Urinary diversion is indicated for patients who have refractory conditions such as severe radiation or chemical cystitis, intractable bladder pain from interstitial cystitis, severe urinary incontinence, neurogenic bladder, extensive trauma, large fistula formation involving the bladder, or recurrent pyocystis. Simple cystectomy can also be undertaken for invasive nongenitourinary cancers that are not amenable to resection with partial cystectomy.

Previous attempts at urinary diversion without concomitant simple cystectomy have led to complications in 54% to 80% of patients (1,2,3). Complications include pyocystis, intractable hemorrhage, severe pain or spasms, and the sensation of incomplete emptying. In these patients, the salvage cystectomy rate ranges from 20% to 30% (1,2,3). One recent series purports much lower rates of complications. They describe only 7% of their 60 cases as having complications (three pelvic pains and one pyocystis) with none requiring salvage cystectomy (4). Given the lack of quality data, we recommend concomitant simple cystectomy when permanent urinary diversion is undertaken.

Additionally, the risk of developing urothelial cancer of the bladder is significantly increased in patients who have received previous pelvic irradiation (relative risk = 4.6) (3). Some authors have even cited a risk for malignant degeneration in the setting of chronic irritation such as interstitial cystitis (3).

Radical cystoprostatectomy in men and radical cystectomy in women should be considered as alternatives to simple cystectomy in the setting of possible prostate cancer or urothelial carcinoma (UCC) and can be considered as alternatives in nongenitourinary malignancies that are locally invasive into the bladder or in many benign diseases of the bladder. In the majority of patients, continued observation, hyperbaric oxygen, analgesic prescription, and other symptomatic treatments are the initial options, with simple cystectomy only being offered as a final intervention in patients with refractory nonmalignant disease.

In patients with nongenitourinary malignancies that are locally invasive into the bladder, simple cystectomy can be considered if the resection can be accomplished with negative margins. Laparoscopic and robotic-assisted laparoscopic techniques are also being refined and are certainly an option for appropriately trained surgeons, despite the fact that these procedures are often difficult due to the challenges of previously irradiated fields, previous surgery, and chronic infection or inflammation. Further, one group has developed a novel operative technique where the bladder is bivalved and resected, leaving a bladder base including the trigone and bladder neck. The remaining mucosa is then resected and fulgurated, with a small rim of detrusor muscle preserved (5). This technique may become another option with further validation over time.

Simple cystectomy can be undertaken extraperitoneally to avoid abdominal adhesions due to multiple previous surgeries or radiation; however, we prefer an intraperitoneal approach as these patients also frequently require concomitant urinary diversion. Antithrombotic medication, pneumatic compression cuffs, or compression stockings should be strongly considered prior to induction of anesthesia. The patient is positioned supine on the operating room table with the anterior superior iliac spines positioned over the inferior portion of the table break or kidney rest. The table is flexed to facilitate exposure, and the bed is slightly tilted in the Trendelenburg position until the abdomen is parallel to the floor. When urethrectomy is planned, a modified lithotomy position provides improved exposure to the perineum. The abdomen and pelvis are then
prepped with an antimicrobial solution extending from the costal margin superiorly to the perineum, including the penis in men and the vagina in women. The patient is draped, and a Foley catheter is inserted following sterile procedures. The bladder is allowed to drain completely. Filling the bladder with 150 to 200 mL of sterile water may facilitate the dissection.

An intravenous antibiotic agent should be administered less than 1 hour prior to skin incision. A lower midline incision extending from the umbilicus to the pubic symphysis is made. The anterior rectus fascia should be opened sharply, and the rectus abdominis muscles in the midline should then be separated to facilitate entry into the space of Retzius.

The extraperitoneal space lateral to the bladder should be bluntly developed by extending the dissection from the bladder neck cranially to the dome of the bladder. In benign conditions, incising the anterior bladder wall may facilitate the dissection. The peritoneum should be incised lateral to the bladder in a posterior direction. The ureters can often be identified as the peritoneum is divided and reflected. They should then be dissected from their surrounding attachments, with care being taken to maintain a sufficient amount of periureteral tissue. The ureteral dissection should be continued proximally and distally. In women, care must be taken to avoid the uterine artery during the distal ureteral dissection. When the superior vesical arteries are encountered crossing anterior to the distal ureters, they should be ligated with 2-0 silk ties and divided (Fig. 18.1) to allow for improved exposure of the distal ureter and maximization of the ureteral length. The ureters are then clipped close to their insertion into the bladder and divided sharply. They can be packed away to prevent injury during the remainder of the bladder dissection.

In male patients, we begin our posterior dissection several centimeters anterior to the peritoneal reflection and enter the plane between the bladder (anterior) and the vasa deferentia and seminal vesicles (posterior) (Fig. 18.2). This dissection is continued to the prostatovesical junction using a combination of blunt and sharp dissection. Attention is then returned to the anterior dissection of the prostatovesical junction. The veins overlying the prostate and bladder can be ligated with 3-0 silk suture and divided. The bladder is then drained and the Foley catheter removed. Bovie cautery is used to transect the bladder in an anterolateral direction, and the posterior bladder wall is then divided to expose the previously exposed vasa deferentia and seminal vesicles (Fig. 18.3). The lateral vascular pedicles should be readily visible and can be ligated with 2-0 silk ties and divided. Instead of suture ligation, these pedicles can also be divided using an electrothermal bipolar sealing system such as a LigaSure device or using a linear cutting surgical stapler with the appropriate staple load. At this point, the bladder should be free and can be removed. The urethra is oversewn with 3-0 Vicryl suture, and the prostatic surgical capsule is oversewn with 0 Vicryl suture (Fig. 18.4). If significant prostatic hyperplasia prevents adequate closure of the capsule, a simple prostatectomy should be considered followed by closure of the prostatic surgical capsule as previously described.