Body Image and Bladder Cancer Specific Quality of Life in Patients With Ileal Conduit and Neobladder Urinary Diversions

doi:10.1016/j.urology.2010.01.087

Urology

Volume 76, Issue 3, September 2010, Pages 671-675

https://doi.org/10.1016/j.urology.2010.01.087 Get rights and content

Purpose

Patients undergoing radical cystectomy with neobladder for bladder cancer are hypothesized to tolerate worse urinary function than ileal conduit patients because of improved body image. The purpose of this study was to compare body image and quality of life between the 2 diversion types after surgery.

Materials and Methods

Patients who underwent radical cystectomy at the University of Michigan from November 1999 onwards and completed follow-up between July 2007 and August 2008 were eligible for the study. Patients who had cystoscopy for bladder cancer were enrolled as a reference group. Urinary, bowel, and sexual outcomes were assessed using the Bladder Cancer Index, and body image was evaluated using the EORTC Body Image Scale. Cross-sectional analysis at baseline, 1 month, 6 months, and 1, 2, 4, 6, and 8 years after treatment was performed.

Results

A total of 139 neobladder, 85 conduit, and 112 cystoscopy patients were studied. After cystectomy, both conduit and neobladder groups had worse body image scores that improved over time, although the neobladder group did not return to baseline. Age was associated with score but gender was not. Urinary function was better in conduit patients but urinary bother was the same in both diversion types.

Conclusions

Radical cystectomy has a significant impact on body image that improves slowly over time. No difference in body image scores between ileal conduit and neobladder patients exists after surgery. Factors other than just body image are likely involved in the patient's acceptance of worse urinary function associated with a neobladder.

Section snippets

Patient Population

Patients who underwent a radical cystectomy at the University of Michigan from November 1999 onwards and completed follow-up between July 2007 and August 2008 were eligible for the study. A third cohort of patients who had cystoscopy for bladder cancer during the follow-up period was enrolled as a reference group.

Outcome Measurement

Health-related quality of life (HRQOL) outcomes were measured using the Bladder Cancer Index (BCI) and the Body Image Scale (BIS) for cancer patients. The BCI was developed at the

Results

A total of 336 patients participated in the study and completed the BCI. Of the 224 radical cystectomy patients, 139 had an orthotopic neobladder diversion and 85 had an ileal conduit. The remaining 112 patients comprising the referent group underwent cystoscopy with or without intravesical chemotherapy. The demographic and clinical characteristics of each group can be seen in Table 1. Neobladder patients were more likely to be younger, male, and less likely to have positive lymph nodes at

Comment

Radical cystectomy has a significant impact on patients' quality of life. Different types of urinary diversion are associated with their own functional and bothersome consequences.⁸ Although continent diversions have increased complication rates, they do not bear the visual stigma of a urostomy. In this study, we evaluated body image and urinary, sexual, and bowel domains after cystectomy to assess whether neobladder patients have worse functional outcomes because of an improved body image.

Conclusions

Using 2 validated quality-of-life instruments, one specifically for bladder cancer patients and the second for body image in all cancer types, our study reveals that patients with continent urinary diversions live with slightly more functional urinary impairment than those with ileal conduits but exhibit little difference in overall bother. Surprisingly, changes in body image between diversion types are equivalent throughout the recovery process. The factors that account for neobladder patients

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Quality of life after definitive treatment for bladder cancer: A systematic review and meta-analysis
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Radical cystectomy (RC) is considered the standard treatment for muscle invasive bladder cancer (MIBC). However, RC is often burdened by significant impact on quality of life (QoL); Continence preserving methods (e.g., continent cutaneous urinary diversion and orthotopic neobladder-ONB), have been proposed as alternatives to improve postoperative QoL. Trimodal therapy (TMT) emerged as alternative to surgery. To assess the impact of these treatments from the patients’ perspective, we undertook a systematic review and meta-analysis of literature, focusing on studies reporting QoL data about each of the abovementioned approaches.
A systematic review was carried out including all prospective and retrospective studies enrolling patients treated with radical intent for non-metastatic MIBC from 1999 to 2021 (either RC or TMT). All studies included specifically reported QoL for one of the main treatment approaches explored (RC followed by ileal conduit urinary diversion-ICUD, ONB or TMT).
Pooled analysis for EORTC QLQ-C30 and BLM-30 questionnaires showed that ONB yielded a significant advantage only for Physical Functioning (pooled mean standardized difference −0.73 SD, p-value 0.019, I 2 = 93 %) and for Emotional Functioning (pooled mean standardized difference −0.16 SD, p-value 0.029, I 2 = 0 %). A trend in favour of higher mean reported values after TMT for Global Health Score, Physical Functioning and Role Functioning was found, if compared to both RC approaches.
Significant benefit for ONB if compared to ICUD was detected only for specific subdomains of QoL questionnaires. No direct comparison with TMT is available, but data suggest advantage of this approach when compared to both reconstructive scenarios.
Sexual Activity, Function and Dysfunction After a Diagnosis of Bladder Cancer
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Sexual dysfunction is common in those affected by cancer and local and radical treatments for Bladder Cancer (BC) can affect sexual function directly.
To evaluate sexual function following a bladder cancer (BC) diagnosis.
Self-reported sexual function was collected 10 years after a diagnosis of BC as part of a cross-sectional patient reported outcome measure (PROM) survey exploring life after BC diagnosis and treatment.
Participants completed a combined EORTC QLQ-BLM30 and QLQ-NMIBC24 questionnaire, including questions on sexual activity, intimacy, erectile/ejaculatory function and vaginal dryness.
A total of 1796 participants returned a completed survey out of 3279 eligible participants (55%). Of the participants who returned a completed survey, a total of 1530 (85%) participants answered sexual function questions. The median (IQR) age was 75 (70–81). Participants were predominantly men (78%) and married/in civil partnerships (66%). In total, 31% were sexually active. Vaginal dryness was common (66%) in women. Erectile and ejaculatory dysfunction (80% and 58% respectively) were common in men. Compared to TURBT +/- intravesical treatments, those who had radical treatment were less likely to be sexually active (adjusted OR 0.56, 95% CI: 0.44–0.72, P<0.001) and had worse mean scores for intimacy problems (29.1 [radical treatment] vs 12.1, P<0.001), male sexual problems (72.2 [radical treatment] vs 45.7, P<0.001) and overall sexual function (17.1 [radical treatment] vs 20.3, P=0.01).
These findings highlight the magnitude of sexual dysfunction in the BC patient cohort and can help inform patients during the pre-op counselling process and shared decision making prior to BC treatments.
This study provides the largest in-depth analysis of sexual activity and function after BC diagnosis and treatment, to date. Limitations include the lack of data on participants’ sexual function prior to BC treatment and the heterogeneity with respect to time passed since last BC treatment.
Sexual dysfunction in BC patients is common and rates appear higher following radical treatments compared to endoscopic. It is important to elicit these problems in clinics to enable counselling and treatment.
Jubber I, Rogers Z, Catto JWF, et al. Sexual Activity, Function and Dysfunction After a Diagnosis of Bladder Cancer. J Sex Med 2022;19:1431–1441.
Long-term Health-related Quality of Life (HRQOL) After Radical Cystectomy and Urinary Diversion - A Propensity Score-matched Analysis
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Radical cystectomy (RC) and urinary diversion by ileal conduit (IC) or ileal orthotopic neobladder (ONB) is the standard-of-care for surgical treatment of muscle-invasive bladder cancer. Yet, it is unclear how urinary diversion affects the patient's health-related quality of life (HRQOL) in the longer-term.
HRQOL was assessed preoperatively, 3mo postoperatively and then annually until a maximum follow-up of 48 months using the validated EORTC QLQ-C30- as well as the bladder cancer-specific FACT-BL- and QLQ-BLM30-questionnaires. A propensity-score matching for the variables “age,” “ASA-classification,” “cardiovascular co-morbidity,” “sex” as well as “tumor stage,” and “preoperative physical functioning score” was performed. Hypothetical predictors for decreased general HRQOL were analyzed using multivariable logistic regression models.
After propensity-score matching, 246 patients were analyzed. HRQOL assessment revealed significant differences regarding preoperative QLQ-C30 symptoms which diminished during the postoperative time course. Similarly, we did not find significant differences based on bladder cancer-specific FACT-BL and QLQ-BLM HRQOL assessment including body image (48 months: 29.6.4 [IC] vs. 40.7 [ONB]; P = .733). Regarding general HRQOL, we found increased global health status scores for ONB throughout the whole observational period without reaching statistical significance (48 months: 55.0 [IC] vs. 70.1 [ONB]; P = .079). In multivariate analysis, cardiovascular comorbidity was an independent predictor of impaired HRQOL 24 months (HR 2.20; CI95% 1.02-5.72, P = .044) and 36 months (HR 6.84; CI95% 1.61-29.14, P = .009) postoperatively.
We did not observe significant differences in bladder-specific as well as generic HRQOL in the longer-term and consequently, the type of urinary diversion was not an independent predictor of good general HRQOL in a follow-up period of 4 years.
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Sexual health concerns are prevalent and distressing in oncology patients and survivors. While urologic cancers are more prevalent in men, women often have more advanced disease at initial diagnosis, require more advanced surgical resection, and experience higher postoperative complication rates, as well as morbidity and mortality. Women with urologic cancers undergo treatment that is highly likely to impact their sexual function and well-being, however, attention to sexual recovery in this patient population has been limited. Barriers to sexual recovery in women with urologic cancers are biopsychosocial in nature and include complications related to treatment procedures, cancer-related distress, sexual anxiety and avoidance, partner and relational dynamics, and sexual communication skills. Healthcare providers do not adequately address sexual difficulties for these patients and their partners. Sexual minority women and transgender patients with urologic cancer have unique psychosocial and sexual health needs though, due to a lack of research, these remain poorly understood. More research is needed to pinpoint the sexual health needs of this specific oncology population and to explore how various treatment options, such as pelvic organ-sparing cystectomy, can impact sexual health outcomes. Evidence-based and multidisciplinary oncologic and survivorship care, which includes licensed mental health providers, certified sex therapists, and other sexual health experts, is essential for assisting women in their sexual recovery following urologic cancer.
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2022, European Urology
Radical cystectomy (RC) has the potential for profound changes to health-related quality of life (HRQOL).
To evaluate a broad range of HRQOL outcomes in a large RC cohort.
A single-center prospective study enrolled RC patients from 2008 to 2014. We collected 14 separate patient-reported outcome measures at the presurgical visit and at 3, 6, 12, 18, and 24 mo after RC.
To visualize the patterns of recovery over time across domains, we used generalized estimating equations (GEEs) with nonlinear terms. Given substantial differences in patient selection for the type of urinary diversion, we separately modeled longitudinal HRQOL within conduit and continent diversion groups. The mean pre-RC scores were compared to illustrate the baseline HRQOL differences between diversion groups.
The analyzed cohort included 411 patients (n = 205 ileal conduit, n = 206 continent diversion). At baseline, patients receiving continent diversion reported better mean physical (p < 0.001), urinary (p = 0.006), and sexual function (p < 0.001), but lower social function (p = 0.015). After RC, GEE modeling showed physical function scores decreasing 5/100 points by 6 mo, and subsequently stabilizing or returning to baseline. By 12 mo, social function improved by 10/100 points among continent diversions, while remaining stable among ileal conduits. Global quality of life exceeded baseline scores by 6 mo. Sexual function scores were low before RC, with limited recovery. Psychosocial domains were stable or improved, except for 10/100-point worsening of body image among ileal conduits.
RC patients reported favorable HRQOL recovery within 24 mo in most areas other than body image (ileal conduits) and sexual function (both). Importantly, large measurable decreases in scores were not reported by 3 mo after RC. These contemporary outcomes and the excellent locoregional control provided by RC further support it as the gold standard therapy for high-risk bladder cancer.
We review quality of life in the 24 mo following radical cystectomy. Large decreases in health-related quality of life were not reported, with most areas returning to, or exceeding, baseline, except for sexual function and body image.

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: The first author (RCH) is supported, in part, by funding from an NIH training grant through the National Institute of Diabetes and Digestive and Kidney Diseases (5T32DK007782-08).

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Renal CancerBody Image and Bladder Cancer Specific Quality of Life in Patients With Ileal Conduit and Neobladder Urinary Diversions

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Patient Population

Outcome Measurement

Results

Comment

Conclusions

Urol Clin North Am

J Urol

Urol Clin North Am

Eur J Cancer

J Urol

J Urol

J Urol

Urology

J Urol

Renal Cancer
Body Image and Bladder Cancer Specific Quality of Life in Patients With Ileal Conduit and Neobladder Urinary Diversions