|Year : 2013 | Volume
| Issue : 3 | Page : 190-196
Quality of life after radical cystectomy for bladder cancer in men with an ileal conduit or continent urinary diversion: A comparative study
MA Asgari1, MR Safarinejad2, N Shakhssalim3, M Soleimani1, A Shahabi1, E Amini1
1 Department of Urology, Shahid Modarress Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Private Practice of Urology and Andrology, Tehran, Iran
3 Department of Urology, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
|Date of Submission||24-Mar-2012|
|Date of Acceptance||12-Jun-2012|
|Date of Web Publication||29-Jul-2013|
M R Safarinejad
Professor of Urology, Associate Editor of Urology Journal, P.O. Box 19395-1849, Tehran
| Abstract|| |
Aim: To investigate quality of life (QoL) domains with three forms of urinary diversions, including ileal conduit, MAINZ pouch, and orthotopic ileal neobladder after radical cystectomy in men with muscle-invasive bladder cancer.
Materials and Methods: In a prospective study, 149 men underwent radical cystectomy and urinary diversion (70 ileal conduit, 16 MAINZ pouch, and 63 orthotopic ileal neobladder). Different domains of QoL, including general and physical conditions, psychological status, social status, sexual life, diversion-related symptoms, and satisfaction with the treatment were assessed using an author constructed questionnaire. Assessment was performed at three months postoperatively.
Results: In questions addressing psychological status, social status, and sexual life, patients with continent diversion had a more favorable outcome ( P = 0.002, P = 0.01, and P = 0.002, respectively). The rate of erectile dysfunction did not differ significantly between the three groups ( P = 0.21). The rate and global satisfaction was higher with the MAINZ pouch (68.7%) and ileal neobladder (76.2%) as compared with the ileal conduit group (52.8%) ( P = 0.002).
Conclusion: Continent urinary diversion after radical cystectomy provides better results in terms of QoL as compared with ileal conduit diversion.
Keywords: Bladder cancer, continent diversion, orthotopic bladder substitution, radical cystectomy, quality of life
|How to cite this article:|
Asgari M A, Safarinejad M R, Shakhssalim N, Soleimani M, Shahabi A, Amini E. Quality of life after radical cystectomy for bladder cancer in men with an ileal conduit or continent urinary diversion: A comparative study. Urol Ann 2013;5:190-6
|How to cite this URL:|
Asgari M A, Safarinejad M R, Shakhssalim N, Soleimani M, Shahabi A, Amini E. Quality of life after radical cystectomy for bladder cancer in men with an ileal conduit or continent urinary diversion: A comparative study. Urol Ann [serial online] 2013 [cited 2020 Feb 17];5:190-6. Available from: http://www.urologyannals.com/text.asp?2013/5/3/190/115747
| Introduction|| |
The gold standard care for muscle-invasive bladder cancer in men is radical cystoprostatectomy with urinary reconstruction. Various methods are used for urinary diversion after radical cystectomy, including ileal conduits, cutaneous continent urinary diversion, and orthotopic neobladder reconstruction. Types of urinary diversion have a great impact on different aspects of quality of life (QoL), including micturition status, physical, sexual, and psychosocial functioning, day life activities, and distress related to body image. , A number of studies have addressed these QoL issues following radical cystectomy with various types of urinary diversions. So far, more than 30 articles have made comparisons of the impact of different types of urinary diversion on patient QoL.  A major obstacle is lacking of disease-specific QoL instrument, which universally compares patients after urinary diversion. In addition, the concept of QoL differs significantly between cultures, countries, and races. Apparently, patients with orthotopic neobladders have decreased bother related to urinary leakage, stoma appliance, and better perception of body image.  However, the assumption that continent urinary diversions yield superior QoL than ileal conduit diversion is not demonstrated by the results of most previous studies. In a review article, Gerharz et al. concluded that existing literature do not provide adequate evidence that continent urinary diversion is superior to conduit diversion, and they emphasized the importance of conducting further well designed studies.  To our knowledge, no previous studies have addressed QoL in patients with an ileal conduit urinary diversion and patients with a continent urinary diversion in Iranian population, so we performed this comparison.
| Materials and Methods|| |
During a five year period, between June 2005 and June 2010, a total of 240 patients with muscle-invasive bladder transitional cell carcinoma (TCC) underwent radical cystoprostatectomy in study sites. Of these patients, 149 met study criteria and recruited into analysis. Before proceeding for surgery, a detailed explanation of the aims and potential complications of radical cystectomy and the advantages and disadvantages of each urinary diversion method were provided for the patients. Three different types of urinary diversion were discussed with patients and their families: cutaneous diversion with ileal conduit, MAINZ Pouch II, or lower urinary tract reconstruction using orthotopic ileal neobladder. Seventy patients (47%) had undergone ileal conduit diversion; 16 (10.7%), MAINZ Pouch II; and 63 (42.3%), orthotopic ileal neobladder urinary reservoir. The mean age of these groups were 62.2 ± 8.6 years, 61.6 ± 9.4 years, and 61.9 ± 9.1 years, respectively.
Demographic and clinical characteristics, including age, smoking status, pathologic stage, tumor grade, comorbid conditions, and American Society of Anesthesiologists (ASA) score were obtained from the medical records. Laboratory examination included serum biochemistry, coagulation profile, and liver function tests. All patients underwent chest radiography, computed tomography (CT) of the abdomen and pelvis, and bone scans for tumor staging before surgery. Tumor stage and grade were recorded according to the Tumor-Node-Metastasis (TNM) and World Health Organization (WHO) system, respectively. QoL was evaluated by using the questionnaire, which has been developed by Kitamura et al.  [Appendix] [Additional file 1]. The questionnaire was physician administered.
Quantitative data were expressed as means ± standard deviations (SD). Patient groups were compared according to treatment using χ2 and Kruskal-Wallis tests for categorical variables and the Mann-Whitney U test for continuous variables. All statistical tests were two-tailed, and P < 0.05 was considered as significant. Multivariate logistic regression analysis was done to account for confounding factors. All statistical analyses were conducted by using SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA).
| Results|| |
[Table 1] demonstrates demographic and clinical characteristics of the study groups. No significant difference emerged in the age, clinical staging, and histopathological grading among subjects in the three groups. The bladder substitution group did not differ significantly from the ileal conduit group for demographic and clinical characteristics such as occupational status, level of education, stage of disease, and smoking history.
|Table 1: Distribution of selected demographic and clinical variables among the study groups |
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Urine leakage and catheterization issue
[Table 2] reports the scores of non-psychologic items. Of patients with MAINZ pouch and ileal neobladder, 13 (81.2%) and 54 (85.7%), respectively, had satisfactory continence of urine. Of patients with MAINZ pouch, 2 (12.5%) had difficulty with catheterization, while, 7 (11.1%) of the patients with ileal neobladder required intermittent self-catheterization.
|Table 2: Comparison of answers from IC, MP, and INB patients: Items having statistically significant difference, no. (%) |
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The overall mean score for the bathing, sexual desire, and desire to void like preoperative status had a significant tendency toward a higher value in the patients with bladder substitution as compared with the ileal conduit group [Table 2]. Of patients in ileal conduit, MAINZ pouch, and ileal neobladder groups, 15.7%, 50.0%, and 76.2%, respectively, did not change the way of bathing. The ileal conduit patients used public baths less frequently (11.4%) than the ileal neobladder (58.7%) and MAINZ pouch patients (50.0%) (P = 0.004). Regarding desire to void like preoperative status, patients with bladder substitution had significantly strong desire than ileal conduit patients [Table 2]. The percent 'yes' responses to the question whether they wanted to conceal their stoma (question 9) in public places were 88.6% in ileal conduit group and 62.5% in MAINZ pouch patients (P = 0.01).
Patients with ileal conduit experienced more psychological problems than patients with bladder substitution [Table 3]. There were statistically significant differences between the three groups in the five categories of tension, irritableness, loneliness, anxiety, and depression. For example, of patients in ileal conduit, MAINZ pouch, and ileal neobladder groups, 40.0%, 56.3%, and 60.3%, respectively, did not experience depression at all [Table 3].
|Table 3: Comparison of answers from IC, MP, and INB patients: Items assessing psychological status, no. (%) |
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Three months post operatively, men in ileal conduit, MAINZ pouch, and ileal neobladder groups, experienced 52.9%, 43.7%, and 42.8% decrease in general health domain of questionnaire, respectively.
The rates of patients who reported diminished hobbies were 28.6%, 31.2%, and 31.4% for ileal conduit, MAINZ pouch, and ileal neobladder groups, respectively. There were no statistically significant differences among the three groups for social status items, except for the desire to travel. Patients with ileal neobladder (52.4%) or MAINZ pouch (56.2%) were more likely to travel than patients with ileal conduit diversion (31.4%) (P = 0.02).
Of patients in ileal conduit, MAINZ pouch, and ileal neobladder groups, 7.2%, 18.7%, and 17.5% reported unaltered sexual desire, respectively (P = 0.01). The "very much" decrease in sexual desire was highest in ileal conduit patients (65.7%), followed by patients in the MAINZ pouch (50.0%) and ileal neobladder groups (23.8%). The rate of satisfaction from sexual life was 25.7%, 31.3%, and 25.4% in the ileal conduit, MAINZ pouch, and ileal neobladder groups, respectively. The difference did not reach statistical significance. Erectile dysfunction occurred in 88.6%, 87.5%, and 87.3% of sexually active men after Ileal conduit, MAINZ pouch, and ileal neobladder urinary diversion, respectively (P = 0.21).
Symptoms related to lower urinary tract reconstruction
Problems with stoma appliances, stomal catheterization, urinary incontinence, daytime and night-time urine leakage differed significantly between the three groups. Of patients in ileal conduit groups, 44.3% managed their stoma easily. But, in the MAINZ pouch group, 68.8% managed catheterization and their stoma easily. Catheterization was difficult in 31.2% and 34.9% of patients in the MAINZ pouch, and ileal neobladder groups, respectively (P = 0.43). While 50 patients with ileal neobladder (79.4%) had satisfactory voiding, only 24 (38.1%) reported upsetting to wake up for urination at night. However, global satisfaction was high, with all three forms of diversion, and 81.4% of the ileal conduit, 87.5% of the MAINZ pouch, and 88.9% of the ileal neobladder patients would choose the same diversion again.
Satisfaction with the treatment type
In the ileal conduit patients, satisfaction with the diversion was described as "poor" by 17 (24.3%), "good" by 44 (62.8%), and "very good" by 9 (12.9%). These were, 25.0%, 62.5%, and 12.5%, in the MAINZ pouch group, respectively, and 23.8%, 57.1%, and 19.1% in the ileal neobladder group, respectively. The satisfaction rate was significantly higher in ileal neobladder group as compared with the ileal conduit group (P = 0.007).
General life satisfaction was assessed by the question, "If you were to spend the rest of your life with your condition just the way it is now, how would you feel about that?" The global satisfaction was higher with the MAINZ pouch (68.7%) and ileal neobladder (76.2%) compared with the ileal conduit group (52.8%) (P = 0.002).
| Discussion|| |
This study demonstrated that patients with continent urinary diversions had better outcomes in terms of different domains of QoL, including sexual functioning, psychological status, and global satisfaction rate. The principal goal in selection of urinary diversion method is local cancer control; however, the potential for short-term and long-term complications, and the best QoL are also important factors. The ileal conduit urinary diversion is one of the oldest, simplest, and most commonly performed techniques. Many studies reported that this technique has yielded similar health-related QoL when compared with continent urinary diversions. ,, But, our study demonstrated higher global satisfaction rate with continent diversions. Despite universal popularity of the ileal conduit-type urinary diversion, the reported long-term complications with this technique is considerably high. Madersbacher et al. reported that patients who underwent ileal conduit diversion and survived at least five years had an overall complication rate of 66%, with 24% stomal complications, 24% bowel-related complications, 23% urinary tract infection, and 27% renal function deterioration.  In the present study, psychiatric distress was also low in both groups of MAINZ pouch and ileal neobladder patients. They were characterized by having a lack of sexual desire. In line with our finding, several other studies have also shown similar findings. ,, After controlling for confounding factors, type of treatment independently affects sexual function scores. In our study, treatment-related factors have a larger impact on different QoL domains, indicating that they may be more important than comorbidity in affecting QoL scores. Most studies reporting on QoL after radical cystectomy found no difference in overall QoL, ,,, which was generally good for all types of diversions.  In our series, global satisfaction rate also differed significantly across study groups.
One major problem in comparing the results of different studies is a lack of universal standard questionnaire for the purpose of addressing different domains of QoL in cystectomized patients. The problems include lack of a standard definition of Qol, and cultural differences in discernment and expression of both physical and emotional health. In addition, sample size, study design, characteristics of the population analyzed, and study site (primary vs. tertiary) are also confounding factors. The potential effects of sociocultural settings on the concept of QoL have also been raised. The cultural pattern of the studied population can affect the study results. Mansson et al. investigated possible differences between Italian and Swedish men in health-related quality of life (HRQoL) after cystectomy.  They did not find major differences in HRQoL. Another interesting confounding factor in reporting QoL after radical cystectomy is the role of a third party. Mansson et al.  demonstrates a neutral third party evaluation of QoL, as different findings were achieved when a study was performed and analyzed by a neutral third party as compared with the author or their institution.
There is a wide disparity in practice in the selection of method for urinary diversion worldwide. ,, The rates of ileal conduit diversion and orthotopic bladder replacement differ significantly from centre to centre ranging from less than 20% to more than 75%,  but most European countries favor orthotopic bladder replacements. ,, In the present study, 47.0% of recruited patients underwent ileal conduit urinary diversion. A recent consensus conference of experts under the sponsorship of the WHO and Société international d'Urologie (SIU) on urinary diversion demonstrated a change in the surgeons' practice, with nearly 50%-90% of their procedures being bladder substitution.  Patient education, describing the pros and cons of the different urinary diversion methods, and active participation of patient in selecting treatment methods appear to be some of the key points to postoperative QoL and satisfaction.
One of the major limitations of the present study is lack of addressing of the short-term and long-term complications with each technique. They were not among our study purposes. Another limitation of this study was a relatively small size of patients in subgroups. Finally, the number of patients in each of the three groups varies significantly because we did not assigned the 1:1 to each group, rather due to ethical reason they chose themselves the type of diversion.
| Conclusions|| |
Although cancer control is always the priority, QoL and patient satisfaction have also become a more accountable endpoint. We need standard QoL measures for assessing QoL after radical cystectomy and urinary diversion. The ability of current questionnaires to identify differences of neobladder and conduit patients is limited.
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[Table 1], [Table 2], [Table 3]