preventing complications, and initiating early elements to facilitate discharge within 1-2 weeks. This phase emphasizes multimodal interventions to address surgical stress, maintain physiological balance, and promote mobility while monitoring for acute issues such as or . Care is typically guided by Enhanced After Surgery () protocols, which have been shown to reduce length of stay and complications compared to traditional approaches. Pain management employs a multimodal strategy to minimize opioid use and achieve a visual analog scale (VAS) score below 4, thereby reducing side effects like and respiratory depression. Thoracic epidural analgesia at the T10 level is strongly recommended for at least 72 hours in open procedures, combined with intravenous acetaminophen (1 g every 6 hours) and nonsteroidal anti-inflammatory drugs when renal function permits; (PCA) with short-acting opioids like serves as an adjunct for breakthrough pain. In robotic-assisted cases, transverse abdominis plane blocks or intrathecal may supplement systemic agents, with regular assessment to taper epidural use by postoperative day 3. Fluid and electrolyte balance is maintained through goal-directed using monitors like esophageal Doppler to optimize and avoid fluid overload, which can exacerbate ; intravenous hydration targets euvolemia (1-2 mL/kg/hour), with close monitoring of outputs from drains, nasogastric tubes, and urinary diversions to correct imbalances such as from ileal segment absorption. Venous thromboembolism (VTE) prophylaxis is initiated immediately with low-molecular-weight heparin (e.g., enoxaparin 40 mg subcutaneously daily) alongside sequential compression devices and early ambulation, continuing for at least 4 weeks post-discharge due to the high risk in cystectomy patients. Catheter protocols vary by urinary diversion: for ileal conduits, ureteral stents are removed around postoperative day 5-7 with initiation of stoma care education; for neobladders, suprapubic and urethral catheters, along with stents, remain in place for 2-3 weeks to ensure anastomotic healing, followed by cystography to confirm no leaks prior to removal. ERAS elements include early ambulation starting on postoperative day 1 (targeting 4 hours out of bed), progression to clear liquids on day 0 if bowel sounds return, and chewing gum to stimulate gastrointestinal motility, all aimed at meeting discharge criteria such as tolerating oral intake, independent mobility, and pain control without intravenous support.

Long-term recovery

Following cystectomy, patients typically progress their from low-residue foods in the initial weeks to prevent due to the surgical manipulation of intestinal segments used for , gradually introducing higher-fiber options by 4-6 weeks to promote bowel regularity. Low-residue diets emphasize easily digestible items such as refined grains, cooked without skins, and tender proteins, limiting and whole grains that could cause blockages. Once bowel function stabilizes, incorporating soluble fibers from sources like oats, bananas, and peeled fruits supports consistent stool formation and reduces the risk of or associated with ileal conduit or neobladder adaptations. Adequate is essential throughout, with recommendations to consume at least 2-3 liters of fluid daily to maintain urine output above 2 liters, thereby minimizing the formation of urinary stones in the diversion system. Physical activity resumption begins conservatively around week 4 with light exercises such as short walks to enhance circulation and strength without straining the incision site, advancing to full pre-surgery levels by 3 months as endurance improves. Patients should avoid heavy lifting exceeding 5-10 pounds for 6-8 weeks to allow proper healing of abdominal muscles and prevent formation, consulting their surgeon before engaging in vigorous pursuits like or weight training. This phased approach not only aids physical but also supports overall by mitigating fatigue common in the 3-12 month period. For those with a neobladder or ileal conduit, specialized training focuses on strengthening through Kegel exercises, performed by contracting the muscles used to stop flow for 5-10 seconds, 10-20 times several times daily, to improve continence and reduce leakage over time. Intermittent self-catheterization may be scheduled every 2-4 hours initially, especially at night, to prevent and ensure complete emptying, with techniques taught by staff to avoid infections. Stoma care for conduits involves regular cleaning and monitoring for irritation, integrated into daily routines to foster independence. Psychological adaptation addresses body image challenges from the stoma or altered anatomy, with counseling recommended to process grief or anxiety, often through individual therapy or cognitive-behavioral techniques. Participation in support groups, such as those offered by bladder cancer advocacy networks, provides peer validation and has been shown to significantly lower depression rates by facilitating emotional expression and coping strategies. Return to work generally occurs 4-8 weeks post-surgery for minimally invasive approaches, extending to 8-12 weeks or more for open procedures, depending on job demands and residual fatigue.

Follow-up care

Follow-up care after cystectomy focuses on detecting disease recurrence, monitoring for upper urinary tract involvement, and managing long-term complications associated with . Surveillance protocols are typically risk-stratified based on patient age, tumor characteristics, and surgical details, with more intensive monitoring for younger patients or those with high-risk features such as multifocal disease or positive margins. The recommended schedule includes clinical visits every 3 to 6 months during the first 2 to 3 years post-surgery, transitioning to every 6 to 12 months through year 5, and annually thereafter. Each visit incorporates a detailed and to assess for symptoms of recurrence or diversion-related issues, along with laboratory evaluations such as serum and electrolytes to monitor renal function and metabolic status. These intervals align with the natural timing of most recurrences, which occur within the first 2 to 3 years. Imaging plays a central role in surveillance, with urography of the and every 6-12 months for the first 2-3 years, then annually thereafter, recommended to evaluate the upper urinary tracts for recurrence or strictures, supplemented by for upper tract assessment in select high-risk cases, though its yield is limited post-diversion. Chest imaging via is performed at 6- to 12-month intervals for the first 2 to 3 years, then annually as needed to detect distant metastases. For patients undergoing prostate-sparing cystectomy, prostate-specific antigen (PSA) levels are monitored periodically to screen for prostatic involvement or unrelated prostate pathology. Endoscopic evaluation is reserved for symptomatic patients or those with specific concerns. Flexible is indicated for individuals with orthotopic neobladders experiencing or voiding dysfunction, or for routine pouch assessment in high-risk cases, following a schedule adapted from high-risk non-muscle-invasive protocols (e.g., every 3 to 6 months initially). wash cytology or is advised for patients with a retained and risk factors like or prostatic urethral involvement to detect local recurrence. Screening for late complications addresses the metabolic and skeletal effects of . Annual monitoring of levels is essential for patients with ileal segments used in diversion, as resection of more than 60 cm of or the terminal can impair absorption and lead to deficiency. Bone density assessment via is recommended periodically due to the elevated fracture risk ( 1.21) from chronic and potential . Electrolyte panels help identify and manage hyperchloremic , with supplementation as needed to mitigate renal and skeletal impacts. These protocols are informed by the 2024 AUA/ASCO/ASTRO/SUO guidelines and the 2025 EAU guidelines, which emphasize risk-stratified to balance detection efficacy with patient burden.

Prognosis

Oncologic outcomes

Oncologic outcomes following cystectomy for vary significantly based on pathologic stage, nodal involvement, and treatment adjuncts. According to recent analyses from the Surveillance, Epidemiology, and End Results () database, the 5-year overall survival (OS) rate for patients with organ-confined disease (pT2N0) after radical cystectomy is approximately 61%, reflecting favorable control in localized cases. In contrast, node-positive disease (pN1 or higher) is associated with substantially worse prognosis, with 5-year OS rates around 34%, underscoring the impact of lymphatic spread on long-term cancer control. Recurrence after cystectomy remains a major challenge, with patterns differing by site and stage. Local pelvic recurrences occur in 5-15% of cases, typically within the first 2 years postoperatively, while distant metastases develop in 20-40% of patients, most commonly in the lungs, liver, or bones. Adjuvant in patients with advanced pathologic stages (pT3-4) has been shown to reduce distant recurrence risk by improving systemic control, though local failures persist in higher-risk subsets. Surgical margin status and lymph node assessment critically influence outcomes. Positive soft tissue surgical margins are linked to poorer survival, with a hazard ratio (HR) of approximately 2.5-4.0 for overall mortality, independent of other factors, due to increased risk of local and systemic progression. Extended pelvic lymph node dissection (PLND) enhances staging accuracy by identifying occult nodal disease in up to 20-30% more cases compared to standard templates, potentially guiding adjuvant therapy and improving prognostic precision without definitive survival benefits in all cohorts. Neoadjuvant prior to cystectomy offers measurable oncologic advantages in muscle-invasive . Pathologic complete response (, ypT0N0) rates range from 15-25% with cisplatin-based regimens, correlating with downstaging and reduced micrometastatic burden. This translates to an absolute OS gain of 5-11% at 5 years compared to cystectomy alone, particularly in patients achieving , though benefits are less pronounced in those with persistent residual disease. Subgroup analyses reveal disparities in variant histologies. For instance, micropapillary urothelial , comprising 5-10% of cases, portends worse outcomes post-cystectomy, with 5-year OS rates below 50% even after accounting for , driven by aggressive biology and higher rates of nodal involvement.

Functional outcomes

Functional outcomes following cystectomy significantly influence patients' long-term , with urinary continence, , and metabolic health being key domains affected by the type of performed. Orthotopic neobladder reconstruction typically yields daytime continence rates of 85-95% by 12-18 months postoperatively, in contrast to ileal conduits, which are appliance-dependent and provide no spontaneous continence. Nighttime continence with neobladder is lower, with leakage occurring in 20-30% of patients at one year, often improving gradually with pelvic floor training. These differences in diversion types directly impact daily activities and well-being, though neobladders generally support better overall function. Sexual function preservation remains challenging but achievable in select cases through nerve-sparing techniques during cystectomy, with potency rates of 40-60% reported at 12 months in men undergoing such procedures. Adjunctive use of phosphodiesterase-5 (PDE5) inhibitors further aids , enhancing erectile in up to 30% of nerve-spared patients who were initially non-potent. Women may experience and orgasmic preservation more frequently with pelvic organ-sparing approaches, though comprehensive sexual health counseling is essential for both genders. Metabolic complications arise primarily from intestinal urinary diversions, with progression observed in 20-30% of patients over long-term follow-up due to factors like obstruction, , and . In ileal conduits, enteric increases the risk of kidney stone formation, with cumulative rates of approximately 20% at 10 years and 38% beyond 15 years, necessitating vigilant monitoring and dietary interventions to mitigate absorption. These issues can compound renal deterioration if not addressed promptly. Quality-of-life assessments using the EORTC QLQ-BLM30 questionnaire reveal an initial decline in physical and social functioning scores post-cystectomy, often dropping 20-30% below baseline in the first three months due to surgical recovery and adaptation to diversion. By two years, scores typically recover to about 80% of preoperative levels, reflecting adaptation to new urinary habits and resolution of early symptoms. Recent trends as of 2025 emphasize robotic-assisted diversions, which reduce intra-abdominal adhesions and thereby improve continence and potency outcomes compared to open techniques, with complication rates decreasing by up to 15% in contemporary series.