Urinary diversion after radical cystectomy

Involving Patients in the Development and Evaluation of an Educational and Training Experiential Intervention (ETEI) to Improve Muscle Invasive Bladder Cancer Treatment Decision-making and Post-operative Self-care: a Mixed Methods Approach

This study aims to describe the acceptability and feasibility of an educational and training experiential intervention (ETEI) we developed to enhance muscle invasive bladder cancer (MIBC) patients with treatment decision-making and post-operative self-care. Twenty-five patients were randomized to a control group (N = 8) or ETEI group (N = 17). ETEI group participated in a nurse-led session on MIBC education. The control group received diet and nutrition education. Study questionnaires were completed at baseline and at 1-month post-intervention. Our results showed acceptable recruitment (58%) and retention rates (68%). The ETEI group reported increased knowledge (82% vs. 50%), improved decisional support (64% vs. 50%), improved communication (73% vs. 50%), and increased confidence in treatment decisions (73% vs. 50%) compared to the control group. Patients in the control group reported improved diet (50% v. 27%) as well as maintaining a healthy lifestyle (67% vs. 45%) compared to the ETEI group. Patients in the ETEI group reported a significant decrease in cancer worries and increases in self-efficacy beliefs over time compared to the control group. The ETEI was feasible, acceptable, and showed a potential for inducing desired changes in cancer worries and efficacy beliefs.

Socioeconomic status is associated with urinary diversion utilization after radical cystectomy for bladder cancer

PURPOSE

To assess socioeconomic disparities in urinary diversion utilization in a contemporary American cohort.

METHODS

In the National Cancer Database, we identified 4538 patients who underwent cystectomy with urinary diversion for clinical T1-2N0M0 bladder cancer from 2010 to 2013. Multivariable logistic regression was used to identify predictors of urinary diversion type: ileal conduit (IC), continent cutaneous reservoir (CCR), or orthotopic neobladder (ON). Covariates included age, gender, race, income, Charlson score, clinical T stage, hospital cystectomy volume, teaching status, and surgical approach. Subgroup analysis by hospital volume (low, intermediate, or high) and teaching status (academic or non-academic) was performed to ascertain the impact of regionalization on urinary diversion use.

RESULTS

The final cohort included 4066 (89.6 %) patients with IC, 292 (6.4 %) with CCR, and 180 (4.0 %) with ON. On multivariable analysis, younger age (p < .01), higher income (p < .01), and high cystectomy volume predicted increased use of CCR and ON. Female gender predicted increased use of CCR versus IC (p < .01), and academic hospital status predicted increased use of ON versus IC (p = .04). On subgroup analysis, after further adjustment for hospital volume and teaching status, higher income remained an independent predictor of ON use.

CONCLUSIONS

Despite regionalization of care, higher income patients are more likely to receive complex urinary diversions after radical cystectomy. Other related socioeconomic factors, especially patient education, may influence this practice pattern.

Unmet informational and supportive care needs of patients following cystectomy for bladder cancer based on age, sex, and treatment choices

PURPOSE

Assessing the unmet needs of cancer patients can help providers tailor health care services to patients' specific needs. This study examines whether the unmet informational and supportive care needs of the patients with muscle-invasive bladder cancer vary by the patients' age, sex, or individual treatment choices.

METHODS AND MATERIALS

Participants (N = 30 survivors; 73.3% men) were recruited from the Mount Sinai Medical Center and through advertisements posted on a national Bladder Cancer Advocacy Network website between December 2011 and September 2012. Data were collected through individual interviews and electronic medical record review. A prior qualitative study of this cohort, using immersion/crystallization approach, confirmed the prevalence of unmet needs across the disease trajectory. This is a secondary quantitative analysis of the initial interview data we collected (i.e., quantitative analyses of transformed qualitative data using Chi-square and Fisher exact tests) to examine differences in unmet needs based on the patient's age, sex, and treatment choices.

RESULTS

Younger patients (<60y) were less satisfied with the treatment information received presurgery and more likely to report posttreatment complications, choose a neobladder, and seek and receive professional support regarding sexual function, than were older patients (P<0.05). More women than men reported difficulties with self-care and relied on themselves in disease self-management as opposed to relying on spousal support (P<0.05). Patients with neobladder were more likely to report difficulties with urinary incontinence and deterioration in sexual function, whereas patients with ileal conduit were more likely to require spousal help with self-care. Patients who received chemotherapy were significantly more likely to report changes in everyday life (P<0.05). Lastly, regardless of age, sex, or treatment choice, up to 50% of patients reported feeling depressed before or after treatment.

CONCLUSIONS

Unmet informational and supportive needs of patients with muscle-invasive bladder cancer during survivorship, and vary by age, sex, and treatment choices. Educational and psychological assessments as well as clinical interventions should be tailored to a patient's specific unmet needs, and to specific clinical and demographic characteristics.

Strategies to improve quality of life in bladder cancer patients

Bladder cancer is a heterogeneous disease that includes both tumors with low risk of dissemination as well as highly malignant tumors with a considerable potential to metastasize. The patient's quality of life is closely related to the management of the disease. The challenge for the urologist is to acknowledge the malignant potential of the cancer and to adjust the approach to the patient accordingly. Patients with low-risk bladder cancer should avoid an exaggerated follow-up, but on the other hand high-risk patients must be sufficiently surveyed to secure that definitive surgical treatment is performed before it's too late. When the decision to perform a cystectomy has been made, it is crucial that the patient understands the consequences of the surgery as well as the possible options for urinary reconstruction. This review focuses on aspects of bladder cancer management that we believe are vital for the quality of life of these patients.

Muscle invasive bladder cancer: from diagnosis to survivorship

Bladder cancer is the fifth most commonly diagnosed cancer and the most expensive adult cancer in average healthcare costs incurred per patient in the USA. However, little is known about factors influencing patients' treatment decisions, quality of life, and responses to treatment impairments. The main focus of this paper is to better understand the impact of muscle invasive bladder cancer on patient quality of life and its added implications for primary caregivers and healthcare providers. In this paper, we discuss treatment options, side effects, and challenges that patients and family caregivers face in different phases along the disease trajectory and further identify crucial areas of needed research.

Quality-of-life assessment in patients with bladder cancer

Health-related quality of life (HRQOL) in patients with bladder cancer is important, because radical cystectomy and urinary diversion significantly affect urinary and sexual function, and lead to associated sex-specific morbidity. This article reviews the current methods for defining HRQOL, describes the specific challenges in measuring HRQOL in patients with bladder cancer, and critically analyzes the existing literature on bladder cancer HRQOL. Previous studies have been limited by study design, generalizability, and by the different instruments used, namely nonvalidated questionnaires that are not specific for bladder cancer. To date, only two prospective studies with baseline HRQOL data have been published and few conclusions can be drawn from these cross-sectional, retrospective studies. On the basis of the published literature, there is no convincing evidence that superior HRQOL is achieved with a particular type of urinary diversion after cystectomy for bladder cancer. Patients should be counseled on all reconstructive alternatives and a diversion chosen on the basis of patient preference, patient anatomy and tumor status, rather than on a potential difference in HRQOL. Prospective studies with appropriate adjustment for confounding factors, which use validated and disease-specific questionnaires, are needed for HRQOL research on bladder cancer.

Pelvic exenteration without external urinary or fecal diversion in gynecological cancer patients

In 1993, the authors introduced an orthotopic bladder replacement technique in the treatment of gynecological cancer patients. In this series, they report their long-term experience with orthotopic urinary reconstruction in case of primary- and radiotherapy-treated recurrent gynecological malignancies. Between 1993 and 2003, in 29 patients orthotopic ileocecal ascending colon reservoirs (Budapest pouch) were created. Twenty-one of the 29 patients received radiotherapy prior to their operation. In 12 out of these 29 cases, the fecal stream was reconstructed with the use of low rectal anastomosis. Two patients (6.9%) died in the perioperative period. Orthotopic reconstruction of the lower urinary system was successful in 77% of the cases. Success rate was 68% in the irradiated cohort of patients. All orthotopic bladder replacement patients voided voluntarily at the time of their follow-up, without the need of self-catheterization, and 23.5% of them complained of some degree of daytime incontinence and 47% of nighttime incontinence. Low rectal anastomosis reconstruction of the fecal stream was successful in all but one case. Our present experience demonstrated that anterior and total supralevator pelvic exenteration in patients with gynecological malignancies is feasible with orthotopic reconstruction of the lower urinary tract.

Quality of Life Issues in Bladder Cancer Patients Following Cystectomy and Urinary Diversion

HRQOL outcomes in bladder cancer patients undergoing cystectomy and urinary diversion are an important component in the critical assessment of bladder cancer treatment. To date, understanding of HRQOL in these patients remains poor. Although it is known that there are common factors that most likely affect HRQOL for all patients, it is unclear whether factors unique to a specific type of diversion impact HRQOL in a way that makes one type of diversion superior to another. Factors such as stoma maintenance, catheter use, urinary incontinence, body image, and sexual side effects are potentially different for each major type of diversion and most likely impact HRQOL, but a consistent advantage of one type of diversion over another has yet to be demonstrated. With slight changes in the approach to studying HRQOL outcomes, this question could be answered. Prospective study designs, appropriate adjustment for confounding factors, diverse patient populations, and the use of validated and disease-specific instruments would greatly enhance understanding of HRQOL in patients undergoing cystectomy for bladder cancer. By understanding these issues more completely, patients could be counseled not only about their predicted surgical risks and survival but also about the impact their disease will have on their longer-term quality of survival. Patients will then be able to make a more fully informed decision on the most appropriate form of therapy for this serious life-altering disease.