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ORIGINAL ARTICLE
Quality of life associated with orthotopic neobladder and ileal conduit in women: A multicentric cross-sectional study
Qualité de vie chez les femmes après enterocystoplastie de remplacement orthotopique ou dérivation urinaire non continente trans-iléale : étude transversale multicentrique
X. Biardeau
a,∗, N. Lamande
a, L. Tondut
b, B. Peyronnet
b, G. Verhoest
b, M. Kyheng
d,
M. Soulie
c, X. Game
c, J.-C. Fantoni
a, F. Marcelli
aaDepartmentofurology,CHULille,universityLille,ClaudeHuriezhospital,59000Lille, France
bDepartmentofurology,Rennesuniversityhospital,35000Rennes,France
cDepartmentofurology,Toulouseuniversityhospital,Rangueilhospital,Toulouse,France
dEA2694,departmentofbiostatistics,CHULille,59000Lille,France
Received5August2019;accepted28November2019 Availableonline12February2020
KEYWORDS Bladdercancer;
Pelvicexenteration;
Functionaloutcomes;
EORTCQLQC-30;
EORTCQLQ-BLmi30;
SF-12
Summary
Purpose.—To compare quality of life and functional outcomes associated with orthotopic neobladder(ONB)andilealconduit(IC)afteranteriorpelvicexenterationforbladdercancer inwomen,throughamulticentriccross-sectionalstudy.
Methods.—All womenwho haveundergoneananteriorpelvic exenterationassociated with ONBorIC forabladdercancerbetweenJanuary 2004andDecember 2014withinthethree participatinguniversityhospitalcentersandthatwerestillaliveinFebruary2016wereincluded.
Threedistinctauto-administeredquestionnaireswere submittedtothepatients:theEORTC QLQ-C30,theEORTCQLQ-BLmi30andtheSF-12.Comparisonofresponsetothesequestionnaires betweenwomenwithONBandthosewithICwere studiedwithMann-WhitneyU tests,with astatisticallysignificantP-value setat<0.05. Theprimaryendpointwas the‘‘globalhealth status’’sub-scoreextractedfromtheEORTCQLQ-C30questionnaire.Thesecondaryendpoints werethefunctionalsub-scoresandsymptomssub-scoresobtained withtheEORTC QLQ-C30 questionnaireaswellasthesub-scoresobtainedwiththeEORTCQLQ-BLmi30 andtheSF-12 questionnaires.
∗Correspondingauthor.Departmentofurology,Lilleuniversity hospital,ClaudeHuriezhospital,1,ruePolonovski,59037Lillecedex, France.
E-mailaddress:biardeau.xavier@gmail.com(X.Biardeau).
https://doi.org/10.1016/j.purol.2019.11.010
1166-7087/©2019ElsevierMassonSAS.Allrightsreserved.
Results.—Fortywomenwereincludedinthestudy(17ONB,23IC).Theprimaryendpointwas comparablebetweentheONBandICwomen(83.3vs.66.7P=0.22).Similarly,nosignificant statisticaldifferencecouldbepointedbetweentheONBandICwomenintermsofsecondary endpoints.
Conclusion.—Thepresentstudy didnotreportanysignificancedifferenceintermsofqual- ityoflifeandfunctionaloutcomesbetweenwomenwithONBandthosewithICafterpelvic exenterationforbladdercancer.
Levelofevidence.—3.
©2019ElsevierMassonSAS.Allrightsreserved.
MOTSCLÉS Cancerdevessie; Exenteration pelvienne antérieure; Résultats fonctionnels; EORTCQLQC-30; EORTCQLQ-BLmi30; SF-12
Résumé
Introduction.—Leprésentarticleapourobjectifdecomparerl’enterocystoplastiedesusb- stitutionorthotopique(ESO)àladérivationurinairenoncontinentedetypeBricker(DUNC), entermesdequalitédevieetderésultatsfonctionnels,aprèsréalisationd’uneexentération pelvienneantérieurepourcancerdevessie,auseind’unpopulationstrictementféminine.
Méthodes.—Touteslesfemmesayanteuuneexentérationpelvienneantérieureassociéeàla confectiond’uneESOoud’uneDUNCpourcancerdevessie,entrejanvier2004etdécembre 2014, aseinde 3centres hospitalo-universitaires franc¸ais,etqui étaienttoujours vivantes enfévrier2016, étaientéligibles.Troisautoquestionnairesdistinctsétaientsoumis auxpar- ticipantes :EORTC QLQ-C30,EORTCQLQ-BLmi30 etSF-12.Le critèrede jugementprincipal correspondaitausous-score«qualitédevieglobale»del’autoquestionnaireEORTCQLQ-C30.
Lescritèresdejugementsecondairescorrespondaientauxautressous-scoresobtenuàpartir del’autoquestionnaireEORTCQLQ-C30ainsiquelessous-scoresissusdesautoquestionnaires EORTCQLQ-BLmi30etSF-12.Lesréponsesàcesautoquestionnairesétaientcomparéesentreles femmesayanteuuneESOetcellesayanteuuneDUNCàl’aidedutestduUdeMann-Whitney, avecunesignificativitéstatistiquefixéeàp<0,05.
Résultats.—Quarantefemmesétaientincluesdansl’étude(17ESO,23DUNC).Lecritèrede jugementprincipalétait comparableentrelesfemmesayanteuuneESO etcellesayanteu uneDUNC(83,3vs66,7p=0,22).Demême,aucunedifférencesignificativen’apuêtremiseen évidenceentrelesdeuxgroupspourlescritèresdejugementsecondaires.
Conclusion.—Leprésentarticlen’apaspermisdemettreenévidencededifférencestatistique- mentsignificativeentermesdequalitédevieouderésultatsfonctionnelsentrelesfemmes ayanteuuneESOetcellesayanteuuneDUNCaprèsexentérationpelvienneantérieurepour cancerdevessie.
Niveaudepreuve.— 3.
©2019ElsevierMassonSAS.Tousdroitsr´eserv´es.
Abbreviations
ASAscore AmericanSocietyofAnaesthesiologistsscore ECOG-PS EasternCooperativeOncologyGroupPerformance
Status
EORTCQLQ-BLM30 EuropeanOrganisationforResearchand TreatmentofCancermuscleinvasivebladdercan- cermodule
IC ilealconduit
ONB orthotopicneobladder SF-12 shortformhealthsurvey WHO WorldHealthAssociation
Introduction
Anterior pelvic exenteration with urinary tract diversion is currently considered the standard of care in women withnon-metastaticmuscleinvasivebladdercancerornon- muscle invasive bladder cancer after failed intra-vesical therapy[1].Although,itis associatedwithsatisfyingmid- term oncological outcomes, this invasive procedure has regularlybeenreportedtosignificantlydecreasequalityof life[2].Inordertolimit thispotentialimpact,orthotopic neobladder(ONB)hasbeensuggestedasaninterestingalter- nativetotheclassicalilealconduitdiversion(IC)[3].Indeed, suchareconstructivesurgeryis supposedtominimizethe
alteration of the body image, while maintaining micturi- tionsthroughtheurethra,withoutincreasingperi-operative complications [4—6]. However, it has been reported to exposethepatienttospecificlong-termcomplications,such asurinaryincontinence or urinaryretention requiring the introductionofintermittentself-catheterization[7,8].Fur- thermore, its impact on quality of life has rarely been studied in women, nor even directly compared to IC[9];
whenresultsissuedfrommalecohorts haverecentlybeen reported to be contradictory [10—12]. Thus, there is an urgentneedtoevaluatethegaininqualityoflifeprovided byONBinthefemalepopulation.
Thepresentmulticentriccross-sectionalstudyaimedto retrospectivelycomparequalityoflifeandfunctionalout- comes associated with ONB and IC after anterior pelvic exenterationforbladdercancerinwomen.
Methods
General methodology
TheprotocolhasbeenapprovedbytheFrenchAdvisoryCom- mitteeonInformationProcessinginMaterialResearchinthe Fieldof Health(no 15.957).Allwomen whichhave under- goneananteriorpelvicexenterationassociatedwithONBor ICforabladdercancerbetweenJanuary2004andDecem- ber 2014 and that werestill alive in February 2016 were considered eligible. The present work was designed as a multicentriccross-sectionalstudy,implicating3Frenchuni- versityhospitalcentresandwascarriedoutinthefirsthalf ofyear2016.Afterdatacollectionandparticipationagree- ment,allincluded patientswereaskedtofill-in3distinct qualityoflifeauto-administeredquestionnaires.Epidemio- logical,oncologicalandsurgicaldatawerefirstlyextracted from computerised medical record. Epidemiological data includeddateofbirth,weight(kg),high(m),EasternCoop- erativeOncologyGroupPerformanceStatus(ECOG-PS)and AmericanSocietyofAnaesthesiologistsscore(ASAscore)at thetimeofsurgery.Oncologicaldataincludedthehistoryof aneo-adjuvanttherapy—cytotoxicchemotherapyorradia- tiontherapy—thehistologicaltype,thecytologicalgrade, thepTNMstage—tumour,node,metastasis—accordingto the2004 WorldHealth Association (WHO) classificationof bladdertumour, theoccurrence of a postoperative recur- rence and the need for an adjuvant therapy — cytotoxic chemotherapyorradiation therapy.Surgical dataincluded thetypeofsurgicalapproach—laparotomyorlaparoscopy
—andthepresenceofasparingsurgery—vaginaoruterus sparing surgery. A phonecall wasthen planned toobtain verbalparticipationagreement.Duringthesameinterview, thepatientswereaskedaboutthemaintenanceofaregular sexualactivity.InpatientswithONB,urinaryincontinence
—defined asthe occurrence of>1 urinaryleakage during thelastweek—andtheneedtoperformself-intermittent catheterizationtoemptythebladderwerealsospecified.
TheEORTCQLQ-C30(EuropeanOrganisationforResearch andTreatmentofCancergenericquestionnaire),theEORTC QLQ-BLM30(EuropeanOrganisationforResearchandTreat- mentofCancermuscleinvasivebladdercancermodule)and theSF-12(Short Formhealth survey)questionnaireswere sentbypostaccompaniedwithaninformationsheetanda
written participationagreement to complete. The EORTC QLQ-C30 questionnaire has been validated to specifically assess the quality of life and the importance of related- diseasesymptomsassociatedwithoncologicalpathologies.
Differentaspectsofthequalityoflifeareexploredthrough6 distinctsub-scores:‘‘globalhealthstatus’’,‘‘physicalfunc- tioning’’, ‘‘role functioning’’, ‘‘emotional functioning’’,
‘‘cognitivefunctioning’’and‘‘socialfunctioning’’.Eachof these sub-scores is quoted from 0 to 100, with a higher value correspondingtoa betterqualityoflife ora better functioning.Similarly, 9distinctrelated-diseasesymptoms aresuccessivelyexploredand quotedfrom0 to100,with ahighervalue correspondingtoa higherdisturbance.The EORTC QLQ-BLM30 questionnaire has been validated to specificallyassessthequalityoflifeassociatedwithmuscle invasive bladdercancer. The urinary, digestiveand sexual symptomsandfunctioningaswellasthebodyimagearesuc- cessivelyexploredandquotedfrom0to100,withahigher scorecorrespondingtoabetterfunctioningorabetterbody image acceptation.The SF-12is amore generic question- nairethathasbeenvalidatedtoassessqualityoflifewithout focusingonanyspecificconditions.Itisconstitutedof2dis- tinctsub-scores:the‘‘physicalhealth’’sub-scoreaswellas the ‘‘mentalhealth’’ sub-scorefor which amaximal note of56.6and60.8isattributed,respectively.Here,ahigher valuecorrespondstoabetterqualityoflife.
Primary endpoint
Theprimaryendpointwasthe‘‘globalhealthstatus’’sub- scoreextractedfromtheEORTCQLQ-C30questionnaire.
Secondary endpoints
The secondary endpoints were the functional sub-scores andsymptomssub-scoresobtainedwiththeEORTCQLQ-C30 questionnaire aswell asthesub-scoresobtained withthe EORTC QLQ-BLM30 and the SF-12 questionnaires. Regard- ing ‘‘sexual functioning’’ assessed using the QLQ-BLM30 questionnaire, we reported data issued from the overall population aswell asfromthesexually activepopulation, definedbyasexualactivityinthelast4weeks.
Statistical analysis
Data are expressed as median [range] for quantitative variablesandcount(percentage)forcategoricalvariables.
Patients, tumour and surgical procedure characteristics werecomparedbetweenwomenwithONBand thosewith IC.Quantitative variablesandorderedcategoricalvariable werecomparedwithMann-WhitneyUtestsandcategorical variables with fisher’s exact tests. No statistical compar- ison was done for categorical variables with a modality frequency<5.Comparison ofresponse totheEORTC QLQ- C30,QLQ-BLM30andSF-12questionnairesbetweenwomen withONBandthosewithICwerestudiedwithMann-Whitney Utests.Statisticaltestingwasconductedatthetwo-tailed
␣-levelof0.05.DatawereanalysedusingtheSASsoftware version9.4(SASInstitute,Cary,NC).
Table1 Comparisonofpopulation,tumorandsurgicalprocedurecharacteristicsbetweenwomenwithONBandthose withIC.
ONB n=17
IC n=23
P-value
Populationcharacteristicsatthetimeofsurgery
Age,median[range] 60.0 [47.0—75.0] 71.0 [37.0—84.0] 0.008
BMI,median[range] 23.2 [18.9—29.4] 24.7 [0.0—35.8] 0.45
ECOG-PS
0 15 (88.2%) 16 (69.6%) 0.26
1 2 (11.8%) 7 (30.4%)
≥2 0 (0.0%) 0 (0.0%)
ASAscore
I 7 (41.2%) 1 (4.4%) 0.005
II 9 (52.9%) 17 (73.9%)
≥III 1 (5.9%) 5 (21.7%)
Tumorcharacteristicsatthetimeofsurgery Histologicaltype
Transitionalcellcarcinoma 16 (94.1%) 21 (91.2%) NA
Otherhistologicaltypes 1 (5.9%) 2 (8.8%)
Cytology
Lowgrade 2 (11.8%) 3 (13.0%) 1.00
Highgrade 15 (88.2%) 20 (87.0%)
pTstage
pT0 5 (29.4%) 4 (17.4%) 0.60
pTcis-pT1-pT2 7 (41.2%) 9 (39.1%)
≥pT3 5 (29.4%) 10 (43.5%)
pNstage
pN0 15 (88.2%) 18 (78.3%) 0.68
≥pN1 2 (11.8%) 5 (21.7%)
Surgicalprocedurecharacteristics Surgicalapproach
Laparotomy 15 (88.2%) 21 (91.2%) NA
Laparoscopy 2 (11.8%) 2 (8.8%)
Sparingsurgery
Vaginasparingsurgery 6 (35.3%) 1 (4.4%) 0.030
Uterussparingsurgery 5 (29.4%) 2 (8.7%) 0.11
Populationcharacteristicsatthetimeofquestionnairessubmission
Age,median[range] 65.0 [57.0—77.0] 75.0 [40.0—86.0] 0.015
Delayfromsurgery(months), median[range]
42.0 [18.0—137.0] 50.0 [4.0—109.0] 0.64
Activesexuallife 5 (29.4%) 2 (8.7%) 0.11
Valuesare expressed withnumber(percentage) unlessotherwiseindicated. P-valueswerecomputed using fisher’sexact tests for categoricalvariablesandquantitativeandordinalvariableswerecomparedwithMann-WhitneyUtests.NA:notapplicableforcaseof smallsample.
Results
Patients characteristics
Between January 2004 andDecember 2014, withinthe 3- participating universityhospitalcentres,113 womenhave undergonean anteriorpelvicexenterationassociatedwith ONBorICforabladdertumour.Fifty-sixwomenwerestill alive in February 2016. Among them, 8 women were not interestedor able toparticipateand8 more werelostof follow-upatthetimeofinclusion.Fortywomenwerefinally includedinthestudy(17ONB,23IC).
Women with ONB were significantly younger (60.0 [47.0—75.0]vs.71.0[37.0—84.0],P=0.008)andpresented withasignificantlylowerASAscore(P=0.005)atthetime ofsurgerywhencomparedwithIC(Table1).Noneofthe40 includedwomenreceivedanyneo-adjuvanttherapy,and,at thetimeofsurgery,allwomenwereconsideredtobemetas- tasisfree.Adjuvanttherapywasadministeredin1woman withONB(1radiotherapy)andin2womenwithIC(1cyto- toxicchemotherapy and 1 radiotherapy). Recurrence was diagnosedin1ONBwomanaswellasin1ICwomanaftera follow-upof77and16months,respectively. Tumourchar- acteristicsatthetimeofsurgerywerecomparablebetween
Table2 ComparisonofresponsetoquestionnairesbetweenwomenwithONBandthosewithIC.
ONB n=17
IC n=23
P-value
EORTCQLQ-C30 Globalhealthstatus
Globalhealthstatus 83.3 [16.7—100.0] 66.7 [33.3—100.0] 0.22
Functionalscales
Physicalfunctioning 93.3 [40.0—100.0] 80.0 [33.3—86.7] 0.06
Rolefunctioning 100.0 [0.0—100.0] 100.0 [16.7—100.0] 0.75
Emotionalfunctioning 91.7 [8.3—100.0] 83.3 [16.7—100.0] 0.40
Cognitivefunctioning 100.0 [6.7—100.0] 83.3 [8.3—100.0] 0.15
Socialfunctioning 100.0 [0.0—100.0] 100.0 [0.0—100.0] 0.95
Symptomscales
Fatigue 22.2 [0.0—100.0] 22.2 [0.0—100.0] 1.00
Nauseaandvomiting 0.0 [0.0—50.0] 0.0 [0.0—100.0] 0.63
Pain 0.0 [0.0—100.0] 0.0 [0.0—66.7] 0.67
Dyspnea 33.3 [0.0—66.7] 0.0 [0.0—66.7] 0.27
Insomnia 0.0 [0.0—100.0] 33.3 [0.0—100.0] 1.00
Appetiteloss 0.0 [0.0—100.0] 0.0 [0.0—100.0] 0.77
Constipation 0.0 [0.0—100.0] 0.0 [0.0—100.0] 0.11
Diarrhea 0.0 [0.0—100.0] 0.0 [0.0—100.0] 0.55
Financialdifficulties 0.0 [0.0—100.0] 0.0 [0.0—100.0] 0.60
EORTCQLQ-BLM30
Urinarysymptoms 83.3 [23.8—100.0] 77.8 [11.1—100.0] 0.78
Bowelsymptoms 83.3 [0.0—100.0] 66.7 [0.0—100.0] 0.19
Sexualfunctioninga 0.0 [0.0—83.3] 0.0 [0.0—55.6] 0.50
Sexualfunctioningb 72.2 [33.3—83.3] 36.1 [16.7—55.6] 0.19
Bodyimage 66.7 [11.1—100.0] 88.9 [0.0—100.0] 0.83
SF-12
Physicalhealth 50.9 [23.4—59.4] 42.5 [26.2—56.1] 0.15
Mentalhealth 50.8 [20.8—62.3] 50.5 [26.7—59.9] 0.98
Valuesareexpressedwithmedian[range].P-valueswerecomputedusingMann-WhitneyUtests.
aOverall.
b Sexuallyactivepatients(5ONBpatientsand2ICpatients).
thetwotypesofurinarydiversion(Table1).Inwomenwith ONB,vagina-sparingsurgerywassignificantlymorefrequent whencomparedwithIC(35.3%vs.4.4%,P=0.030)(Table1).
Themaintenanceofaregularsexualactivityatthetimeof questionnairessubmissionwasreportedin5(29.4%)women withONBand2(8.7%)womenwithIC(P=0.11).AmongONB women,10(58,8%)reported>1episodeofurinaryinconti- nenceduringthelastweek and7(41,2%)usedtoperform self-intermittentcatheterizationonaregularbasis.
Women withIC weresignificantly older at the timeof questionnairessubmissionwhen comparedwithONB(65.0 [57.0;77.0]vs.75.0[40.0;86.0],P=0.015),whilethedelay betweensurgeryandquestionnairescompletion—expressed in months — werecomparable between the two types of urinarydiversions(42.0[18.0;137.0]vs.50.0[4.0;109.0], P=0.64).
Primary endpoint
Theprimaryendpointdefinedasthe‘‘globalhealthstatus’’
sub-scoreextractedfromtheEORTCQLQ-C30questionnaire wascomparablebetweentheONBandICwomen(83.3[16.7;
100.0]vs.66.7[33.3;100.0]P=0.22)(Table2,Fig.1).
Secondary endpoints
Allqualityof lifesub-scoresandthesymptomssub-scores obtainedwiththeEORTC QLQ-C30questionnaire (Table2, Fig.1) aswell asthe functionalsub-scores obtainedwith theEORTCQLQ-BLM30questionnaire(Table2,Fig.2)were comparable between the ONB and IC women. Similarly, nostatistical difference couldbepointed out interms of
‘‘physicalhealth’’sub-scoreand‘‘mentalhealth’’sub-score obtained with the SF-12 questionnaire between the two typesofurinarydiversions(Table2,Fig.3).
Discussion
In the present study, no significant differences were reportedintermsofqualityoflifeandfunctionaloutcomes betweenwomenwithONBandICfollowinganteriorpelvic exenterationforbladdercancerafteramedianfollow-upof 42.0monthsand50.0months,respectively.Onlyatrendwas observedinthe‘‘physicalfunctioning’’sub-scoreobtained with the EORTC-QLQ C30 questionnaire, which tended to behigher inthe ONB group.This result,correspondingto
Figure1. Distributionofsub-scoresissuedfromtheEORTCQLQ-C30questionnairebetweenwomenwithONBandthosewithIC—Boxplots.
ONB:orthotopicneobladder;IC:ilealconduit.Eachofthesesub-scoresisquotedfrom0to100,withahighervaluecorrespondingtoa betterqualityoflifeorabetterfunctioning.
ahigheraptitudetoperformdailyactivities,hasprobably moretodowiththeyoungerageandthelowerASA score inthisgroupthanwiththetypeofurinarydiversionitself.
Infact,itseemsimportanttonotethatinspiteofalower ageandlesscomorbidities,theONBgroupdidnotpresent any significant differences in terms of qualityof life and functionaloutcomeswhencomparedwiththeICgroup.
Similar results have already been demonstrated in a smaller series.Gacci et al.compared 9women withONB to 16 women with IC after anterior pelvic exenteration performed for bladder cancer through a cross-sectional study[9].Thesepatientsweresubmittedtodifferentauto- administeredquestionnaires,includingtheEORTCQLQ-C30 and the EORTC QLQ-BLM30, more than 36 months after surgery.
The authors did not report any significant difference betweenthesetwotypesofurinarydiversions.Assupported byrecentpublications,wethinkthatthespecificproblems encountered with the ONB, such as urinary incontinence andtherequirementofself-intermittentcatheterizationfor urinaryretention may partly explain the absence of gain in terms of quality of life associated withthe confection of ONB in our cohort. Indeed, in a study conducted on 89 patients (women=95%) after ONB, Henningsohn et al.
demonstrated that the introduction of self-intermittent catheterizationforurinaryretentionwasassociatedwitha significantincrease in thelevel of anxiety [8]. Withinour study,nearlyhalfofthepatientswithONBreportedtoreg- ularlyperformself-intermittentcatheterizationatthetime of questionnaires submission. Furthermore, Zahran et al.
Figure2. Distributionofsub-scoresissuedfrom theEORTCQLQ-BLM30questionnairebetweenwomenwithONBand thosewithIC— Boxplots.ONB:orthotopicneobladder;IC:ilealconduit.Eachofthesesub-scoresisquotedfrom0to100,withahigherscorecorresponding toabetterfunctioningorabetterbodyimageacceptation.*:overall;**:sexuallyactivepatients(5ONBpatientsand2ICpatients).
Figure3. Distributionofsub-scoresissuedfromtheSF-12questionnairebetweenwomenwithONBandthosewithIC—Boxplots.ONB:
orthotopicneobladder;IC:ilealconduit.The‘‘Physicalhealth’’andthe‘‘Mentalhealth’’sub-scoresarequotedfrom0to56.6and0to 60.8,respectively,withahighervaluecorrespondingtoabetterqualityoflife.
recently assessed the impact of urinary incontinence on qualityof life in womenwith ONB using theEORTC QLQ- C30questionnaire[7].Among the74included patients,29 (39,2%)reportedurinaryincontinence.Inthesepatients,the
‘‘globalhealthstatus’’sub-scoreandthe‘‘socialfunction- ing’’sub-scorewassignificantlylowerwhencomparedwith continent patients. Within our cohort, more than half of thewomenwithONBreportedurinaryincontinenceat the timeofquestionnairessubmission.Asaresult,accordingto Hedgepethetal.,morethantherespectofthebodyimage, thesatisfactoryfunctionoftheurinaryderivation—what- everitstype—isfundamentalinmaintainingagoodquality oflifeafterpelvicexenteration[13].
Because the advantage of the ONB over the IC could have been considerably limited by the important rate of urinaryincontinenceandurinaryretentionassociatedwith it,we assumethatthefutureeffortstogainin qualityof lifeassociatedwithurinarydiversioninwomenafterpelvic exenteration should follow two distinct axes. Firstly, an efforthastobemadeinimproving theONBfunction.This stepshouldincludeacompletepreoperativeassessment— in order toselect the women that will most benefitof a ONB — associated with improvement in technical aspects of the reconstruction. As a second axe, we assume that the placeof continentpouches hastobe reconsideredin thisindication.Therefore, weadvocatefurtherstudies to directly compare the quality of life and functional out- comes associated with ONB and continent pouches after pelvicexenteration in womenperformed for bladder can- cer.
To our knowledge, the present study is currently the largest one to compare quality of life and functional outcomesbetweenONBandICperformedafterpelvicexen- teration for bladder cancer in women. The large panel of validated auto-administered questionnaires allowed us toprecisely assessthe qualityof life,the related-disease symptoms as well as the urinary, digestive and sexual functionsassociatedwiththesetwotypesofurinarydiver- sions. However, we agree with the limitation due to a potentiallackofpower associatedwithourstudy.Indeed, it seems reasonable to think that a larger cohort could haveshownasignificantdifferencebetweenthetwotypes of urinary diversion in terms of quality of life and/or functional outcomes.Furthermore,the absenceof preop- erative assessment as well as the lack of bladder diary, pad-test and measurement of the post-void residual vol- umewithin ONB women,could havemade our evaluation difficult tointerpret. Moreover, the results regarding the sexual functioning should be taken with caution due to the small numbers of women reporting an active sexual life at the time of questionnaires submission. Finally, it is important tonote that the French version of the QLQ- BLM30 questionnaire has not been fully validated by the EORTC.
Although the present data will not allow any defini- tive conclusion, they constitute preliminary data for futureresearch.Therefore,theresultsreportedhere,will undoubtedlyhelpresearchprotocols,comparingqualityof lifeandfunctionaloutcomesbetweenONBandICinwomen, tobedesigned.
Conclusion
Inthismulticentric,retrospectiveseries,wefoundnoevi- dence, in a context of anterior pelvic exenteration for bladdercancer,thatONBissuperiortoICintermsofquality oflife.Furtherprospectivestudiesareneededtovalidate ourfindings.
Disclosure of interest
Theauthorsdeclarethattheyhavenocompetinginterest.
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