# Radical Cystectomy and Urinary Diversion

## Overview

Radical cystectomy involves the surgical removal of the bladder along with a pelvic lymph node dissection. The boundaries of lymph node dissection vary depending on the template used, ranging from standard to extended and super-extended templates. Urinary diversion options after cystectomy include the ileal conduit, orthotopic neobladder, and continent cutaneous diversion. Enhanced recovery after surgery (ERAS) protocols have been developed to optimize perioperative care and improve patient outcomes.

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## Indications for Radical Cystectomy

The primary indication for radical cystectomy is muscle-invasive bladder cancer, specifically stages T2 through T4a. It is also indicated for patients with high-risk non-muscle-invasive bladder cancer (NMIBC) that is unresponsive to Bacillus Calmette-Guérin (BCG) therapy, especially when adverse features are present. Recurrent high-grade NMIBC that progresses despite maximal intravesical therapy is another indication. Additionally, radical cystectomy is appropriate for non-urothelial histologies with muscle invasion, such as squamous cell carcinoma, adenocarcinoma, and small cell carcinoma. In cases of refractory or nonfunctional bladder conditions, such as radiation cystitis or a contracted bladder, cystectomy may be performed for palliative reasons.

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## Preoperative Assessment

A thorough preoperative assessment is essential and includes complete staging with imaging such as CT scans of the chest, abdomen, and pelvis, and a bone scan if symptoms suggest metastatic disease. Renal function must be evaluated, typically by assessing the glomerular filtration rate (GFR), as this influences the choice of urinary diversion. Nutritional optimization is important, with albumin levels ideally above 3.0 g/dL, and prehabilitation programs can improve surgical fitness. Cardiopulmonary evaluation ensures the patient can tolerate major surgery. Neoadjuvant chemotherapy should be considered according to current guidelines. Preoperative stoma site marking by a wound or ostomy nurse is critical for patients undergoing diversion. Counseling patients on all available diversion options facilitates shared decision-making. Finally, venous thromboembolism (VTE) risk assessment is necessary, with high-risk patients benefiting from extended prophylaxis.

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## Surgical Technique — Radical Cystectomy

### In Males

The male radical cystectomy involves removal of the bladder, prostate, seminal vesicles, distal ureters, and pelvic lymph nodes. The urethra is resected if there is a positive urethral margin or involvement of the prostatic urethra. Nerve-sparing techniques may be employed in select patients who are younger and have organ-confined disease to preserve sexual potency.

### In Females

In females, the procedure typically includes removal of the bladder, urethra (often), uterus, fallopian tubes, ovaries, anterior vaginal wall, and pelvic lymph nodes. The urethra may be preserved if it is free of tumor and an orthotopic neobladder is planned. Ovarian preservation in premenopausal women requires individualized discussion. Vaginal-sparing techniques, which avoid anterior vaginectomy in select cases, can reduce sexual dysfunction.

### Approach: Open vs. Robotic

The traditional open approach involves a longer incision and provides direct tactile feedback. Robot-assisted radical cystectomy (RARC) is increasingly performed, with the RAZOR trial demonstrating non-inferior two-year progression-free survival compared to open surgery. Regarding urinary diversion, extracorporeal diversion involves constructing the diversion through an abdominal incision and is the traditional method used with RARC. Intracorporeal diversion, where the entire procedure including the diversion is performed robotically, has been shown in the iROC trial to reduce complications and shorten hospital stay. Consequently, intracorporeal diversion is increasingly considered the standard approach for RARC.

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## Pelvic Lymph Node Dissection

### Standard Template

The standard pelvic lymph node dissection (PLND) includes removal of nodes in the external iliac, obturator fossa, and internal iliac regions. This template is considered the minimum adequate dissection as it removes the majority of involved nodes.

### Extended Template

The extended template adds dissection of the common iliac and presacral nodes up to the aortic bifurcation. This approach detects more positive nodes and may provide a therapeutic benefit. It is recommended for all patients with muscle-invasive bladder cancer undergoing cystectomy. However, the LEA AUO AB 25/02 trial found no improvement in recurrence-free survival with extended PLND compared to the standard template, making its therapeutic benefit controversial.

### Super-Extended Template

The super-extended template includes nodes up to the inferior mesenteric artery, adding para-aortic nodes to the extended template. Due to limited data, this approach is not routinely performed.

### Lymph Node Count

Adequate staging requires removal of at least 10 to 14 lymph nodes. Higher lymph node counts correlate with improved survival, likely due to stage migration effects and potential therapeutic benefits.

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## Urinary Diversion Options

### Ileal Conduit (Incontinent Diversion)

The ileal conduit is the most common urinary diversion worldwide, accounting for approximately 70% of cases. It involves isolating a 15 to 20 cm segment of ileum on its mesentery. The ureters are anastomosed to the proximal end of this segment using the Bricker technique, which is an end-to-side ureteroileal anastomosis. The distal end is brought to the skin as a stoma, typically located in the right lower quadrant. Urine drains continuously into an external collection appliance or ostomy bag. The ileal conduit is technically simpler, has a shorter operative time, and a lower complication rate, making it suitable for all patients. However, it requires an external appliance, which can cause body image concerns and stoma-related complications such as stenosis (5-15%), parastomal hernia (10-20%), skin irritation, and stoma retraction.

### Orthotopic Neobladder (Continent Diversion — Voiding)

The orthotopic neobladder uses a detubularized bowel reservoir that is sutured to the urethra, allowing the patient to void by Valsalva maneuver and pelvic floor relaxation. The most common configurations are the Studer neobladder and the Hautmann W-pouch, both constructed from ileum. This diversion offers the advantage of no external appliance and voiding per urethra, providing the best body image and quality of life for many patients. However, it is a complex surgery with longer operative time. Nighttime incontinence occurs in 20-40% of patients, and 5-15% may experience hypercontinence requiring clean intermittent catheterization (CIC). Metabolic complications can also occur. Candidates must have adequate renal function (GFR >40-50), no urethral tumor involvement, negative urethral margins confirmed by frozen section, motivation and dexterity to perform CIC if needed, and sufficient bowel length. Contraindications include positive urethral margins, significant renal insufficiency, high-dose pelvic radiation, inflammatory bowel disease, and inability or unwillingness to perform CIC. In females, neobladder construction is feasible if the urethra is preserved, though adoption rates are lower; outcomes are comparable in select patients.

### Continent Cutaneous Diversion (Indiana Pouch, Kock Pouch)

Continent cutaneous diversion involves creating a bowel reservoir with a continent catheterizable stoma, usually located in the right lower quadrant or umbilicus. Patients empty the reservoir by self-catheterization every 4 to 6 hours. The Indiana pouch uses the right colon and terminal ileum, with the efferent limb plicated to maintain continence. This diversion avoids the need for an external appliance and urethral anastomosis. However, it requires reliable CIC and has higher revision rates, with stomal stenosis occurring in about 20% of cases. Metabolic complications are also a concern. This option is less commonly performed and is reserved for patients desiring continence but who cannot have a neobladder due to urethral involvement or prior urethrectomy.

| Feature | Ileal Conduit | Orthotopic Neobladder | Continent Cutaneous (Indiana Pouch) |
|---|---|---|---|
| Frequency | ~70% of diversions | ~25% | ~5% |
| Continence mechanism | None (incontinent) | Urethral sphincter + Valsalva | Catheterizable stoma (CIC q4-6h) |
| External appliance | Yes (ostomy bag) | No | No |
| CIC required | No | 5-15% (hypercontinence) | Always |
| Nighttime incontinence | N/A | 20-40% | Rare |
| Operative complexity | Simplest | Most complex | Complex |
| Key contraindications | None (suitable for all) | Positive urethral margin, GFR <40-50, prior pelvic XRT, inability/unwillingness for CIC | Inability to perform CIC |
| Stomal complications | 15-35% (stenosis, hernia) | N/A | ~20% stomal stenosis |
| Body image | External bag concerns | Best (voids per urethra) | Good (no external bag) |

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## Metabolic Complications of Urinary Diversion

The most common metabolic complication is hyperchloremic metabolic acidosis, which occurs because the bowel segment absorbs chloride and ammonium while excreting bicarbonate. This is more frequent with longer bowel segments and prolonged urine contact time. Treatment involves oral sodium bicarbonate supplementation. Vitamin B12 deficiency can develop when more than 60 cm of terminal ileum is used, necessitating annual monitoring starting 3 to 5 years postoperatively. Deficiencies of fat-soluble vitamins A, D, E, and K may occur due to ileal loss. Electrolyte abnormalities such as hypokalemia (especially with colonic segments) and hyponatremia are possible. Renal deterioration occurs in 10-20% of patients long-term due to factors like reflux, obstruction, infection, and metabolic disturbances. There is a theoretical risk of secondary malignancy at the urointestinal anastomosis site after more than 10 years, although the incidence is low. Nephrolithiasis risk is increased due to metabolic derangements.

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## Enhanced Recovery After Surgery (ERAS) for Cystectomy

Key elements of ERAS protocols for radical cystectomy begin preoperatively with carbohydrate loading and avoidance of prolonged fasting. Alvimopan, a mu-opioid receptor antagonist, is administered to reduce postoperative ileus. Intraoperatively, goal-directed fluid therapy and maintenance of normothermia are emphasized, with minimally invasive approaches used when feasible. Postoperatively, early ambulation is encouraged starting on the day of surgery or postoperative day one. Early oral intake begins with clear fluids on the day of surgery and advances as tolerated on postoperative day one. Multimodal analgesia aims to minimize opioid use and includes regional anesthesia or transversus abdominis plane (TAP) blocks, acetaminophen, NSAIDs, and gabapentin. Alvimopan is continued for up to 15 doses postoperatively. Early removal of catheters and drains is part of the protocol, along with extended venous thromboembolism prophylaxis using low molecular weight heparin for 28 days after discharge. Chewing gum is used as sham feeding to stimulate bowel motility. ERAS protocols have been shown to reduce length of hospital stay (median 5-7 days versus 8-12 days), 30-day complications, and readmission rates. Despite these improvements, the 90-day complication rate remains high at 50-60% for Clavien grade 2 or higher, reflecting the high morbidity associated with cystectomy.

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## Complications

### Early (≤30 Days)

The most common early complication is ileus, occurring in 10-25% of patients. Wound infection and dehiscence are also frequent. Urine leaks from the ureteroileal anastomosis occur in 3-5% of cases. Pelvic abscesses and lymphoceles may develop. Deep vein thrombosis and pulmonary embolism occur in 3-5%. Cardiac events and pneumonia are additional concerns during the early postoperative period.

### Late (>30 Days)

Late complications include ureteroileal strictures, which occur in 3-10% of patients and can lead to hydronephrosis, urinary tract infections, and renal deterioration. Stomal complications in conduit patients include stenosis, hernia, and prolapse. Neobladder-specific issues include hypercontinence, nocturnal enuresis, urinary retention, and pouch stones. Incisional hernias develop in 10-20% of patients, and small bowel obstruction occurs in 5-10%. Chronic kidney disease progression is a significant long-term concern.

### Mortality

The 90-day mortality rate ranges from 2-5% at high-volume centers but is higher at low-volume centers. There is a strong volume-outcome relationship, with significantly better outcomes at centers performing 20 or more cystectomies per year.

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<image>An anatomical illustration showing the three main types of urinary diversion after radical cystectomy side by side: ileal conduit (showing isolated ileal segment with stoma and external appliance), orthotopic neobladder (showing detubularized ileal reservoir anastomosed to urethra in Studer configuration), and continent cutaneous diversion (Indiana pouch with right colon reservoir and catheterizable stoma). Each type is labeled with key surgical landmarks, ureteral anastomosis sites, and continence mechanism. Surgical anatomy illustration style with anterior view of pelvis.</image>

<image>A diagram illustrating the pelvic lymph node dissection templates during radical cystectomy: standard (external iliac, obturator, internal iliac), extended (adding common iliac and presacral up to aortic bifurcation), and super-extended (to inferior mesenteric artery). Overlaid on an anterior pelvic vascular anatomy diagram with lymph node groups color-coded. Key anatomical landmarks labeled including ureters, iliac vessels, obturator nerve, and genitofemoral nerve. Surgical anatomy illustration style.</image>

<image>An ERAS protocol infographic for radical cystectomy organized as a timeline from preoperative (day -1) through postoperative days 0-7. Each day shows key interventions: carbohydrate drink, alvimopan, ambulation targets, diet advancement, pain management strategy, drain/catheter management, and discharge criteria. Icons represent each intervention category. Hospital-based clinical pathway format with color-coded categories.</image>

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## Clinical Pearls

Radical cystectomy is associated with the highest morbidity among urologic procedures, with 90-day complication rates of 50-60% even at high-volume centers, underscoring the importance of thorough preoperative optimization. ERAS protocols significantly reduce length of hospital stay and complications, with alvimopan administration and early oral intake being particularly impactful. The orthotopic neobladder is not suitable for every patient; adequate renal function, negative urethral margins, patient motivation for potential clean intermittent catheterization, and absence of contraindications must be ensured before offering this option. Extended pelvic lymph node dissection should be performed for all muscle-invasive bladder cancer cystectomies to improve staging accuracy, despite ongoing debate about its therapeutic benefit. Intracorporeal urinary diversion during robot-assisted radical cystectomy reduces complications compared to extracorporeal diversion and is becoming the standard approach. Lifelong monitoring of all patients with urinary diversion is essential to detect renal function decline, metabolic acidosis, vitamin B12 deficiency (especially with ileal diversions), ureteroileal strictures, and secondary malignancy. Finally, there is a strong volume-outcome relationship in radical cystectomy; patients should be referred to high-volume centers performing at least 20 cases per year whenever possible.

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## References

- Parekh DJ, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR). Lancet. 2018;391(10139):2525-2536  
- Catto JWF, et al. Effect of robot-assisted radical cystectomy with intracorporeal urinary diversion vs. open radical cystectomy (iROC). JAMA. 2022;327(20):2011-2022  
- Hautmann RE, et al. ICUD-EAU International Consultation on Bladder Cancer: Urinary diversion. Eur Urol. 2013;63(1):67-80  
- Cerantola Y, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: ERAS Society recommendations. Clin Nutr. 2013;32(6):879-887  
- NCCN Clinical Practice Guidelines in Oncology: Bladder Cancer, Version 3.2024