E F F E C T OF ILEAL CONDUIT ON PATIENTS' ACTIVITIES F O L L O W I N G RADICAL CYSTECTOMY R. JOSEPH BABAIAN, M.D. DOROTIIY B. SMITH, R.N. From the Departments of Urology and Nursing Services, The University of Texas M. D. Anderson Cancer Center, IIouston, Texas
ABSTRACT---Over the last twenty months, 110 patients who have undergone a radical cysteetomy for bladder cancer at The University of Texas M. D. Anderson Cancer Center were surveyed to assess the effect of an ileal conduit urinary diversion on postoperative activity. Postoperatively, 4 7.3 percent of the patients were very active, 34.5 percent were moderately active, and 18.2 percent were sedentary. Chemotherapy and the patient's gender were found to have a statistically significant eJJect on postoperative activity level. Chemotherapy resulted in a decrease of very active t)atients ~rom 55.6 percent to 27.9 percent and an increase in sedentary patients from 11.2 percent ito 30.2 percent (P = 0.005). No diJ-ference in activity levels was seen in 73.9 percent of the nonchemotherapy patients. Fifty-one percent of the men were very active as compared with only I9.1 percent o-f the women, whereas 20 percent more women than men were moderately active and 113 percent more were sedentary. Our experience indicates that the ileal conduit had no significant ~negative effect on activity if the e-f-fects o-f chemotherapy are controlled: 82.6 percent o-f the patients not receiving chemotherapy experienced either no change or an increase in their activity.
Although technology, has made tremendous strides in the last six years in developing alter;hate forms of urinary diversion, have we, the ~surgeons, lost touch with our patients? A1!fhough there can be no disagreement about the ideal of a nerve-sparing radical cystectomy and !iia continent urinary diversion, the means re!~!quired to achieve that end must alwavs be kept m proper perspective. The complication and reoperation rates (31%) of the Koek pouch, !~;vhich is the most common form of continent ildiversion, are not considered here': instead, the ieffect of urinary diversion on patients' activities :~s addressed. We found disconcerting a report !by Boyd et al. 2 showing approximately a 70 percent decrease in recreational activities in pa:tients who had an ileal conduit, which is the !grineiple form of diversion performed at our in:stitution. Several months prior to the appear:ance of this study, we had started a prospective qnvestigation to determine the effect of this .form of diversion on our patients. Herein we
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report our findings regarding changes in activity. Material and Methods Between May 1986 and March 1988, 128 patients underwent a radical cystectomy and ileal conduit urinary diversion for bladder cancer at The University of Texas M. D. Anderson Cancer Center. An assessment of preoperative activity was completed for 118 patients, and an assessment of postoperative activity (usually within the first 4 months after surgery or 3 months after the completion of chemotherapy) was completed for 115. Both pre- and postoperative activity levels were assessed for 110 patients. Assessment was performed by an interview conducted by one of us (D.S.), and every attempt was made to have the patient's spouse or "significant other" present. Activity levels were classified into three categories: first, very, active, which included participation in sports such as
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swimming, tennis, golf, and hunting, occupations requiring manual labor such as construction or ranching, and yard work such as mowing grass; second, moderate activit3; which included performing household chores or exercise such as walking or fishing; and third, sedate, which included none of the above and no physical activity outside the home. The assessment also included questions pertaining to financial status, formal education levels, physical handicaps, occupation, changes in self-image, and who changes the urostomy appliance. Our patient population consisted of 102 men and 26 women. Their mean age was 63.7 years (range, 42-82). Thirty-seven percent of our patients (43) received chemotherapy postoperatively. At the time of the interviews, none of the patients in the nonchemotherapy group had either recurrent or persistent disease, whereas 16 in the chemotherapy group were found to have persistent or recurrent disease. Statistical analysis was p e r f o r m e d by the chi-square method. '~
Ta.~LE I. Relationship of chemotherapy to postoperative activity Activity Level. . . . Chemotherapy - - V e r v - - Moderate- Sedentary Status No. % No. % No. % No (n = 72) 40 55.6 24 33.3 8 11.1 Yes (n = 43) 12 27.9 18 41.9 13 30.2 Total (n = 115) 52 45.2 42 36.5 21 18.3 TABLE II. Belationship between chemotherapy and diJJerence in activity level Patients
No Diff. in Activity No. %
Diff. in Activity No. %
No Yes Total
51 22 73
18 19 37
73.9 53.7 66.4
26.1 46.3 33.6
Belationship between variables and postoperative activity status*
TABLE I I I .
Results Preoperatively; 59.3 percent of the 118 patients surveyed were very active, 36.4 percent were moderately active, and 4.2 percent were sedentar?~ In contrast, among the 115 surveyed postoperatively; 45.2 percent were very active, 36.5 percent were moderately active, and 18.3 percent were sedentary. To determine possible reasons for these changes, we analyzed the level of postoperative activity according to several variables: gender, postoperative ehemotherapx; education level, financial status, occupation, presence of a physical handicap, and perceived change in self-image. Gender had a significant relationship to activity. Among the 94 men surveyed, 51.1 percent (48) were very active postoperativel}; 33 percent (31) were moderately active, and 16 percent (15) were sedentary; whereas of the 21 women surveyed only 19.1 percent (4) were very active, 52.4 percent (11) were moderately active, and 28.6 percent (6) were sedentary. Among the men, 32.6 percent reported a change in activity level postoperatively; 32.6 percent of this group became more active while 67.4 percent became less active. A change in activity level was reported by 38.1 percent of the women, 25 percent of whom became more active and 75 percent less active. Patients who did not have chemotherapy were more active than patients who had under-
Variable Education High Moderate Poor Financial status Wealthy Moderate Poor Occupation Prof./white collar Housewife Blue collar Physical handicap Yes No Changed self-image 5bs No
Pts. - - A e t M t y Level ( % ) - Evaluated "vgry Moderate Sedentary 49 40 7
51 37.5 4'2.9
33.8 37.5 28.6
10.2 25 28.6
68 22 17
5(1 40.9 35.3
36.8 36.4 29.4
13.2 22.7 35.3
52 10 44
50 20 50
84.6 60 31.8
15.4 20 18.2
*Not all patients were evaluated in all categories.
gone chemotherapy (Table I). A postoperative change in activity level occurred in 46.3 percent of the chemotherapy patients, 10.5 percent of whom had an increase in activity while 89.5 percent reported a decrease. In the nonchemotherapy group, 26.1 percent experieneed a ehange between their pre- and postoperative activity levels, 33 percent becoming more a c tive and 66.7 percent becoming less active (Table II). The effects of the five other variables on the postoperative activity status are shown in Table III.
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Comment Although the literature is replete with studies detailing the physical complications after radical eysteetomy and urinary diversion, only a few investigators have reported the psyehosocial problems associated with these surgical procedures, z,4,5 Ib minimize these problems, all our patients are counseled preoperatively about the effects of the diversionary procedure. After a discussion of their expectations for sexual and physieal activity; they are advised of the various types of urinary diversion available and a recommendation for an ileal conduit is usually made. Patients are told that, for the most part, they can be as active as they were preoperatively. Furthermore, we mention some of our patients' activities such as swimming, dancing, skiing, fishing, hunting, ranching, bowl;ing, boating, and traveling. This study revealed that the patient's gender and the requirement for postoperative ehemoii:therapy significantly affected the level of posti:~operative activities (P = 0.028 and P = 0.005, :~respectively), Surprisingly, whereas 51.1 per}cent of the men were very active, only 19.1 per::ieent of the women were equally active; 20 per:;cent more of the women than the men vcere ~moderately active and 13 percent more were se?dentarv The difference in preoperative versus ?postoperatwe activity was affected significantly I~Y whether or not chemotherapy was given (P : gi= 0.03). Chemotherapy resulted in a decrease ~in the Percentage of very active natients from ':N5.6 to 27.9 and an increase in the percentage !~6f sedentary patients from 11.1 to 30.2. Activity' ;!)]evels were unchanged in 73.9 percent of the ~[nonchemotherapv patients as compared with $a.7 percent of the chemotherapv patients. We )~found no statistically significan't relationship ':~etween the level of postoperative activity and !~ducation, financial status, physical handicap, ~6eeupation, or chan~e in self-ima~e Therefore .~,n our experience, 82.6 percent of the patients ! lid not experience a reduction from their prei ~perative activity levels following an ileal conMt urinary diversion for bladder cancer. These ~ u l t s corroborate those of Fossa and associ:}~tes.' ,N'
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Although this study did not employ definitive scientific psychosocial testing methods, it was designed by authors who have had some, although limited, experience in social research. No reliability and validity studies were performed, but the questionnaire used was based on daily-life clinical experience with these patients. Despite these limitations, we believe we have obtained meaningful and relevant data. The surgeon must acquaint himself with his patient well enough to discuss and listen to his patient's life expectations and concerns regarding quality of life. Issues important to one patient are of much less concern to another. Just as some patients want to minimize their operative risks at any cost (even to the extent of sacrificing a continent diversion), many patients in the age group usually treated for bladder cancer at our institution infrequently participate in strenuous physical and recreational activities; therefore maintaining a strenuous activity level cannot be used to justify a continent diversion. The results of our study convince us that the ileal conduit urinary diversion need not diminish the activity level of patients who elect this form of diversion following radical cystectomy if they do not require chemotherapy postoperatively. We believe firmly that preoperative psychosocial counseling and continued postoperative support are essential elements in complete patient rehabilitation. 1515 Holcombe Boulevard Houston, Texas 77030 (DR. BABAIAN) References
1. I,ieskovsky G, Boyd SI), and Skinner DG: Management of late complications of the Koek pouch form of urinary diversion, J Urol 137:1146 (1987). 2. Boyd SD, et al: Quality of life survey of urinary diversion patients: comparison of ileal conduits versus continent Koek ileal reservoirs, J Urol la8:13s6 (1987). 3. Snedoeor G\~,( and Coehran WG: Statistical Methods, ed 6, Ames, Iowa State College Press, 1967, p 20. 4. Fossa SD, ReRan JB. Ous S, and Kaalhus O: Life with an ileal conduit in eysteetomized bladder cancer patients: expectations and experience, Seand J Urol Nephrol 21:97 (1987). 5. Jones MA, Breckman B, and Hendry WF: Life with an ileal conduit: restdts of questionnaire surveys of patients and urological surgeons, Br J Urol 52:"21 (1980).
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