Bladder pain syndrome/Interstitial cystitis (BPS/IC) is a poorly understood chronic debilitating inflammatory disease of unknown aetiology that is familiar to most practitioners in urology and urogynaecology. Due to it is frequent association with negative behavioural, sexual or emotional experiences, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction. Surgical intervention is reserved for the most severe refractory cases, and includes subtotal cystectomy, orthotopic neobladder formation, total cystectomy and urinary diversion. However, to date, there is no consensus on patient selection for surgery or the optimal surgical approach. We aimed to systematically review the available literature, and evaluate the evidence relating to safety and efficacy of surgical interventions for treating BPS/IC.

A systematic search of the PubMed and Scopus databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) (fig.1) 
Published studies were searched for using the search terms “interstitial cystitis AND surgery”,  and “bladder pain syndrome AND combined with the terms cystectomy and surgery. Articles were reviewed and screened by three independent reviewers. A total of 20 studies met the inclusion/exclusion criteria. The results were tabulated, and classified by surgical technique.

A total of 450 subjects were identified from the 20 eligible studies (1990-2017): mean age 54.5 years: 406 female patients (90.2%): 44 male patients (9.8%). The median duration of symptoms pre-operatively was 60 months (range 9-84), with median follow-up 49.4 months.  The NIDDK diagnostic criteria were used in 11 studies totaling 240 patients (53.3%): the remaining patients were diagnosed using other clinical criteria. A total of 448 patients underwent surgery: 218 subtotal cystectomy with augmentation (48.6%); 98 cystectomy and orthotopic neobladder (21.9%); 40 cystectomy and ileal conduit (11.2%); and 82 urinary diversion only (18.3%). Satisfactory symptomatic improvement occurred in 77.2%. Rates were highest in the total cystectomy and orthotopic neobladder group (94.9%). A total of 31 patients (6.9 %) required a secondary procedure (i.e. total cystectomy and/or ileal conduit diversion): 48.4% had subsequent symptomatic improvement. Seventeen studies (357 patients) reported complication rates: 102 complications were reported overall (26.5%), with post-operative sepsis being the most common (26.6%). Mortality occurred in 5 patients (1.4%).

Total cystectomy with orthotopic neobladder appears to offer the highest rate of satisfactory symptomatic improvement following surgery; whilst urinary diversion alone produces the lowest rate. This may be attributed to recurrent/residual disease in the remaining bladder. Despite this, surgical intervention of any kind offers symptomatic improvement and patient satisfaction greater than 60%.  Interpretation of this data should be guarded, however, given the low patient numbers and variable outcome measures used.

To our Knowledge this is the first systematic review that analyses all major open surgical techniques for treating Interstitial Cystitis/Bladder pain syndrome. The choice of operation for patients within this cohort remains a topic of debate and one which we cannot categorically recommend in this review. There is a clear need for prospective studies and randomisation of patients to fully differentiate between total cystectomy and bladder conserving procedures. However, the data suggests that in all instances, total removal of the bladder may yield more favourable long-term results in patients who do not have typical end-stage disease, and reduces the risk of requiring a secondary procedure. Interpretation of this data should be guarded given the relatively low patient numbers, risk of selection bias and lack of a consensus on diagnostic criteria. Ultimately the decision to operate and the best procedure to perform should be a joint MDT decision that takes into account patients choice on continence, self-catheterisation, body image and the risk of complications for a syndrome that is fundamentally benign. Ultimately, any procedure offers over a 60% chance of success and for some patients who have exhausted all other therapy, this may be a viable option. We have to keep in our minds that the management of patent expectations throughout this process is as important as the pre, peri and post-operative clinical management and should remain central in the treatment of BPS.