Quality of Life after Surgery for Bladder Cancer

The treatment of muscle-invasive urothelial bladder cancer (MIUBC) often involves radical cystectomy (removal of the bladder) and reconstruction of the urinary system. Removing a major urological organ and reconstructing the urinary system can have major impact on the quality-of-life of patients both in the immediate post-operative period and long-term as they become survivors of the disease. This blog will review the current understanding of quality-of-life (QOL) after cystectomy and urinary reconstruction.

DIFFICULTIES ASSESSING QOL IN THE BLADDER CANCER POPULATION

Determining QOL can be difficult for patients undergoing major cancer surgeries. Many cancers and subsequent operations do not have questionnaires designed specifically to address the issues of a patient recovering from that disease and surgery. Bladder cancer and radical cystectomy is no exception. Determining the important questions to ask a patient with bladder cancer who is undergoing surgery can be challenging. In addition, there are a variety of urinary diversions offered to patients undergoing radical cystectomy including:

• Incontinent, Ileal Conduit (or other bowel segment conduit)
• Continent, Catheterizable Reservoir (i.e. Indiana Pouch, Koch Pouch, etc.)
• Orthotopic Neobladder - reservoir attached to the native urethra

Ileal conduit (left); Continent, Catheterizable Reservoir (Indiana Pouch, middle);
Orthotopic Neobladder (right)

Each urinary reconstruction carries different risks and benefits, and, in general, is offered to very different groups of patients. In general, older, sicker patients are often only offered an incontinent conduit; while neobladders are more common in younger, healthier patients. Creating a QOL questionnaire that address the concerns of each patient group can be challenging and frankly, does not exist.

TIMING OF QOL

Inherent to all cancer operations, patients must undergo a period of recovery which can be challenging both physically and emotionally. Knowing when to evaluate QOL relative to surgery date may give differing outcomes at different times for different patients. For instance, a patient who is slow to recover may have a worse QOL shortly after surgery when compared to a patient who recovers differently.  If they have different urinary diversions, parsing out QOL related to recovery and urinary diversion can be difficult.

It is known is that levels of psychological distress decrease significantly 1 month after surgery compared to preoperative levels. One study demonstrated that 45% of patients demonstrated psychological distress prior to cystectomy, which decreased to 34% one month after surgery and included significant improvements in general distress, depression and anxiety.[1] While recovery may affect QOL and vary from patient to patient, it is also demonstrated that psychological and health-related QOL stabilizes at about 12 months following radical cystectomy.[2]

From Kulaksizoglu etal. EurUrol, 2002 [2].

QOL AFTER SURGERY

Health and body image are two of the biggest concerns for patients facing radical cystectomy and urinary diversion. Family relationships, general health and finances are the biggest determinants of QOL following surgery for an individual.[3] 
Much emphasis has been placed on the QOL as related to different urinary diversions. Most patients assume that an incontinent diversion (conduit) will lead to an adverse QOL compared to a continent diversion (catheterizable reservoir or neobladder). However, each diversion has a different subset of complications and each patient group has different priorities that determine their QOL. In addition, most surgeons (and therefore researchers) do not routinely perform all diversions and have a preference for their patients. Importantly, no urinary diversion has been demonstrated to be superior to another with regard to QOL.

ILEAL CONDUIT COMPARED TO CONTINENT RESERVOIR

One of the only long-term study comparing ileal conduit to a continent reservoir demonstrated that QOL was good in all long-term survivors of bladder cancer. In general, all patients were satisfied with their diversion and had adapted well socially, physically and psychologically; and the type of urinary diversion does not appear to be associated with differential quality of life.[4] Another study demonstrated that, while patients with a continent reservoir had enhanced QOL regarding the stoma, travel and sleeping habits; they were bothered by night time self-catheterization.[5]

ILEAL CONDUIT COMPARED TO ORTHOTOPIC NEOBLADDER

In one study of 102 patients, neobladder patients were more able to adapt to their new life and had a better QOL with regard to self-confidence, rehabilitation; and restoration of leisure, professional, travelling, and social activities.[6] However other studies indicated that the QOL differences between neobladder and ileal conduit are non-existent or marginal at best, highlighting that the younger age and improved health in general of neobladder patients may account for the small differences in QOL.[7,8]

Results of individual SF-36 Questionnaire domains. GH, general health.
HC, health change. PF, physical functioning. PH, physical health.
EH, emotional health. SF, social functioning. Pain, overall pain.
Energy, energy/fatigue level. EWB, emotional well-being.
Asterisk indicates domains that significantly favored patients
with neobladder.[7]

No difference in overall global satisfaction after urinary diversion.[7]

COMPARISON OF ILEAL CONDUIT, CONTINENT CATHETERIZABLE RESERVOIR AND NEOBLADDER

A systematic review of all the literature comparing all urinary diversions after radical cystectomy failed to reveal a difference in QOL among the urinary reconstructions.[9]

 

SUMMARY

• A variety of reconstructive techniques exist for patients undergoing radical cystectomy for bladder cancer. These include continent and incontinent reconstructions that may use the native urethra or a new urostomy (opening).
• Determining QOL after surgery for bladder cancer is difficult given the heterogeneous nature of patients with bladder cancer and the complex decision-process to determine the most appropriate urinary diversion for a given patient.
• Given the limitations of QOL research for urinary diversion, a number of research studies fail to demonstrate superiority of any diversion type with regard to psychological or health-related QOL.
• The decision regarding urinary diversion should take into account a variety of patient, cancer and surgeon factors.  Consultation with a surgeon or center experienced in multiple diversions may help patients make the best decision for them.

 
[1] Palapattu GS, Haisfield-Wolfe ME, Walker JM, BrintzenhofeSzoc K, Trock B, Zabora J, Schoenberg M. Assessment of perioperative psychological distress in patients undergoing radical cystectomy for bladder cancer. J Urol. 2004 Nov;172(5 Pt 1):1814-7.
[2] Kulaksizoglu H, Toktas G, Kulaksizoglu IB, Aglamis E, Unlüer E. When should quality of life be measured after radical cystectomy? Eur Urol. 2002 Oct;42(4):350-5.
[3] Somani BK, Gimlin D, Fayers P, N'dow J. Quality of life and body image for bladder cancer patients undergoing radical cystectomy and urinary diversion--a prospective cohort study with a systematic review of literature. Urology. 2009 Nov;74(5):1138-43. doi: 10.1016/j.urology.2009.05.087. Epub 2009 Sep 20.
[4] Hart S, Skinner EC, Meyerowitz BE, Boyd S, Lieskovsky G, Skinner DG. Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, cutaneous or urethral kock pouch. J Urol. 1999 Jul;162(1):77-81.
[5] Okada Y, Oishi K, Shichiri Y, Kakehi Y, Hamaguchi A, Tomoyoshi T, Yoshida O. Quality of life survey of urinary diversion patients: comparison of continent urinary diversion versus ileal conduit. Int J Urol. 1997 Jan;4(1):26-31.
[6] Hobisch A, Tosun K, Kinzl J, Kemmler G, Bartsch G, Höltl L, Stenzl A. Quality of life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion. World J Urol. 2000 Oct;18(5):338-44.
[7] Dutta SC, Chang SC, Coffey CS, Smith JA Jr, Jack G, Cookson MS. Health related quality of life assessment after radical cystectomy: comparison of ileal conduit with continent orthotopic neobladder. J Urol. 2002 Jul;168(1):164-7.
[8] Autorino R, Quarto G, Di Lorenzo G, De Sio M, Perdonà S, Giannarini G, Giugliano F, Damiano R.Health related quality of life after radical cystectomy: comparison of ileal conduit to continent orthotopic neobladder. Eur J Surg Oncol. 2009 Aug;35(8):858-64. doi: 10.1016/j.ejso.2008.08.002. Epub 2008 Sep 27.
[9] Gerharz EW, Månsson A, Hunt S, Skinner EC, Månsson W.Quality of life after cystectomy and urinary diversion: an evidence based analysis. J Urol. 2005 Nov;174(5):1729-36.