What is the management approach for cysts in the bladder?

Management of Bladder Cysts

The management of bladder cysts depends entirely on their nature: benign simple cysts require surgical excision (laparoscopic partial cystectomy preferred), while cystic bladder lesions suspicious for malignancy require cystoscopic biopsy followed by treatment based on pathology. 1, 2

Initial Diagnostic Approach

Imaging and Cystoscopy

• Perform cystoscopy to directly visualize the cystic lesion and determine its characteristics (location, size, appearance, whether it communicates with the bladder lumen). 1, 2
• CT urography without and with IV contrast provides comprehensive evaluation of the bladder and can help characterize cystic lesions, assess for associated pathology, and evaluate the upper urinary tract. 3
• Voiding cystourethrography (VCUG) may be indicated if there are associated voiding symptoms or concerns about bladder outlet obstruction. 3

Key Diagnostic Distinctions

• Differentiate between benign simple cysts (subserous, urachal cysts) versus cystic presentations of bladder pathology (cystitis cystica, cystic bladder tumors). 1, 2, 4
• Simple bladder cysts are rare and typically subserous, while cystitis cystica can present as large solitary cystic lesions within the bladder wall. 1, 2
• Microcystic transitional cell carcinomas can mimic benign cysts and require tissue diagnosis to exclude malignancy. 5

Management Based on Cyst Type

Benign Simple Cysts

• Laparoscopic partial cystectomy is the preferred operative procedure for confirmed benign bladder cysts. 1
• For cysts at the bladder dome potentially related to urachal remnants, remove the cyst with the urachus using laparoscopic surgery. 1
• Transurethral resection may be attempted first for accessible lesions, but definitive excision often requires partial cystectomy. 1

Cystitis Cystica

• Transurethral deroofing of the bladder wall cyst is the treatment of choice for cystitis cystica presenting as a large solitary cyst. 2
• This can be performed cystoscopically under general anesthesia with urethral dilatation if needed. 2
• Histologic confirmation is essential as this presentation is rare and can be confused with neoplastic processes. 2

Suspicious or Indeterminate Cystic Lesions

Biopsy Approach

• Perform cystoscopic biopsy of any suspicious cystic lesion where malignancy is in the differential diagnosis. 6
• Flexible cystoscopy with biopsy provides diagnostic yield in approximately 89% of cases, with about 18% detecting malignancy. 6
• If initial flexible cystoscopy biopsy is non-diagnostic (occurs in ~11% of cases) but suspicion for malignancy remains, proceed to rigid cystoscopy with deeper biopsy. 6
• Be aware that microcystic transitional cell carcinomas can be deeply invasive and may cause interpretation problems, particularly in limited biopsy specimens. 5

If Malignancy Confirmed

• For superficial disease (Ta, T1, Tis): Follow non-muscle invasive bladder cancer protocols with transurethral resection and intravesical BCG therapy. 7
• For muscle-invasive disease: Radical cystectomy is standard, though bladder-sparing approaches may be considered in highly selected cases (solitary lesions <2 cm with minimal muscle invasion, no hydronephrosis, no carcinoma in situ). 7

Follow-Up After Treatment

Post-Surgical Monitoring

• Cystoscopy at 3-month intervals for the first year, then at increasing intervals to monitor for recurrence or complications. 7, 8
• Post-surgical monitoring should continue for at least 3-6 months to ensure proper healing after bladder procedures. 8
• Monitor for complications including strictures, reduced bladder compliance, or impaired function during the healing period. 8

Critical Pitfalls to Avoid

• Do not assume all bladder cysts are benign—microcystic transitional cell carcinomas can present with prominent cystic features and be deeply invasive. 5
• Do not rely solely on flexible cystoscopy biopsy if the sample is inadequate—proceed to rigid cystoscopy for better tissue sampling. 6
• Do not confuse simple bladder cysts with urachal tumors—imaging characteristics and location help distinguish these entities. 1
• False-positive imaging results can occur from benign prostatic hypertrophy mimicking bladder lesions or intravesical blood clots. 3