A cystectomy is a major surgical procedure involving the removal of the urinary bladder. This surgery is most frequently performed to treat aggressive or recurrent cancers of the bladder lining. Because the bladder stores and controls the elimination of urine, surgeons must create a new system for the body to manage waste after removal. This process is called urinary diversion.
Medical Conditions Requiring Removal
The most common reason for a cystectomy is muscle-invasive bladder cancer (MIBC), where malignant cells have grown into the deep muscle layers of the bladder wall. This stage carries a significant risk of metastasis, making complete organ removal the standard of care for achieving a cure. The procedure is also required for high-grade non-muscle-invasive bladder cancer (NMIBC) that does not respond to initial treatments, such as intravesical immunotherapy.
Beyond cancer, severe, non-malignant conditions can necessitate bladder removal. These include debilitating interstitial cystitis, a chronic pain syndrome that has failed all other therapeutic measures. A cystectomy may also be required to manage severe, chronic radiation injury to the bladder, known as radiation cystitis, resulting from previous pelvic radiation. In rare instances, severe trauma or complex congenital abnormalities of the urinary tract that cannot be functionally repaired may also lead to the recommendation for removal.
Defining Partial and Radical Cystectomy
The term cystectomy encompasses two distinct surgical approaches: partial and radical. A partial cystectomy involves removing only the portion of the bladder wall containing the tumor or damaged tissue. This approach is reserved for highly localized, solitary tumors that are not muscle-invasive and are located away from the bladder’s neck, allowing the remaining bladder to stay intact and functional.
A radical cystectomy involves the complete removal of the entire bladder and is the standard procedure for muscle-invasive bladder cancer. Because bladder cancer often spreads to nearby lymph nodes, a thorough dissection and removal of the pelvic lymph nodes is performed simultaneously for staging and treatment purposes. This extensive surgery also includes the removal of surrounding reproductive organs due to their close proximity to the bladder.
In male patients, a radical cystectomy usually involves removing the prostate gland and seminal vesicles. For female patients, the procedure involves the removal of the uterus, ovaries, fallopian tubes, and often a portion of the anterior vaginal wall.
Reconstructing Urinary Function
Since a radical cystectomy removes the organ responsible for urine storage, a critical part of the surgery is creating a new pathway for urine to exit the body, known as urinary diversion.
Ileal Conduit
The ileal conduit is the most common method and is an incontinent diversion. Surgeons use a short segment of the small intestine (ileum) to connect the ureters to the outside of the body. This segment is brought through the abdominal wall to create an opening called a stoma. Urine drains continuously from the stoma and is collected in a pouch worn externally on the abdomen.
Continent Cutaneous Reservoir
This alternative allows the patient to store urine internally without an external bag. A pouch is created inside the abdomen using a segment of the intestine to hold the urine. The patient empties this internal reservoir several times a day by inserting a catheter through a small, valved stoma. This option offers continence but requires the patient to perform intermittent self-catheterization.
Orthotopic Neobladder
The orthotopic neobladder aims to restore the most natural urinary function by avoiding a stoma entirely. A new reservoir is constructed from a segment of the intestine and connected to the patient’s existing urethra. Following recovery, the patient learns to void through the urethra by contracting abdominal muscles, though self-catheterization may still be necessary to fully empty the neobladder.
The neobladder is a more complex procedure and is not suitable for all patients, particularly those with poor kidney function or pre-existing urinary control issues. Both the neobladder and the continent cutaneous reservoir are considered continent diversions, but they carry a higher risk of complications compared to the simpler ileal conduit. The choice of diversion depends on the patient’s overall health, manual dexterity, and personal preference.
Non-Surgical Treatment Options
Before proceeding with a cystectomy, patients with bladder cancer are evaluated for non-surgical alternatives that aim to preserve the bladder. For non-muscle-invasive bladder cancer, a primary treatment is intravesical immunotherapy, most commonly using Bacillus Calmette-Guérin (BCG). This involves instilling a solution directly into the bladder to stimulate a localized immune response against the cancer cells.
For muscle-invasive bladder cancer, a bladder-sparing approach involves trimodality therapy. This regimen combines a maximum transurethral resection of the tumor with systemic chemotherapy and external beam radiation therapy. This option is reserved for selected patients who are not surgical candidates or who wish to avoid bladder removal.
Systemic chemotherapy, known as neoadjuvant therapy, is also commonly used prior to surgery to shrink tumors and treat any microscopic spread before the radical cystectomy. Newer treatments include immune checkpoint inhibitors, such as pembrolizumab, which activate the body’s T-cells to attack cancer cells. These agents are increasingly used for patients whose bladder cancer is unresponsive to traditional therapies.