Recent Trends in Postcystectomy Health-related Quality of Life (QoL) Favors Neobladder Diversion: Systematic Review of the Literature

Psychosocial distress and quality of life in patients after radical cystectomy - one year follow-up in 842 German patients

PURPOSE

This study aims to report on psychosocial distress and QoL in bladder cancer patients after radical cystectomy (RC) and urinary diversion to obtain a better basis for patient counseling and postoperative care.

METHODS

The study relied on prospectively collected data for 842 patients, who underwent three weeks of inpatient rehabilitation after RC and creation of an ileal conduit (IC) or ileal neobladder (INB). Data on QoL and psychosocial distress were collected by validated questionnaires. Multivariate logistic regression was performed to identify predictors for high psychosocial distress.

RESULTS

Four-hundred and forty-seven patients (326 male, 121 female) received an IC, while 395 patients (357 male, 38 female) received an INB. Health-related QoL improved steadily in the whole cohort during follow-up. Patients with an INB reported better physical function but suffered more from diarrhea and financial worries. Patients with an IC reported reduced satisfaction with their body image, increased worries about the future, and suffered more from constipation. Psychosocial distress increased significantly during follow-up. One year after surgery, 43.1% of patients suffered from high psychosocial distress. Multivariate regression analysis identified age ≤ 59 years (OR 1.731; CI 1.056-2.838; p = 0.030) and lymph node metastases (OR 2.073; CI 1.133-3.793; p = 0.018) as independent predictors for high psychosocial distress.

CONCLUSION

QoL improves significantly in all patients one year after RC. However, psychosocial distress remains high in a substantial number of patients.

IMPLICATIONS FOR CANCER SURVIVORS

To prevent chronic psychological disorders, easily accessible opportunities for psycho-oncological counseling are needed for patients following RC.

Long survivors after radical cystectomy versus healthy population: propensity score matched analysis of health-related quality of life

PURPOSE

To investigate Health Related Quality of Life (HRQoL) features of long survivors after radical cystectomy (RC) compared to healthy population (HP) control.

METHODS

Patients with cT2-4/N0/M0 or Bacillus Calmette-Guérine (BCG) failure high-grade non-muscle-invasive bladder cancer (NMIBC) undergoing RC and ileal Orthotopic Neobladder (iON) from 2010 to 2015 were enrolled in "BCa cohort". Patients aged ≥ 18 yrs old, with no previous diagnosis of BCa or any genitourinary cancer disease were included from General Practitioner outpatients and enrolled in "HP cohort". A 1:1 propensity score matched (PSM) analysis was performed, and HRQoL outcomes were collected according to European Organization for Research and Treatment of Cancer (EORTC), and generic (QLQ-C30) questionnaires.

RESULTS

A total of 401 patients were enrolled in the study, 99 and 302 in BCa and HP cohorts, respectively. After applying 1:1 PSM analysis 67 patients were included for each group. Analysis of self-reported HRQoL outcomes described a better HRQoL in BCa cohort. Particularly, in the long run patients receiving RC and iON significantly experienced higher global health-status/QoL (p < 0.001), emotional (p = 0.003) and cognitive functioning (p < 0.001) than HP cohort, providing a significantly lower impairment in terms of fatigue (p = 0.004), pain (p = 0.004), dyspnea (p = 0.02) and insomnia (p = 0.005).

CONCLUSIONS

Long survivors after RC and iON seems to have a major awareness of self-reported HRQoL compared to HP control group.

Neoadjuvant Cisplatin-Based Chemotherapy Followed by Selective Bladder Preservation Chemoradiotherapy in Muscle-Invasive Urothelial Carcinoma of the Bladder: Post Hoc Analysis of Two Prospective Studies

PURPOSE

Bladder preservation chemoradiotherapy (CRT) in patients with a clinical complete response (cCR) following cisplatin-based neoadjuvant chemotherapy (NAC) is a promising treatment strategy for muscle-invasive bladder urothelial carcinoma (MIBC). A combined analysis of raw data from two prospective phase II studies was performed to better evaluate the feasibility of selective bladder preservation CRT.

MATERIALS AND METHODS

The analysis was based on primary efficacy data from two independent studies, including 76 MIBC patients receiving NAC followed by bladder preservation CRT. The efficacy data included metastasis-free survival (MFS) and disease-free survival (DFS). For the present analysis, starting point of survival was defined as the date of commencing CRT.

RESULTS

Among 76 patients, 66 had a cCR following NAC. Sixty-four patients received gemcitabine and cisplatin (GC) combination chemotherapy in neoadjuvant setting, and 12 received nivolumab plus GC. Bladder preservation CRT following NAC was generally well-tolerated, with low urinary tract symptoms being the most common late complication. With a median follow-up of 64 months, recurrence was recorded in 43 patients (57%): intravesical only (n=20), metastatic only (n=16), and both (n=7). In 27 patients with intravesical recurrence, transurethral resection, and Bacillus Calmette-Guerin treatment was given to 17 patients. Salvage cystectomy was performed in 10 patients. Median DFS was 46.3 (95% confidence interval [CI], 25.1 to 67.5) months, and the median MFS was not reached. Neither DFS nor MFS appeared to be affected by any of the baseline characteristics. However, DFS was significantly longer in patients with a cCR than in those without (hazard ratio, 0.465; 95% CI, 0.222 to 0.976).

CONCLUSION

The strategy of NAC followed by selective bladder preservation CRT based on the cCR is feasible in the treatment of MIBC. A standardized definition of cCR is needed to better assess disease status post-NAC.

A prospective evaluation of quality of life, psychosocial distress, and functional outcomes two years after radical cystectomy and urinary diversion in 842 German bladder cancer patients

PURPOSE

This study aims to evaluate survival, health-related quality of life (HRQoL), psychosocial distress, and functional outcomes after radical cystectomy (RC) and urinary diversion for ileal neobladder (INB) or ileal conduit (IC) in a contemporary German cohort of bladder cancer patients.

METHODS

Patients undergoing inpatient rehabilitation after RC between April 2018 and December 2019 in one high-volume rehabilitation center were surveyed regarding HRQoL, psychosocial distress, and functional outcomes until two years after RC.

RESULTS

Eight-hundred forty-two patients (683 male, 159 female; 395 INB, 447 IC) were included. Patients with an IC suffered more often from locally advanced disease (≥ pT3; 41.4% vs. 24.1%, p < 0.001) and lymph node metastases (19.9% vs. 11.8%, p = 0.002), resulting in worse probability of survival (p < 0.001). Global HRQoL improved steadily during follow-up, but significant differences in subscales persisted between cohorts. Multivariable regression analysis identified IC, male sex, and patient age ≤ 59 years as independent predictors for persistent high psychosocial distress. Almost 42% of female patients reported severe urinary incontinence two years after RC. Most men reported severely diminished erectile function, even after nerve-sparing surgery.

CONCLUSION

Global HRQoL two years after RC is comparable to the general German population. Female patients should be informed about worse continence rates. Conversely, men should be educated about erectile dysfunction. Aftercare should include psycho-oncologic counseling, especially for patients at risk.

IMPLICATIONS FOR CANCER SURVIVORS

Patients should be counseled on long-term functional outcomes and persistent psychosocial distress after RC. Closer cooperation between urologists and psycho-oncologists is needed.

Management of urinary incontinence after radical cystectomy and orthotopic neobladder: A scoping review of international practices

OBJECTIVES

To identify and describe international practice in incontinence management after radical cystectomy and orthotopic neobladder.

MATERIALS AND METHODS

A systematic scoping review following the methodology of the Joanne Briggs Institute was conducted in which the application searched 15 data sources to identify papers published in English, from 1979 to 2022.

RESULTS

Of the 16 papers that met the eligibility criteria, articles in Eastern countries mainly focus on the effect of conservative treatment, while in Western countries, more attention is paid to the effect of surgical treatment. Clinical characteristics of patients included conservative treatment failure, duration of post-operative intervention and unique differential treatment of male and female patients. Reported factors influencing the achievement of urinary incontinence (UI) include lack of evidence to guide management practice, limited value of conservative treatment, high risk of surgical treatment and uncertainty of efficacy; currently, early behavioural research and multimodal rehabilitation training have good results.

CONCLUSIONS

UI in neobladder patients is a distressing condition that is difficult to treat and often requires high-quality rehabilitation guidance and surgical intervention. Further research to address current knowledge gaps is important to inform practice.

Health-related quality of life after curative treatment for muscle-invasive bladder cancer

Muscle-invasive bladder cancer (MIBC) is an aggressive disease for which the gold-standard treatment is radical cystectomy (RC) in combination with cisplatin-based neoadjuvant chemotherapy. Bladder-sparing strategies such as trimodal therapy (TMT) have also emerged to improve health-related quality of life (HRQoL) of patients. However, an improved understanding of the effect of all these treatment modalities on HRQoL is essential to provide personalized patient care. Different combinations of generic, cancer-specific and bladder cancer-specific questionnaires can be used as instruments for HRQoL evaluation in patients with MIBC before and after curative treatments, which can largely affect multiple domains of HRQoL including general health as well as physical, functional, social and emotional well-being. However, diagnosis of MIBC per se is also likely to affect HRQoL, and the perspective of cure after RC or TMT could induce a return to baseline HRQoL values for most of these domains. A considerable amount of data on HRQoL after RC is available, but conflicting results have been reported regarding the effect of urinary diversion (ileal conduit or orthotopic neobladder) and surgical approach (open or robotic surgery) on patient quality of life. Data on HRQoL after TMT are scarce, and additional comparative studies including patients receiving RC (especially using ileal orthotopic neobladder) are needed.

Factors Influencing Quality of Life and Functional Outcomes in Patients With Bladder Cancer

Here, we review the quality of life and functional outcomes of patients with bladder cancer after treatment and assess potential contributing factors. For current scoring systems, we highlighted the most commonly used specificity scores. In addition, we discuss the impact and bias on the quality of life of patients undergoing urinary diversion modalities, robotic surgery, perioperative rehabilitation, and bladder-preserving radiochemotherapy. Through this review, clinicians will gain better insights regarding the importance of improving patients' quality of life with the goal of restoring their patients' normal function and participating in social activities.

Tyro3 Targeting as a Radiosensitizing Strategy in Bladder Cancer through Cell Cycle Dysregulation

Bladder cancer is a common cancer; it is the tenth most common cancer in the world. Around one fourth of all diagnosed patients have muscle-invasive bladder cancer (MIBC), characterized by advanced tumors and which remains a lethal disease. The standard treatment for MIBC is the bladder removal by surgery. However, bladder-preserving alternatives are emerging by combining chemotherapy, radiotherapy and minimal surgery, aiming to increase the patient’s quality of life. The aim of the study was to improve these treatments by investigating a novel approach where in addition to radiotherapy, a receptor, TYRO3, a member of TAM receptor tyrosine kinase family known to be highly expressed on the bladder cancer cells and involved in the control of cell survival is targeted. For this, we evaluated the influence of TYRO3 expression levels on a colony or cell survival assays, DNA damage, γH2AX foci formation, gene expression profiling and cell cycle regulation, after radiation on different bladder cell models. We found that TYRO3 expression impacts the radiation response via the cell cycle dysregulation with noeffets on the DNA repair. Therefore, targeting TYRO3 is a promising sensitization marker that could be clinically employed in future treatments.

Neoadjuvant chemotherapy with gemcitabine and cisplatin followed by selective bladder preservation chemoradiotherapy in muscle-invasive urothelial carcinoma of bladder

Purpose

To assess the safety and efficacy of gemcitabine and cisplatin as neoadjuvant chemotherapy followed by selective bladder preservation chemoradiotherapy in muscle-invasive bladder cancer (MIBC).

Materials and Methods

Patients with clinical T2-T4aN0M0 MIBC eligible for radical cystectomy and cisplatin-based chemotherapy were treated with gemcitabine 1,000 mg/m² on days 1, 8 and 15, and cisplatin 70 mg/m² on day 1 every 28 days for 3 cycles. After clinical re-staging with computed tomography scans and cystoscopy, patients with clinical complete response (CR) were eligible to proceed without cystectomy and receive bladder preservation chemoradiotherapy involving weekly cisplatin 10 mg/m² and up to 70.2 Gy of radiation. The primary endpoint of the present prospective phase II study was metastasis-free survival (MFS).

Results

Between Oct 2017 and Nov 2019, a total of 138 MIBC patients were enrolled and treated with neoadjuvant gemcitabine/cisplatin. Neoadjuvant chemotherapy was well-tolerated, with fatigue, nausea, and pruritus being the most commonly observed adverse events. After completion of planned neoadjuvant chemotherapy, 54 patients with a clinical CR and 10 patients who did not have CR but refused surgery received bladder preservation chemoradiotherapy. With a median follow-up duration of 34 months (95% confidence interval [CI], 32%–36%), the 3-year MFS rate in 64 chemoradiotherapy patients was calculated to be 70% (95% CI, 58%–82%).

Conclusions

Neoadjuvant chemotherapy followed by selective bladder preservation chemoradiotherapy based on the clinical CR was feasible and efficacious in the treatment of MIBC.

Penile implant infection factors: a contemporary narrative review of literature

Objective

We aim to review and summarize published literature that features implanted penile devices and details infection of these devices as a complication. In particular, we will detail the factors that influence infection of penile implants.

Background

Types of penile prostheses (PP) include inflatable implants and semirigid implants; these are utilized for treatment of erectile dysfunction. Likely the most feared complication of penile implants is infection. There are a handful of factors that are implicated in device infection.

Methods

Searches were performed using MEDLINE and PubMed databases using keywords and phrases ‘penile implant AND infection’; ‘penile prosthesis AND infection’; ‘penile implant infection’. We have presented results from our literature search. We divided these into ‘Surgical Elements’ and ‘Patient Selection and Factors.’ Each topic is discussed in its own section.

Conclusions

Strides have been made since the initial penile prosthesis (IPP) surgeries to improve infection rates including diabetes control, antibiotic coating of devices, and antibiotic implementation. Going forward, more studies, especially randomized control trials, need to focus on defining levels of diabetic control (sugar control and A1C control), determining the role of metabolic syndrome in infection promotion and determining laboratory values which could be predictive of infection. We present a discussion of important factors to consider in the realm of PP infections. In addition, we include studies which discuss topics for future directions in decreasing the number of infections seen with PP.

Patient Reported Sexual Function Outcomes in Male Patients Following Open Radical Cystoprostatectomy and Urinary Diversion

OBJECTIVE

To report sexual health outcomes in male patients undergoing open radical cystoprostatectomy using a validated questionnaire.

MATERIALS AND METHODS

Beginning in 2017, male patients were asked to complete a validated questionnaire during scheduled post-cystectomy clinic visits that assessed sexual function using the 5 item International Index of Erectile Function (IIEF-5) and supplemental questions which evaluated libido, orgasm, partner interest, and adequacy of pre-operative counselling. Baseline data and functional outcomes were compared and multivariable analysis performed.

RESULTS

A total of 134 patients who met inclusion criteria completed the questionnaire. Pre-operative IIEF-5 was available in 78 patients with a median score of 16 (IQR:5-23). In those patients, median age at cystectomy was 68.9 years (IQR:60.2-72.4) and median duration of follow-up was 17.3 months (IQR:6.3-28.7). Median IIEF-5 score at time of survey completion was 1 (IQR:1-11). Increasing age, shorter follow-up duration, insufficient counselling, and absence of partner interest were predictive of lower scores. Younger age, pre-operative erectile function, and neurovascular preservation were predictive of a higher IIEF-5 score on univariate and multivariate analysis. Median libido score was 2 "low" (IQR:1-3) and ability to orgasm was reported by 34 (43.6%) patients. Neurovascular preservation (OR:3.03 95% CI:1.10-8.26, P = .03) and sufficient preoperative counselling (OR:3.078 95% CI:1.17-8.098, P = .02) were associated with preserved ability to orgasm. Libido was influenced by partner interest (OR 11.7, 95% CI:3.793-6.14, P <.0001).

CONCLUSION

Sexual dysfunction after radical cystoprostatectomy is prevalent with many contributing factors. As such, establishing appropriate expectations and goals during preoperative counseling, performing neurovascular preservation when appropriate, and readily identifying and treating dysfunction in follow-up may improve sexual recovery.

Surgery for Bladder and Upper Tract Urothelial Cancer

The cornerstone for diagnosis and treatment of bladder and upper tract urothelial carcinoma involves surgery. Transurethral resection of bladder tumors forms the basis of further management. Radical cystectomy for invasive bladder carcinoma provides good oncologic outcomes. However, it can be a morbid procedure, and advances such as minimally invasive surgery and early recovery after surgery need to be incorporated into routine practice. Diagnostic ureteroscopy for upper tract carcinoma is needed in cases of doubt after cytology and imaging studies. Low-risk cancers can be managed with conservative endoscopic surgery without compromising oncological outcomes; however, high-risk disease necessitates radical nephroureterectomy.

Health-related quality of life after radical cystectomy

Herein, we review the assessment of quality-of-life (QoL) in radical cystectomy (RC) patients, summarize the result of studies for different surgical approaches, and provide an overview of patient management, as well as other considerations. In this review article, we reviewed the QoL research and research tools for patients undergoing RC, including urinary diversion methods, gender differences, and surgical methods (open surgery vs. robotic surgery). This narrative review focused primarily on articles indexed in PubMed, Embase, Scopus, and Google Scholar databases. We did not used formal search strategy and meta-analysis was not performed.

Long-term chronological changes in urination status of patients who underwent ileal neobladder reconstruction at a single institution

PURPOSE

This study aimed to investigate the long-term chronological changes in urination status of patients who underwent radical cystectomy (RC) followed by orthotopic ileal neobladder (ONB) reconstruction using the International Prostatic Symptoms Score (IPSS) and the Overactive Bladder Symptoms Score (OABSS).

METHODS

This retrospective study focused on patients who underwent RC followed by ONB reconstruction and those who consented for IPSS, quality of life (QOL) based on urinary symptoms (IPSS-QOL), and OABSS assessments in the follow-up period. The patients were divided according to gender into the male group (M-group) and female group (F-group). All patients were evaluated using IPSS, IPSS-QOL, and OABSS every 3 months. The primary endpoint was to assess chronological changes in the urination status of patients who underwent ONB reconstruction after RC.

RESULTS

The median age of the enrolled patients (n = 122) was 65 years and the median follow-up period was 92.0 months. The median voiding symptom score in IPSS after 10 years of surgery was significantly higher in the M-group than in the F-group. Contrarily, the F-group demonstrated a significantly higher median storage symptom score at 60-66 and 102-114 months than the M-group. The median OABSS scores were relatively higher in the F-group than in the M-group.

CONCLUSIONS

Although long-term urinary function with ONB demonstrated acceptable results, dysfunctional voiding was observed > 10 years after surgery. Thus, the changes in long-term urinary function should be considered when deciding ONB.

The relationship between type of urinary diversion and quality of life after radical cystectomy: Ileal conduit versus orthotopic bladder

Objectives

Methods

Results

Conclusions

HRQOL related to urinary diversion in Radical Cystectomy: a systematic review of recent literature

Introduction:

The health-related QoL is a patient-centered evaluation covering several aspects. This evaluation seems to be particularly important in patients submitted to radical cystectomy (RC) and urinary diversion with ileal conduit (IC) or a neobladder (NB).

Objective:

Review all recent data comparing QoL outcomes after radical cystectomy with NB and IC diversions.

Evidence Acquisition:

A systematic search in PubMed/Medline, Embase, and Cochrane databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement in December 2018. All articles published from January 01, 2012 to December 31, 2018, were included. A study was considered relevant if it compared QoL outcomes using validated questionnaires (EORTC QLQ C30, FACT-G, FACT-BL, FACT-VCI, and BCI).

Evidence Synthesis:

In 11 included studies, a total of 1389 participants were accounted (730 NB and 659 IC cases). The studies were conducted in 8 different countries, two were prospective, and none was randomized. There were two studies favoring results with a neobladder, 3 with incontinent diversion and 6 with no differences. The EORTC-QLQ-C30 was the most used instrument (5 studies) followed by FACT VCI and BCI (3 studies each). Given the heterogeneity of data and lack of prospective studies, a meta-analysis was not performed.

Conclusion:

No superiority of one urinary diversion was characterized. It seems that the choice must be individualized with an extensive preoperative orientation of the patient and their relatives. That will probably influence how the patient accepts the new condition.

Orthotopic Neobladder Reconstruction: Patient Selection And Perspectives

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure that may be performed in a patient with bladder cancer following a radical cystectomy. The selection of a patient for an ONB reconstruction is strict as not everyone may be suitable to undergo this complex surgery. Patients must be not only mentally competent but also physically dexterous enough to allow for appropriate neobladder training post-procedure, to achieve best urinary function. However, even with a carefully chosen patient population, various complications specific to ONB reconstruction may result. Metabolic acidosis may result from electrolyte shifts, resulting in secondary complications such as bone demineralization and urinary calculi. In addition, nutritional deficiencies may result from the use of a transposed intestinal segment for the fashioning of the reservoir. A widely used outcome measure when assessing for ONB reconstruction is continence. With a strict neobladder training regimen, daytime continence may be achieved in roughly 70% of patients post-ONB procedure. This number may increase over the course of several years, although may decrease in up to 20 years of follow-up. Similarly, quality of life (QoL) measures have been widely studied, and current literature suggests slightly better QoL achieved with ONB compared to other urinary diversion procedures. Of note, the tools used to assess continence and QoL vary between studies, limiting the interpretability of the summarized data. Nevertheless, ONB reconstruction is a procedure that is still evolving, with ongoing modifications that can reduce complications and improve patient urinary function.

Recovering from Cystectomy: Patient Perspectives

BACKGROUND

Bladder cancer patients who undergo cystectomy and urinary diversion face functional and quality-of-life challenges. Little is known about these patients' experiences during decision-making, surgery, and recovery, or how they vary by treatment setting.

OBJECTIVE

To learn about patients' experiences with treatment choice, surgical care, and recovery across health settings. Understanding patient experiences is essential to closing care gaps and developing patient-reported measures.

METHODS

We conducted focus groups with cystectomy patients and family caregivers at a large comprehensive health care system (N = 32 patients) and an NCI-designated comprehensive cancer center (N = 25 patients and 5 caregivers). Using standard qualitative methods, we identified themes that are not well-represented in existing research.

RESULTS

Across both systems, patients described variable experiences in decision-making about their cystectomy and urinary diversion. Some felt overwhelmed by information; others felt poorly informed. Many found self-care equipment challenging; many felt they knew little about what to expect regarding chemotherapy, recovery, and transitioning home. At times, health care personnel could not help manage patients' ostomies or catheterization equipment. Our study also contributes a grounded theoretical framework for describing meaningful domains of patient experience with cystectomy and urinary diversion. We identified a common trajectory that includes decision-making, surgery and post-operative recovery, mastery of self-care, and reintegration.

CONCLUSIONS

Patients with radical cystectomy and urinary diversion report a wide variety of experiences not captured by quantitative measures. These findings demonstrate that many cystectomy patients could benefit from additional post-operative support. We offer a framework to measure patient-centered domains in future research.

Quality of life in bladder cancer patients receiving medical oncological treatment; a systematic review of the literature

Background

Previous quality of life (QoL) literature in bladder cancer (BC) patients has focused on finding the preferred urinary diversion while little is known about the QoL of patients in medical oncological treatment (MOT). We performed a systematic review to assess the existing literature on QoL in patients with muscle-invasive BC (MIBC) undergoing MOT.

Methods

A systematic search of Pubmed and Embase was performed. Inclusion criteria were studies containing QoL data for patients undergoing chemo- and/or radiotherapy. We extracted all QoL scorings at different time intervals and on the six most prevalent domains: overall QoL, urinary, bowel sexual symptoms, pain and fatigue. The study was carried out according to PRISMA guidelines for systematic reviews and GRADE was used to rate the quality of evidence from the included studies.

Results

Of 208 papers reviewed, 21 papers were included. Twenty-one different QoL instruments were applied. The only data on QoL during chemotherapy was from patients in clinical trials investigating new treatments. No studies were found for patients in neoadjuvant treatment. The level of evidence at each time point was graded as very low to moderate. From the studies included the overall QoL seemed inversely related to the organ-specific impairment from sexual and urinary symptoms and increased with decreasing organ-specific symptoms for long term survivors > 6 months after treatment.

Conclusions

Collection of data on QoL from patients with MIBC disease undergoing MOT has been sparse and diverse. The present data can act as a summary but prompts for more prospective collection of QoL data from BC patients.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-1077-6) contains supplementary material, which is available to authorized users.

Bladder Cancer Survivorship

PURPOSE OF REVIEW

Bladder cancer (BC) is the second most common genitourinary malignancy, with a growing population of survivors globally. Over the past two decades, there has been a growing awareness of not only the oncologic, but also the quality of life ramifications of a BC diagnosis, treatment, and surveillance. In the current review, the literature surrounding the many domains that encompass bladder cancer survivorship is summarized and analyzed.

RECENT FINDINGS

There have been ongoing efforts to decrease perioperative morbidity, particularly in patients undergoing radical cystectomy, with mixed results. There is a growing emphasis on the short and long-term health-related quality of life (HR-QoL) impacts of bladder cancer spanning the domains of physical and mental QoL related to urinary function, sexual function, and financial and psychological burden, with validated measures specific to BC patients. There continue to be disparities in oncologic outcomes by race and gender. The impact of BC is prolonged and there is an unmet need for long term support and survivorship resources to address this. There is a growing global population of bladder cancer patients, and their needs are complex and vary by stage, treatment, and certain demographic features. Outcome-centered perioperative strategies show potential to diminish treatment morbidity, and validated BC specific HR-QoL tools have helped to define the impact and burden of BC, but there continue to be large areas of unmet need that warrant greater study and intervention.

Urinary function following radical cystectomy and orthotopic neobladder urinary reconstruction

INTRODUCTION

An orthotopic neobladder urinary diversion aims to minimize the physical and psychological effects of radical cystectomy through avoidance of a stoma and maintenance of urethral voiding. Neobladder function reported in the literature ranges widely due to differences in patient selection and method of assessment. The objective of the study was to characterize functional outcomes of consecutive patients treated at a tertiary care hospital.

METHODS

A historical cohort of patients who underwent radical cystectomy with a neobladder diversion performed at The Ottawa Hospital between January 2006 and December 2014 were reviewed. Outcomes of interest were urinary continence, use of clean intermittent catheterization (CIC), post-void residual volume, and uroflowmetry at three, six, and 12 months following cystectomy.

RESULTS

During the study period, 158 neobladder diversions were performed. The mean age of patients was 63.1 years (standard deviation [SD] 8.1), and 81.7% were male. Significant daytime incontinence (>1 pad) three months following surgery was common (65%), but decreased to 8.6% by 12 months. Nighttime incontinence was also common at three months (54%) and improved at 12 months (20%). While no appreciable differences between men and women were observed for continence, more women performed CIC at 12 months post-surgery (59% of women; 9% of men; relative risk [RR] 0.15; 95% confidence interval [CI] 0.07-0.30). Among patients who did not catheterize, uroflowmetry and post-void residual volume parameters were stable between three and 12 months postoperative.

CONCLUSIONS

Daytime and nighttime incontinence is common in neobladder patients following surgery, but improves considerably with time. Correspondingly, many female neobladder patients at our institution use CIC.

Quality of Life After Radical Cystectomy

Approximately 1 in 5 new cases of clinically localized bladder cancer is muscle invasive and requires the patient to choose from 1 of 2 prevailing options for treatment: radical cystectomy or radiation to the bladder. However, these treatments are associated with detrimental effects on patient well-being and quality of life, particularly with respect to functional independence, urinary and sexual function, social and emotional health, body image, and psychosocial stress. Compared with the literature on other malignancies like breast or prostate cancer, high-quality studies evaluating the effects of bladder cancer treatment on quality of life are lacking.

Bladder cancer

Bladder cancer is a highly prevalent disease and is associated with substantial morbidity, mortality and cost. Environmental or occupational exposures to carcinogens, especially tobacco, are the main risk factors for bladder cancer. Most bladder cancers are diagnosed after patients present with macroscopic haematuria, and cases are confirmed after transurethral resection of bladder tumour (TURBT), which also serves as the first stage of treatment. Bladder cancer develops via two distinct pathways, giving rise to non-muscle-invasive papillary tumours and non-papillary (solid) muscle-invasive tumours. The two subtypes have unique pathological features and different molecular characteristics. Indeed, The Cancer Genome Atlas project identified genetic drivers of muscle-invasive bladder cancer (MIBC) as well as subtypes of MIBC with distinct characteristics and therapeutic responses. For non-muscle-invasive bladder cancer (NMIBC), intravesical therapies (primarily Bacillus Calmette-Guérin (BCG)) with maintenance are the main treatments to prevent recurrence and progression after initial TURBT; additional therapies are needed for those who do not respond to BCG. For localized MIBC, optimizing care and reducing morbidity following cystectomy are important goals. In metastatic disease, advances in our genetic understanding of bladder cancer and in immunotherapy are being translated into new therapies.

Prospective evaluation of health-related quality of life after radical cystectomy: focus on peri- and postoperative complications

OBJECTIVES

To analyse the impact of perioperative complications and complex treatment courses on postoperative health-related quality of life (HRQOL) after radical cystectomy (RC) and continent (ONB) or incontinent (IC) urinary diversion at multiple prospective time points.

METHODS

A total of 121 consecutive patients underwent RC with curative intent between 2013 and 2014. HRQOL was prospectively assessed preoperatively, after 3 and 12 months, using the QLQ-C30 questionnaire. The impact of complex perioperative treatment courses including cases requiring surgical re-interventions was retrospectively assessed using Martin criteria and the Clavien-Dindo scale. Urinary continence was determined using the validated ICIQ-SF questionnaire. Statistical analysis included Kruskal-Wallis ANOVA, Spearman's rank correlation, and ordinal regression models (p < 0.05).

RESULTS

A total of 100 patients underwent further analysis. Physical functioning (PF), role functioning (RF), and global health status (GHS) scores were higher in the ONB subgroup both preoperatively (p < 0.001, 0.010, 0.048) and 3 months after RC (p = 0.003, 0.048, 0.019). Clavien complications ≥III led to reduced PF levels after 3 months (p = 0.050) without effect on GHS (p = 0.825). Operating time and length of critical care monitoring correlated with 3 months pain scores in the ONB subgroup (p = 0.003, 0.009) without affecting GHS (p = 0.603, 0.653). Continent urinary diversion was an independent predictor of increased HRQOL after 3 months (p = 0.021), however, not after 12 months (p = 0.803).

CONCLUSIONS

Patients receiving an IC have lower PF, RF, and GHS scores than those receiving ONB. Perioperative complications and complicated treatment courses can affect HRQOL subdomains but do not significantly impact the GHS. ONB is an independent predictor for better overall HRQOL 3 months, but not 12 months after RC.