What is a Cystectomy?
A cystectomy is the surgical removal of the urinary bladder, performed either as a radical procedure (complete removal with surrounding organs) or partial procedure (segmental removal of bladder tissue), primarily used to treat muscle-invasive bladder cancer. 1
Types of Cystectomy
Radical Cystectomy
Radical cystectomy is the gold-standard surgical treatment for muscle-invasive bladder cancer and involves complete removal of the bladder along with adjacent organs. 1, 2
The procedure differs by sex:
- In men: Includes removal of the bladder, prostate, seminal vesicles, proximal vas deferens, and proximal urethra (cystoprostatectomy) 1
- In women: Includes removal of the bladder, uterus, ovaries, fallopian tubes, urethra, and part of the vagina (cystectomy with hysterectomy) 1
Bilateral pelvic lymph node dissection (PLND) is mandatory and considered an integral part of the procedure, including at minimum the common iliac, internal iliac, external iliac, and obturator nodes. 2, 1 Extended PLND that includes lower para-aortic or para-caval nodes yields more examined nodes and is associated with better survival and lower pelvic recurrence rates. 1
Partial (Segmental) Cystectomy
Partial cystectomy involves removing only a portion of the bladder with surrounding tissue margins and is appropriate in fewer than 5% of muscle-invasive bladder cancer cases. 2, 1
Strict criteria must be met:
- Solitary tumor in a suitable location (typically the dome of the bladder) with ability to achieve a minimum 2 cm margin of uninvolved urothelium 2, 1
- No carcinoma in situ (Tis) present in other areas of the bladder 2, 1
- Adequate bladder capacity and continence can be preserved after resection 1
- Bilateral PLND must still be performed with the same nodal stations as radical cystectomy 2
Lesions in the trigone or bladder neck are relative contraindications, though ureteral reimplantation is not an absolute contraindication. 1, 2
Urinary Diversion Following Radical Cystectomy
After bladder removal, urinary diversion is necessary to redirect urine flow. 1 Options include:
- Ileal conduit: External collection system draining to the abdominal wall 1
- Continent urinary reservoir: Internal pouch with drainage to the abdominal wall or urethra 1
- Orthotopic neobladder: Provides bladder function most similar to native bladder, with drainage to the urethra, though carries increased risk of nighttime incontinence and urinary retention requiring intermittent self-catheterization 1
Relative contraindications to urethral drainage include Tis in the prostatic ducts or positive urethral margin. 1
Critical Caveats
Clinical staging is notoriously inaccurate—42% of patients are upstaged following cystectomy, making preoperative assessment unreliable. 1, 2 This frequent understaging emphasizes the importance of proceeding with definitive surgical treatment when indicated. 1
If intraoperative findings during attempted partial cystectomy reveal more extensive disease than anticipated, immediate conversion to radical cystectomy should be performed. 1, 2
Patient factors that may preclude PLND include severe scarring from previous treatments, advanced age, or severe comorbidities, though these should not automatically exclude patients from cystectomy itself. 1