Purpose <p>Cancer survivors with a history of pelvic radiation may suffer devastating side effects best managed by cystectomy. Simple cystectomy is a less morbid alternative to radical cystectomy. While safe, concern exists that it may place patients at risk for incomplete treatment of secondary bladder malignancy. We assessed the rates of malignancy found on simple, post-radiation cystectomy specimens from patients with a history of radiation therapy for pelvic malignancies.</p> Methods <p>We reviewed all benign cystectomies at our institution from 2010 to 2023. Patients with a known history of urothelial cancer, cystectomy performed for malignancy, non-cancer survivorship indications (i.e. neurogenic bladder or trauma), and patients without a history of radiation were excluded. Surgical pathology was reviewed for residual and/or secondary malignancy.</p> Results <p>111 patients had a history of radiation therapy and met inclusion criteria. Prostate cancer was the most common pelvic malignancy (83.8%). All patients had an end-stage bladder defined by our algorithmic assessment. No patients (0%) had evidence of urothelial malignancy on the final pathology of the post-radiation cystectomy specimen. There were no new diagnoses of secondary malignancy at the median follow-up of 30 (0.1–138) months. Of 42 patients with primary prostate cancer who had not undergone prior prostatectomy, 2 (4.8%) had residual prostate cancer in the remaining prostate on pathology.</p> Conclusion <p>In this cohort, secondary bladder malignancy was not identified. Rates of residual prostate malignancy were low in patients with radiation alone. Post-radiation simple cystectomy is a reasonable option for cancer survivors undergoing extirpative surgery where oncological control is not the primary indication.</p>