Health-related Quality of Life and Mental Health in Adolescents and Adults Operated for Bladder Exstrophy and Epispadias

Factors affecting the postoperative quality of life and psychological well-being in pediatric urology patients

BACKGROUND

While most studies in pediatric urology investigate the clinical results, very few explore the relationship between surgery and quality of life and psychosocial well-being in pediatric urology practice. The determination of the effects of the surgical method on the quality of life (QoL) is of increasing importance.

INTRODUCTION

This study investigated the effect of surgery type on the postoperative QoL and psychological well-being of pediatric urological surgery patients.

METHODS

A total of 151 children and adolescents (4-18 years old) undergoing elective urological surgery between September 2020 and July 2021 were evaluated preoperatively; those who currently had psychiatric disorders were excluded. Of the 98 patients undergoing subsequent detailed preoperative assessment using standardized instruments to evaluate QoL and depression and anxiety symptom levels, only 63 could be re-evaluated postoperatively at a 6-month follow-up. Additionally, preoperative parental psychiatric symptom load was assessed using standardized self-report forms.

RESULTS

The patients were classified into two categories for analysis-open versus endourological surgery and major versus minor surgery. In the latter category, there was a significant increase in the postoperative QoL in children undergoing minor urological surgery (p = 0.037). Furthermore, the table depicted the regression analysis indicating the predictors for lower postoperative QoL. Those predictors were higher parental preoperative psychiatric symptom load, a greater number of previous surgeries, and female gender (p < 0.001, adjusted R² = 0.304).

CONCLUSION

Postoperative QoL of children/adolescents undergoing pediatric urology surgery is affected more by the patient's preoperative medical condition and the psychological status of the patient's parents, rather than the surgical method opted for.

Health-related quality of life among children, adolescents, and adults with bladder exstrophy-epispadias complex: a systematic review of the literature and recommendations for future research

PURPOSE

Bladder exstrophy-epispadias complex (BEEC) is a rare spectrum of genitourinary malformations. Children risk long-term urinary and genital dysfunctions. To achieve a comprehensive understanding, this study aimed to review the literature on generic and disease-specific health-related quality of life (HRQOL) in BEEC patients, and methodologies used.

METHODS

A literature search was conducted in Pubmed/CINAHL/Embase/PsycINFO/Cochrane, from inception to May 2018. A meta-analysis of HRQOL in BEEC patients compared to healthy references was performed.

RESULTS

Twenty-one articles (published 1994-2018), describing HRQOL of children and adolescents (n = 5) and adults only (n = 5), or integrated age populations (n = 11), were identified (median sample size 24, loss to follow-up 43%, response rate 84%). Overall HRQOL was reduced in BEEC patients compared to healthy references in 4/4 studies. Impaired physical or general health in BEEC patients has been described in 9 articles, diminished mental health in 11, restricted social health in 10, and sexual health/functioning or body perception impairments in 13 articles. Urinary incontinence was the most common factor related to worse HRQOL (12 studies). In six studies, HRQOL was better than healthy norms. In eligible studies (n = 5), the pooled estimate of the effect of BEEC indicated worse HRQOL for children and adults (0 > effect sizes < 0.5). Thirty-six HRQOL assessments were used, none developed and validated for BEEC.

CONCLUSIONS

HRQOL in BEEC patients may be negatively impacted, particularly considering mental and social HRQOL. Sexual health/functioning or body perception impairments may be present in adolescents and adults. However, HRQOL is heterogeneously assessed and subsequent findings are differently reported. Additional research is warranted and can be improved.

Using social media for patient-reported outcomes: A study of genital appearance and sexual function in adult bladder exstrophy patients

INTRODUCTION

There have been few prior studies on patient-centered outcomes of adults with bladder exstrophy; those performed have been single institution reviews. In collaboration with the Association for the Bladder Exstrophy Communities (ABeC) - an international support network for patients and families living with bladder exstrophy - an anonymous social media survey was performed of patient-reported genital appearance and erectile function.

OBJECTIVE

The study evaluated the Penile Perception Score (PPS) and the International Index of Erectile Function (IIEF-15) in adult men with bladder exstrophy. It was hypothesized that scores would be significantly lower than prior reported scores for men without the condition.

STUDY DESIGN

After review by an anonymous patient advocate volunteer, the ABeC performed an anonymous online survey using social media.

RESULTS

Adult men with bladder exstrophy reported PPS, and satisfaction with penile length and axis that were lower than prior published controls (n = 54, P < 0.05). Orgasmic function, sexual desire, and overall satisfaction were also lower (n = 46, P < 0.05). There was no difference in erectile function or intercourse satisfaction compared to controls. There was an association between PPS and erectile function, intercourse satisfaction, and overall satisfaction (P < 0.05) (Summary Fig.). Respondents identified urinary issues, genital appearance, and sexual function as the three main domains that warranted further research.

CONCLUSION

This study found that PPS and IIEF-15 were low in adult men with bladder exstrophy, and worse perception of genital appearance was associated with worse sexual satisfaction. Social media is a novel tool for patient-centered outcomes research, and continued collaboration with patients and patient advocate groups is vital.

Long-term psychosocial consequences of surgical congenital malformations

Surgical congenital malformations often represent years of treatment, large number of hospital stays, treatment procedures, and long-term functional sequels affecting patients' psychosocial functioning. Both functional defects and psychosocial difficulties that occur commonly in childhood may pass through adolescence on to adulthood. This overview presents reports published over the past 3 decades to elucidate the long-term psychosocial consequences of surgical congenital malformations. Literature searches conducted on PubMed database revealed that less than 1% of all the records of surgical congenital malformations described long-term psychosocial consequences, but with diverse findings. This inconsistency may be due to methodological differences or deficiencies; especially in study design, patient sampling, and methods. Most of the studies revealed that the functional deficits may have great impact on patients' mental health, psychosocial functioning, and QoL; both short- and long-term negative consequences. Factors other than functional problems, e.g., repeated anesthesia, multiple hospitalization, traumatic treatment procedures, and parental dysfunctioning, may also predict long-term mental health and psychosocial functioning. Through multidisciplinary approach, pediatric surgeons should also be aware of deficits in emotional and psychosocial functioning. To achieve overall optimal psychosocial functioning, the challenge is to find a compromise between physically optimal treatment procedures and procedures that are not psychologically detrimental.

Quality of life in young adult patients treated for bladder exstrophy

Introduction

Bladder exstrophy (BE) is a rare condition that requires complex surgical corrections to achieve the goals of bladder functionality, normal sexual function, continence, and finally cosmesis. The purpose of this study was to identify clinical parameters that predict better quality of life (QOL) scores using a validated questionnaire (SF-36) with young adults after completing surgical reconstruction.

Material and methods

Forty-three young adults (mean age 22.35 years, 29 men and 14 women) treated for BE were evaluated using the Short Form 36 general health questionnaire (SF-36). Clinical assessment involved evaluation of the actual condition regarding continence, sexual function, genital satisfaction and overall cosmesis.

Results

Both genders presented similar QOL scores (p = 0.36). The QOL was not age-related (p = 0.63). Neither genders did not present any differences in the number of procedures (p = 0.27). Although no significant gender difference was found, clinical impairments – such as urinary fistula, incontinence, penile length and infertility – were associated with worse QOL scores and were male-related (p <0.01). The most common complaint after complete surgical repair was about penile length (26/29 patients, 89.6%).

Conclusions

Age and gender were not predictors of better QOL scores. Any clinical impairment, such as urinary leakage due to incontinence or fistula, penile length and infertility, tended to significantly decrease the overall QOL in male patients with BE. The male genitalia seems to be the most troublesome aspect post-adolescence in treated male patients with exstrophy-epispadias. It has an important impact on the overall QOL, mainly having a social affect on those patients.

Quality of life in female patients with bladder exstrophy-epispadias complex: Long-term follow-up

INTRODUCTION

Bladder exstrophy-epispadias complex (BEEC) is a congenital malformation that requires multiple surgeries during childhood and life-long follow-up. It often presents with conditions that have the potential to impact quality-of-life (QoL) and psychosocial functioning of affected patients, such as incontinence and sexual dysfunction. The aim of this study is to examine the QoL, urinary continence, sexual function, and overall health in a long-term series of female patients with BEEC.

METHOD

A retrospective review was performed of female patients with BEEC born between 1964 and 1996. Thirty-three patients were asked to complete four validated questionnaires to evaluate their QoL regarding urinary continence and sexual activity (ICIQ, Potenziani-14, and PISQ-12 questionnaires). Nineteen patients completed and returned the questionnaires. The overall QoL was assessed with the SF-36 questionnaire, and demographics were evaluated. Statistical analysis was performed to compare the general QoL with that of the general population.

RESULTS

The median age of the patients was 26 years (range 18-50) (Table). A low to moderate impact of urinary incontinence on QoL was reported by 30% of patients in the ICIQ. Also as a result of urinary incontinence, 84% of patients reported a moderate to severe impact on their sexual lives. Twelve patients got married with eight gestations and five births. SF-36 reported general QoL comparable with that of the general population in five out of eight items. Differences were seen in the mental health, emotional role, and physical functioning items (p < 0.001). The main factors for the differences were poor body image, anxiety, and urinary incontinence. A satisfactory social life was reported by 70% of patients.

CONCLUSION

Questionnaire studies on BEEC consistently report a high rate of patients not answering, 43% in the present study. The rarity of the disease determines a small sample size, which diminishes statistical power and could potentially conceal small differences with controls. Despite these limitations, the present findings are consistent with previous studies on BEEC with validated QoL questionnaires: adult women with BEEC suffer psychosocial impact mainly from incontinence, and also from gynecological complications, but their resilience and coping mechanisms allow them to achieve a quasi-normal QoL. Female patients with BEEC reported a normal QoL in five of eight items in the SF-36 questionnaire. Urinary incontinence was the main factor for the moderately decreased QoL according to specific questionnaires.

Gender Identity and Sex Role of Patients Operated on for Bladder Exstrophy-Epispadias

PURPOSE

We evaluated whether genital deformity has an impact on gender identity and sex role in patients operated on for bladder exstrophy-epispadias complex.

MATERIALS AND METHODS

A total of 62 adolescents and adults operated on for bladder exstrophy-epispadias complex were mailed questionnaires evaluating gender identity (Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults) and sex role (Bem Sex Role Inventory). Of the patients 33 responded and the results were compared with 99 gender matched controls.

RESULTS

On the gender identity questionnaire female patients had median scores similar to those of their gender matched controls (4.93 vs 4.89, p = 0.412) but in males the score was lower compared to controls (4.87 vs 4.96, p = 0.023), indicating somewhat more conflicted gender identity. However, no patient had gender dysphoria. Female sex role index was higher in female patients vs controls (5.9 vs 5.3, p = 0.003) but was comparable between male patients and controls (5.2 vs 5.0, p = 0.459). Masculine sex role indices were comparable between female patients and controls as well as between male patients and controls. Of 32 patients 17 were considered to have androgynous sex role, as were 24 of 97 controls (p = 0.004). The exact diagnosis (bladder exstrophy or epispadias) or dissatisfaction with appearance of the genitals had no impact on gender identity or on sex role indices.

CONCLUSIONS

Male patients had lower gender identity scores compared to controls and female sex role was enhanced among female patients. Androgynous sex role was more common in patients vs controls. Gender dysphoria was not noted in any patient.