Which one offers the best health-related quality of life in patients undergoing radical cystectomy? A systematic review of

(1)

Disponibleenlignesur

ScienceDirect

www.sciencedirect.com

LITERATURE REVIEW

Ileal conduit vs orthotopic neobladder:

Which one offers the best health-related quality of life in patients undergoing radical cystectomy? A systematic review of

literature and meta-analysis

Bricker vs néovessie de substitution : laquelle offre la meilleure qualité de vie après cystectomie radicale? Une revue systématique de littérature et

méta-analyse

I. Ziouziou

^a^,∗

, J. Irani

^b

, J.T. Wei

^c

, T. Karmouni

^a

, K. El Khader

^a

, A. Koutani

^a

, A. Iben Attya Andaloussi

^a

aServiced’urologieB,facultédemédecineetpharmaciedeRabat,universitéMohamed-V, CHUIbn-Sina,Rabat,Maroc

bServiced’urologie,CHUdeBicêtre,78,rueduGénéralLeclerc,94270LeKremlin-Bicêtre, France

cDepartmentofurology,universityofMichigan,AnnArbor,Michigan,USA

Received4October2017;accepted10February2018 Availableonline20March2018

KEYWORDS Ilealconduit;

Orthotopic neobladder;

Bladdercancerindex;

Summary

Introduction.—Orthotopicneobladder (ONB) andileal conduit(IC) arethe mostcommonly practicedtechniquesofurinarydiversion(UD)afterradicalcystectomy(RC)inbladdercancer patients.DataintheliteratureisstilldiscordantregardingwhichUDtechniqueoffersthebest HR-QoL.

∗Correspondingauthor.

E-mail addresses: [email protected] (I. Ziouziou), [email protected] (J. Irani), [email protected] (J.T.

Wei), karmouni[email protected] (T. Karmouni), [email protected] (K. El Khader), [email protected] (A. Koutani), [email protected](A.IbenAttyaAndaloussi).

https://doi.org/10.1016/j.purol.2018.02.001

(2)

242 I.Ziouziouetal.

Qualityoflife;

Radicalcystectomy;

Systematicreview;

Meta-analysis

Objective.—TheobjectivewastocompareHR-QoLinpatientsundergoingONBandICafter RC,throughasystematicreviewoftheliteratureandmeta-analysis.

Material and methods.—We performed a literature search of PubMed, ScienceDirect, CochraneLibraryandClinicalTrials.GovinSeptember2017according totheCochrane Hand- bookandthePreferredReportingItemsforSystematicReviewsandMeta-Analyzes.Thestudies wereevaluatedaccordingtothe‘‘OxfordCenterforEvidence-BasedMedicine’’criteria.The outcomemeasures evaluatedweresubdomains’scoresofBladderCancerIndexBCI:urinary function(UF),urinary bother(UB),bowelfunction (BF),bowelbother(BB),sexualfunction (SF)andsexualbother(SB).Continuousoutcomeswerecomparedusingweightedmeansdiffer- ences,with95%conﬁdenceintervals.Thepresenceofpublicationbiaswasexaminedbyfunnel plots.

Results.—Fourstudiesmettheinclusioncriteria.ThepooledresultsdemonstratedbetterUF andUB scores inIC patients: differences were−18.17 (95% CI:−27.49,−8.84, P=0.0001) and−3.72(95%CI:−6.66,−0.79,P=0.01)respectively.Therewasnosigniﬁcantdifference betweenICandONBpatientsintermsofBFandBB.SFwassigniﬁcantlybetterinONBpatients:

thedifferencewas12.7(95%CI,6.32,19.08,P<0.0001).Howevernosigniﬁcantdifferencewas observedregardingSB.

Conclusion.—Thismeta-analysisofnon-randomizedstudiesdemonstratedabetterHR-QoLin urinaryoutcomesinICpatientscomparedwithONBpatients.

MOTSCLÉS Bricker; Néovessiede substitution; Bladdercancer index;

Qualitédevie; Cystectomie radicale;

Revuesystématique; Méta-analyse

Résumé

Introduction.—La néo-vessie desubstitution (NVS) etleBricker (B)sont lestechniques de dérivationurinaire(DU)lesplusfréquemmentutiliséesaprèscystectomieradicale(CR)chez lespatientsatteintsdecancerdelavessie.Jusqu’àprésent,lesdonnéesdelalittératuresont discordantesencequiconcernelatechniquedeDUoffrantlameilleurequalitédevie(QdV).

Objectif.—L’objectifétaitdecomparerlaQdVchezlespatientsopérésd’uneNVSetBaprès RC,parlebiaisd’unerevuesystématiquedelalittératureavecméta-analyse.

Matérieletméthodes.—Nousavonseffectuéunerevuedelalittératuredanslesbasesdedon- nées:PubMed,ScienceDirect,CochraneLibraryetClinicalTrials.Govenseptembre2017selon lesrecommandationsdu«CochraneHandbookfor SystematicReviewsofInterventions» et

«PreferredReportingItemsforSystematicReviewsandMeta-Analyses»(PRISMA).Lesétudes ontétéévaluéesselonlescritères«OxfordCentreforEvidence-BasedMedicine».Lescritères dejugementontétélesscoresdessous-domainesduquestionnaire«BladderCancerIndex» (BCI):fonctionurinaire(FU),gêneurinaire(GU),fonctiondigestive(FD),gênedigestive(GD), fonctionsexuelle(FS) etgêne sexuelle(GS).Les variablescontinues ontétécomparées en utilisantlesdifférencespondéréesdesmoyennes,avecdesintervallesdeconﬁanceà95%.La présencedebiaisdepublicationaétéexaminéeparlesgraphiquesdetype«funnelplots».

Résultats.—Quatre étudesrépondaientaux critèresd’inclusion. Lesrésultatscombinés ont démontrédesmeilleursscoresdeFUetdeGUchezlespatientsayanteuunBricker:lesdif- férencesétaientde−18,17(IC95%:−27,49,−8,84,p=0,0001)et−3,72(IC95%:−6,66,

−0,79,p=0,01)respectivement.Iln’yavaitpasdedifférencesignificativeentermesdeFDet GD.LaFSétaitsignificativementmeilleurechezlespatientsNVS:ladifférenceétaitde12,7 (ICà95%,6,32,19,08,p<0,0001).Cependant,iln’yavaitpasdedifférencesignificativeen matièredeGS.

Conclusion.—Cetteméta-analysed’étudesnonrandomiséesadémontréunemeilleureQdVen termesdesrésultatsfonctionnelsurinaireschezlespatientsopérésd’unBrickercomparative- mentauxpatientsNVS.

(3)

Introduction

Therehasbeenanincreasinginterestonthequalityoflife in uro-oncology ﬁeld in the last years.Several newtools were developed toevaluate the health-related qualityof life (HR-QoL) especially in bladder cancer (BC) patients:

EORTC-QLQ-BLS24, FACT-Bladder, FACT Vanderbilt Cystec- tomyIndex,BladderCancerIndex[1—4].

After radical cystectomy (RC), several techniques of urinary diversions (UD) are possible: ureterostomy, ileal conduit (IC), orthotopic neobladder (ONB), etc. The two most commonly practiced techniques are IC and ONB.

Patient and surgeon preferences, health status, disease stage, and targeted QoL should all be considered in the selectionofUD[5].

Two meta-analyses have been publishedby Yanget al.

andCerrutoetal.in2016and2017respectively[6,7].The mainmethodologicalconcernwiththesemeta-analyseswas theinclusionofstudiesusingdifferenttoolsofHRQoLmea- surementwithvariousspeciﬁcitiestoBC,whichwasasource ofsigniﬁcantbiases.Indeed,whileCerrutoetal.concluded toanadvantageofONBcomparedtoICintermsofHR-QoL, Yangetal.reportedacomparableHR-QoLafterradicalcys- tectomyaftereitherONBorIC.Thereforeitisstillunclear afterRCwhichUDoffersthebestHR-QoLforpatients.

The objectiveof ourstudy wasto compare HR-QoLin patientsundergoingONBandICafterRC.

We performed a systematic review of literature and meta-analysis of studies comparing HR-QoL in patients undergoing ONB and IC after RC and using the BCI- questionnaireintheassessmentofHR-QoL.Wehavechosen theBCIasasingletoolofmeasurementinordertoovercome thelimitationofheterogeneityencounteredintheprevious meta-analyses.

Material and methods Search strategy

We performed a computerized bibliographic search on different databases: PubMed, ScienceDirect, CochraneLi- braryand ClinicalTrials.Gov usingthe following keywords:

‘‘Bladder cancer’’, ‘‘Cystectomy’’, ‘‘Orthotopic neobladder’’,‘‘Ilealconduit’’,‘‘Qualityoflife’’,‘‘Bladdercancer index’’,and‘‘BCI’’inSeptember2017.Afterwardsacom- plementarysearchinGoogleScholarwasmade.Weusedthe softwareZotero(http://www.zotero.org)version4.0.29.17, forthemanagementofbibliography.A‘‘PreferredReporting ItemsforSystematicReviewsandMeta-Analyzes’’(PRISMA) chart has been developed to describe the procedure of selectingstudies.

Inclusion criteria

According to the PRISMA guidelines, we used the PICO approachtodeﬁnestudyeligibility.

The clinical question wasformulated according to the PICOcriteria(population,intervention,control,outcome):

• population:patientsundergoingradicalcystectomy(Rad- icalcystectomy);

• intervention:orthotopicneobladder;

• control=ilealconuit;

• outcomes=BladderCancerIndexsubdomains.

‘‘Ileal conduit vs orthotopic neobladder: which one offers thebesthealth-relatedqualityoflifeaccording to the BladderCancer Indexquestionnaire in patients undergoingradicalcystectomy?’’

Inclusioncriteriawerethefollowing:

• comparative studies reporting long-term results with a follow-up≥3years;

• population:Patientsundergoingradicalcystectomy;

• intervention:orthotopicneobladder(ONB);

• control:ilealconduit(IC);

• outcomesBladderCancerIndexsubdomains’scores:

◦ urinaryfunction(UF),

◦ urinarybother(UB),

◦ bowelfunction(BF),

◦ bowelbother(BB),

◦ sexualfunction(SF),

◦ sexualbother(SB).

Oneexclusioncriterionwasapplied:languageotherthan EnglishorFrench.

Norestrictionintimewasused.

Systematic review process

Twoauthors(IZandJI)reviewedthearticles.Weperformed asystematicreviewofliteraturewithmeta-analysisaccord- ing tothe recommendations of the ‘‘Cochrane Handbook for Systematic Reviews of Interventions’’ and ‘‘Preferred ReportingItemsforSystematicReviewsandMeta-Analyzes’’

(PRISMA)[8,9].

Quality of data assessment

The studies were evaluated according to the criteria of

‘‘OxfordCenterforEvidence-BasedMedicine’’[10].

Data extraction

Foreachstudyselected,thefollowingdatawereextracted:

year, country, journal, type of study, total number of patients,number of patients ‘‘ONB’’,number of patients

‘‘IC’’,age,percentageofstagelessorequaltopT2ineach group,follow-up (months),meansandstandard deviations oftheBCIsub-domains’scores(functionandbother).

Statistical analysis

Statistical methods followed the recommendations of the CochraneHandbookforSystematicReviewsofInterventions [8].

Continuous outcomes were compared using weighted meandifferences,with95%conﬁdenceintervals.

TheI²testswereusedtoevaluatetheheterogeneityof thestudiesfor eachoutcome,withtheChi² tests:hetero- geneitywasconsideredsigniﬁcantifI²greaterthan50%with P<0.10.

Inthecase ofsigniﬁcant heterogeneitywithanI²value greater than 50%, a random effect model was applied.

(4)

244 I.Ziouziouetal.

IdentificationScreeningEligibilityIncluded

Articles identifiedat the search in databases

(n= 260) + Complementary search (n= 1)

Studies screened: Titlesand abstracts

(n = 258)

Studies analyzed in full-text for eligibility

(n= 6)

Included studies (n=4) 1 prospective 3 retrospective

Studies (titlesand abstracts) excluded (n= 252)

157 not appropriate 67reviews

26 languagesother than English or French 2 redundancies of the same study

2 studies excluded:

1 follow-up less than 3ys 1 missing statistical data Duplicates excluded (n= 3)

Figure1. PRISMAﬂowdiagram:reviewprocessformeta-analysis.

Otherwise,in the case of non-signiﬁcant heterogeneity,a ﬁxedeffectmodelwasused.Themissingvalues(meanand standarddeviationsofcontinuousoutcomeswhentheywere notpublishedor reported)were calculatedusingtheWan formula[11].The presence ofpublicationbiaswasexam- ined by funnel plots. The analyzes were performed using ReviewManager5.3(version5.3.5).

Results

Included studies

Two hundred and sixty articles were identiﬁed following thesearchinMedLine,ScienceDirect,CochraneLibraryand ClinicalTrials.Govdatabases,usingthekeywords:‘‘Bladder cancer’’,‘‘Cystectomy’’,‘‘Orthotopicneobladder’’,‘‘Ileal conduit’’,‘‘Qualityoflife’’,‘‘Bladdercancerindex’’,and

‘‘BCI’’.Aftertheexclusionofstudiesthatdidnotmeetthe inclusion criteria, or with an exclusion criterion, as well asduplicates, four studies were selected: Gellhaus2017, Goldberg2016,Huang2015,Hedgepeth2010[12—15].

Afterwards a complementary search in Google Scholar identiﬁedastudy,whichwasnotincluded.

The PRISMA chartillustrates the steps in theselection process(Fig.1).

Characteristics and quality of studies

The characteristics oftheselectedstudies aredetailedin the Table1.ICpatients weresigniﬁcantly olderthan ONB patientsinthreestudies(Goldberg,Gellhaus,Hedgepeth).

InthestudyofHuangetal.,therewasnosigniﬁcantdiffer- enceintheagebetweenthetwogroups.

Statistical analysis

The BladderCancerIndexsub-domains’scores correspond toLikertscales:thehigherthescore(whetheritisafunc- tionscoreorbotherscore),thebetterisclinicalstatusand qualityoflife.

Outcome: urinary function BCI subdomain score

The BCI score for urinary function was reported by four studies, including a total of 486 patients (Fig. 2). The pooledresultsaccordingtoarandomeffectmodeldemon- stratedasigniﬁcant differenceof −18.17ofthe BCIscore

(5)

conduitvsorthotopicneobladder245

Table1 Characteristicsofincludedstudies.

1stauthor Year Country Journal Typeofstudy Totalnoof patients (IC/ONB)

%offemale patients (IC/ONB)

%of≤pT2 (IC/ONB)

Age(years) Follow-up (months)

Qualityofthe study

Goldberg 2016 Israel Urologic Oncology

Retrospective 95(49/46) IC=10,ONB4 (NS)

77.55/76.08 IC=72(46-85), ONB=61 (44-75) (P=0.0002)

IC46.6 (mean±20.5) ONB44.4 (mean±31.1)

3

Gellhaus 2016 US TheJournal ofUrology

Retrospective 92(44/48) 21/2.1 (P<0.0001)

68.18/81.25 IC=67.2±9.4, ONB=58.4±9.1 (P<0.0001)

Atleast60 monthsafter RC

3

Hedgepeth 2010 US Oncology Prospective 224(85/139) 22.4/16.6 (P=0.05)

70.78/77.77 IC=71.09 (meanat surgery±8.23 SD);

ONB=60.76 (meanat surgery±9.30 SD)(P<0.001)

Baselineand at1,6,12,24, 48,72,96 monthsafter RC

2b

Huang 2015 China BMC

Urology

Retrospective 117(78/39) 12.8/12.8 79.5/84.6 IC=64.0 (mean,range 52.0—74.8) ONB=63.6 (mean,range 51.5—76.0) (P=0.885)

Baselineand at6,12,18, 24,36,48,60 monthsafter RC

3

NS:non-signiﬁcantdifference.

(6)

246 I.Ziouziouetal.

Figure2. Forestplot:urinaryfunctionsubdomainscore.

Figure3. Forestplot:urinarybothersubdomainscore.

Figure4. Forestplot:bowelfunctionsubdomainscore.

Figure5. Forestplot:bowelbothersubdomainscore.

Figure6. Forestplot:sexualfunctionsubdomainscore.

(7)

Figure7. Forestplot:sexualbothersubdomainscore.

of the urinary function in favor of the ileal conduit (95%

CI:−27.49,−8.84,P=0.0001)withsigniﬁcantheterogeneity (Chi²=84.41,df=3,(P<0.00001),I²=96%).

Outcome: urinary bother BCI subdomain score

TheBCIscoreofurinarybotherwasreportedbyfourstud- ies,includinga total of486 patients (Fig.3). The pooled resultsaccording toarandomeffectmodel demonstrated asigniﬁcantdifferenceof−3.72fromtheBCIscoreofuri- narybotherinfavorofilealconduit(95%CI:−6.66,−0.79, P=0.01)withsigniﬁcantheterogeneity(Chi²=11.51,df=3, (P=0.009),I²=74%).

Outcome: bowel function BCI subdomain score

TheBCIscoreofbowelfunctionwasreportedbytwostud- ies,includinga total of187 patients (Fig.4). The pooled results using a ﬁxed-effect model demonstrated a non- signiﬁcant difference of −0.92 between ONB and IC (95%

CI:−4.30,2.47,P=0.60)withnon-signiﬁcantheterogeneity (Chi²=1.92,df=1(P=0.17),I²=48%).

Outcome: bowel bother BCI subdomain score

TheBCIscoreofbowelbotherwasreportedbytwostudies including187 patients (Fig.5). The pooledresults of the fixed-effect model showed a non-significant differenceof 0.42betweenONBandIC(95%CI,−2.82,3.65,P=0.80)with non-significant heterogeneity (Chi²=0.06, df=1 (P=0.81), I²=0%).

Outcome: sexual function BCI subdomain score

TheBCIscoreforsexualfunctionwasreportedbytwostud- ies including 187 patients (Fig. 6). The pooled results of the fixed-effect model showed a significant differenceof 12.7infavorofONB (95%CI,6.32,19.08,P<0.0001)with non-significant heterogeneity (Chi²=0.00, df=1 (P=1.00), I²=0%).

Outcome: sexual bother BCI subdomain score

The BCIscoreof sexualbotherwasreportedbytwostud- ies including 187 patients (Fig. 7). The pooled results of thefixed-effectmodelshowedanon-significantdifference of −7.08 between ONB and IC (95% CI, −15.13, 0.96, P=0.08) with non-significant heterogeneity (Chi²=1.96, df=1(P=0.16),I²=49%).

Figure8. Funnelplot:urinaryfunctionsubdomainscore.

Figure9. Funnelplot:urinarybothersubdomainscore.

Publication bias

The funnel plots were examined for the six outcomes (Figs.8—13).

Discussion

Why choosing the BCI as a tool of measurement of HR-QoL?

TheBladderCancerIndex(BCI)wasdevelopedandvalidated byGilbertetal.in2010[4].

(8)

248 I.Ziouziouetal.

Figure10. Funnelplot:bowelfunctionsubdomainscore.

Figure11. Funnelplot:bowelbothersubdomainscore.

Figure12. Funnelplot:sexualfunctionsubdomainscore.

ItisareliableandBC-speciﬁcinstrumenttoevaluateHR- QoLinpatientswithlocalizeddisease.Itwasdevelopedin threesteps:review of theliterature,development ofthe questionnaireandvalidationby assessmentof consistency andreproducibility[4].Afterwardsmanytranslatedversions

Figure13. Funnelplot:sexualbothersubdomainscore.

of BCI were validated in French, Spanish, Hungarian and Arabiclanguages[16—19].

ThereisalackofspeciﬁcityinotherHR-QoLinstruments astheyincludedcommonquestionsonwellbeingforonco- logicpatientsinadditiontoaspeciﬁcmoduleforBC.

Therearealsolimitations inthediseasestage:EORTC- QLQ-BLS24andFACT-Bladderquestionnairesareapplicable onlyfor patientswithnon-muscleinvasivebladdertumors (NMIBT) while FACT VanderbiltCystectomy Indexis exclu- sively used for patients with muscle-invasive BC (MIBC) [1—3].ResultsfromcomparativestudiesofHR-QoLinmixed patientswithBCatdifferentstagesmaybedifﬁculttointer- pretusingthesequestionnaires.

TheBCIquestionnaireovercomestheselimitations.Itis entirelyspeciﬁctoBCpatientsandapplicableforNMIBTand MIBCpatients.InarecentcomparativestudywiththeFunc- tional Assessment Cancer Therapy-Vanderbilt Cystectomy Index(FACT-VCI),theBCIwasabettertoolforassessingand counselingpatientsonexpectedtreatment-speciﬁcchanges afterRCwithUD[20].

TheBCIquestionnaireprovidesarobustmeasureofuri- nary,bowelandsexualoutcomes.Itisalsosensitivetothe differencesintreatments,andapplicabletobothsexesand all the UDs [13]. Forthese reasons, we have chosen the BCIsubdomains’scores(urinaryfunctionandbother,bowel function and bother, sexual function and bother) as out- comesinthismeta-analysis.

Urinary function and bother

ICpatientswereolder thanONBpatients.However,unex- pectedly IC patients had signiﬁcantly better long-term resultsofUFandUBcomparedtoONBpatients.

This may be explained by voiding problems in ONB patients [4].In addition,ONB patients have aproblem of urinaryleakagecausedbythelossofreﬂexmicturitionand injurytotheurethralsphincter[14].Theyneedarehabilita- tiontolearnthenewurinationhabitandsomeexercisessuch asKegelExerciseinordertoreinforcetheurethralsphincter [14].

UB score was also better in IC patients although they mayfaceproblemsofperistomialurinaryleakagefromthe pouch,skin irritation,foulurineodor, etc.Thissigniﬁcant

(9)

resultdemonstrates that ICis well tolerated by patients.

Stomial issues are often overcome by good self-care and assistanceofcareproviders[14].

Bowel function and bother

There was no difference between IC and ONB patients regardingbowelsubdomains.Thismaybeexplainedbysim- ilaritiesin theuse ofileal segmentin bothUDs (although thelengthisshorterinIC)andtherespectofsomespeciﬁc contra-indicationsofusingbowelinUDsuchasinﬂammatory chronicboweldisease.

Sexual function and bother

ONBpatients hadbetterSFscorethanICpatients. Thisis due tothe differenceof age:ONB patients were younger thanICpatients.Therewasalsonosigniﬁcantdifferencein sexualbother. Thereforenoconclusioncanbe madefrom theseﬁndingsregardingsexualQoL.

Limitations of our study

Therewerelimitationsinourstudy.Asthestudiesincluded were not randomized, the risk of selection bias wascon- siderable regardingthechoice of UD.Indeedthe agewas higherinICgroup.Sexualfunctionwasnotevaluatedornot reportedintwostudies.

AnotherlimitationwasrelatedtotheBCIquestionnaire:

There was no evaluation of the body image by the BCI.

Hedgepethetal.foundnosigniﬁcantdifferencebetweenIC andONBintermsofbodyimageevaluatedbyEORTCbody imagescale[15].HoweverHuangetal.reportedbetterbody imageevaluatedby thesamescale inONBpatientsat the shortterm,butnodifferencewasobservedatthelongterm (>1year)[14].

Finally,regardingpublicationbias,Funnelplotsweredif- ﬁculttointerpretbecauseofthenumberofstudiesincluded foreachoutcome(≤4).

Conclusion

Thismeta-analysisofnon-randomizedstudiesdemonstrated abetterHR-QoLinurinaryoutcomesinICpatientscompared withONB patients. No conclusion can be made regarding thesexualoutcomesbecauseoftheagedifferencebetween ICandONBpatients.Howevertheseresultsshouldbecon- ﬁrmedbyrandomizedcomparativestudies.

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

References

[1]SprangersMA,CullA,GroenvoldM,BjordalK,BlazebyJ,Aaron- sonNK.TheEuropeanorganizationforresearchandtreatment ofcancerapproachtodevelopingquestionnairemodules:an updateandoverview.QualLifeRes1998;7(4):291—300.

[2]CooksonMS,DuttaSC,ChangSS,ClarkT,SmithJA,WellsN.

Health related qualityof lifein patientstreated withradi- calcystectomyandurinarydiversionforurothelialcarcinoma ofthebladder:developmentandvalidationofanewdisease speciﬁcquestionnaire.JUrol2003;170(5):1926—30.

[3]Anderson CB, Feurer ID, Large MC, Steinberg GD, Barocas DA, Cookson MS, et al. Psychometric characteristics of a condition-speciﬁc, health-related quality-of-life survey: the FACT-Vanderbiltcystectomyindex.Urology2012;80(1):77—83.

[4]GilbertSM,DunnRL,HollenbeckBK,MontieJE,LeeCT,Wood DP,etal.Developmentand validationofthebladdercancer index: a comprehensive,disease speciﬁc measure ofhealth relatedqualityoflifeinpatientswithlocalizedbladdercancer.

JUrol2010;183(5):1764—9.

[5]CrozierJ,HennesseyD,SenguptaS,BoltonD,LawrentschukN.

Asystematicreviewofilealconduitandneobladderoutcomes inprimarybladdercancer.Urology2016;96:74—9.

[6]YangLS,ShanBL,ShanLL,ChinP,MurrayS,AhmadiN,etal.

Asystematicreviewandmeta-analysisofqualityoflifeout- comesafterradicalcystectomyforbladdercancer.SurgOncol 2016;25(3):281—97.

[7]CerrutoMA,D’Elia C,SiracusanoS, PorcaroAB, Cacciamani G, DeMarchiD,etal. Ishealth-relatedquality oflifeafter radicalcystectomyusingvalidatedquestionnairesreallybetter inpatientswithilealorthotopicneobladdercomparedtoileal conduit:ameta-analysisofretrospectivecomparativestudies.

CurrUrol2017;10(2):57—68.

[8]Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions; 2011 [Version 5. 1. 0 (updated March 2011) The Cochrane collaboration, 2011.

http://www.cochrane-handbook.org].

[9]Liberati A, Altman DG, Tetzlaff J, Mulrow C,Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematicreviewsand meta-analysesofstudiesthatevalu- atehealth care interventions:explanation and elaboration.

PLoS Med 2009;6(7):e1000100, http://dx.doi.org/10.1371/

journal.pmed.1000100.

[10]Evidence-Based Cf. Oxford Centre for evidence-based medicine: levels of evidence; 2009 [http://www.cebm.net/

oxford-centre-evidence-based-medicine-levels-evidence- march-2009/].

[11]WanX,WangW,LiuJ,TongT.Estimatingthesamplemeanand standarddeviationfromthesamplesize,median,rangeand/or interquartilerange.BMCMedResMethodol2014;14:135.

[12]GellhausPT,CaryC,KaimakliotisHZ,JohnsonCS,WeinerM, KochMO,etal.Long-termhealth-relatedqualityoflifeout- comesfollowingradicalcystectomy.Urology2017;106:82—6.

[13]Goldberg H, Baniel J, Mano R, Rotlevy G, Kedar D, Yosse- powitch O. Orthotopicneobladder vs. ileal conduit urinary diversion:along-termquality-of-lifecomparison. UrolOncol 2016;34(3):e1—7.

[14]HuangY,PanX,ZhouQ,HuangH,LiL,CuiX,etal.Quality- of-lifeoutcomesandunmetneedsbetweenilealconduitand orthotopicilealneobladderafterradicalcystectomyinaChi- nese population: a 2-to-1 matched-pair analysis. BMC Urol 2015;15:117.

[15]HedgepethRC, GilbertSM,HeC,LeeCT, Wood JrDP.Body imageand bladdercancerspeciﬁcqualityoflifeinpatients withilealconduitandneobladderurinarydiversions.Urology 2010;76(3):671—5.

[16]GaunezN,Larré S,PirèsC,DoréB, WeiJ, Pﬁster C,et al.

[Frenchtranslationandlinguisticvalidation ofthequestion- naireBladderCancerIndex(BCI)].ProgUrol2010;22(6):350—3.

[17]Schmidt S, Riel R, Frances A, Lorente Garin JA, Bonﬁll X, Martinez-ZapataMJ,etal.Bladdercancerindex:cross-cultural adaptationintoSpanishandpsychometricevaluation.Health QualLifeOutcomes2014;12:20.

(10)

250 I.Ziouziouetal.

[18]Hevér NV, Péntek M,BallóA, GulácsiL, Baji P,Brodszky V, etal. Healthrelatedqualityoflifeinpatientswithbladder cancer: across-sectional survey and validationstudyofthe HungarianversionoftheBladderCancerIndex.PatholOncol Res2015;21(3):619—27.

[19]ZiouziouI,TouzaniMA,KarmouniT,ElKhaderK,KoutaniA,Iben AttyaAndaloussiA.Arabictranslationandlinguisticvalidation

ofthequestionnaireBladderCancerIndex.AfrJUrol2017[In press,https://doi.org/10.1016/j.afju.2017.09.007].

[20]Moncrief TJ, Balaji P, Lindgren BB, Weight CJ, Konety BR.

Comparative evaluation of bladder-speciﬁc health-related quality of life instruments for bladder cancer. Urology 2017;108:76—81.