Health-related Quality of Life after Radical Cystectomy for
Bladder Cancer in Elderly Patients with an Ileal Conduit,
Ureterocutaneostomy, or Orthotopic Urinary Reservoir:
A Comparative Questionnaire Survey
Takashi Saika＊, Ryoji Arata, Tomoyasu Tsushima, Yasutomo Nasu,
Bunzo Suyama, Katsuji Takeda, Shin Ebara, Daisuke Manabe,
Tomoko Kobayashi, Ryuta Tanimoto, Hiromi Kumon and
Okayama Urological Research Group
Department of Urology, Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences, Okayama 700ﾝ8558, Japan
he number of elderly patients who are
candidates for radical cystectomy as treatment
for bladder cancer is increasing. For younger
patients, orthotopic neobladder replacement following
radical cystectomy has gained popularity; there are
many reports of satisfactory post-operative quality of
life [1ﾝ12]. In elderly patients with bladder cancer,
however, the standard methods of urinary diversion
To compare the health-related quality of life of elderly patients after radical cystectomy for bladder
cancer in urinary diversion groups: ileal conduit, ureterocutaneostomy, or orthotopic urinary reser-
voir. The 109 participating elderly patients aged 75 or older completed self-reporting questionnaires:
the QLQ-C30, and on satisfaction with urinary diversion methods. Fifty-six patients had undergone
constructions for ileal conduit diversion, 31 for ureterocutaneostomy, and 22 for orthotopic urinary
reservoir (OUR). The median follow-up period for each group was 4.0 years (range 0.3ﾝ11.2), 4.5
years (range 0.3ﾝ18.0), and 3.3 years (range 0.3ﾝ6.7), respectively. Regardless of the type of urinary
diversion, the majority of patients reported having good overall quality of life, although with some
problem of pain. No signifi cant diff erences among urinary diversion subgroups were found in any
quality of life area in the QLQ-C30 questionnaire. More patients in the OUR sub-group felt disappoint-
ment than those in the ileal conduit or cutaneostomy sub-groups. However, a questionnaire which
asked which diversion method would be preferable showed a trend that more patients in the OUR
subgroup would have chosen the same one. Health-related quality of life appeared relatively good in
these 3 groups. Patient demands and expectations may be so diff erent from the results that the details
of each urinary diversion method should be explained thoroughly. OUR construction could be a candi-
date even for elderly patients.
Key words: bladder cancer, cystectomy, neo-bladder, urinary diversion, QOL
Acta Med. Okayama, 2007
Vol. 61, No. 4, pp. 199ﾝ203
CopyrightⒸ 2007 by Okayama University Medical School.
http :/ /www.lib.okayama-u.ac.jp/www/acta/
Received November 15, 2006 ; accepted February 8, 2007.
＊Corresponding author. Phone : ＋81ﾝ86ﾝ235ﾝ7287 ; Fax : ＋81ﾝ86ﾝ231ﾝ3986
E-mail : firstname.lastname@example.org (T｡ Saika)
have been ileal conduit or ureterocutaneostomy.
These methods, however, may cause pouch problems,
such as the diffi culty of self-pouching. Orthotopic
urinary reservoir (OUR), on the other hand, may
disturb the elderly patient’s QOL by weakening
abdominal pressure and causing urinary retention or
increasing night time urine volume resulting in
incontinence. To better inform elderly patients of
their choices of urinary diversion, we investigated
health-related quality of life in elderly patients who
underwent OUR, ileal
ocutaneostomy following radical cystectomy for
bladder cancer. To our knowledge, no such
investigations to date have been reported.
conduit, or ureter-
Patients and Methods
The 109 participating elderly patients aged 75 or
older in our study had undergone radical cystectomy
for bladder cancer at Okayama University Hospital
and in 13 collaborating hospitals with a follow-up
period of at least 3 months.
Two distinct types of urinary tract reconstruction
were discussed with patients and their families:
cutaneous diversion with
ureterostomy, and orthotopic urinary reservoir
substitution. Patients with positive lesions at the
bladder neck, renal dysfunction (creatinine clearance
＜50 mg/dL), impaired heart function (ejection
fraction＜45ｵ), or senile dementia were excluded
from consideration for orthotopic urinary reservoir
Fifty-six patients (42 male, 14 female) had
undergone ileal conduit diversion, 31 (25 male, 6
female) uretero-cutaneostomy, and 22 (20 male, 2
female) orthotopic urinary
distributions of these groups were 75.0ﾝ92.0 years
(median 80.1), 75.0ﾝ90.1 years (median 81.4), and
75.0ﾝ90.5 years (median 78.5), respectively. The
median post-operative follow-up in each group was 4.0
years (range 0.3ﾝ11.2), 4.5 years (range 0.3ﾝ18.0)
and 3.3 years (range 0.3ﾝ6.7), respectively.
Health related QOL (HRQOL) assessment was
performed using the European Organization for the
Research and Treatment of Cancer Quality of Life
Core Questionnaire (EORTC-QLQ-30C) , deve-
loped to measure basic components of HRQOL that are
similar for most malignancies, which comprises 5
ileal conduit or
functional scales covering physical, role, emotional,
cognitive and social aspects, one scale of overall
health status, and overall HRQOL. There are also 3
symptom scales of fatigue, nausea/vomiting and pain,
and 6 single items that deal with dyspnea, insomnia,
appetite loss, constipation, diarrhea, and fi nancial
diffi culties caused by the disease or its treatment.
Questions on the physical scale were answered by a
dichotomous response scale (yes/no), while overall
HRQOL was scored from 1 to 7 (very poor to
excellent). The other items were answered through a
Likert scale and responses graded from 1 to 4 (1＝
not at all, 4＝very much). All scores were linearly
transformed to a 0ﾝ100 scale. For functional and
scales overall higher scores represent a better
outcome on HRQOL, whereas for symptom and
single-item scales higher scores correspond to more
problems and a reduced HRQOL.
In addition to the above, a questionnaire designed
by the Department of Urology in collaboration with the
Department of Psychiatry was used for evaluating
patient satisfaction with the selected urinary
diversion. QOL questionnaires and a cover letter
explaining the nature of the survey were mailed to all
participants of the study. If there was no reply a
reminding letter was sent, followed by a telephone
call, if necessary.
The results of questionnaires were converted into
scores and statistically analyzed using the Mann-
Regardless of type of urinary diversion a majority
of patients reported good functional scoring (Fig. 1A).
As for the symptomatic score, only the element of pain
showed a mild degree problem in each group (Fig.
1B). No signifi cant diff erences among urinary
diversion subgroups were found in any quality of life
area in the QLQ-C30 questionnaires.
The questionnaire “Does Urinary Diversion
Disturb Your Life?” revealed that not many patients
felt disturbance with their urinary diversion.
Although no statistical diff erence between any urinary
diversion group was recognized in this questionnaire,
a small number of patients in both the ileal conduit and
cutaneostomy sub-groups felt severe disturbance while
no one in the OUR sub-group felt any (Fig. 2A).
Acta Med. Okayama Vol. 61, No. 4
Saika et al.
Quality of Life after Radical Cystectomy August 2007
Appetite lossSleep disturbance
Nausea and vomiting
Fig. 1B EORTC QLQ-C30 Symptom scales: A high scale score
represents a high level of symptomatic problems (0ﾝ100). No sta-
tistically signifi cant diff erences on any items.
Fig. 1A EORTC QLQ-C30 Functional scales: A high scale
score represents a high/healthy level of functioning (0ﾝ100). No
statistically signifi cant diff erences on any items.
Fig. 2A Is urinary diversion an obstacle to patients’ life?: In a
questionnaire asking “Does Urinary Diversion Disturb Your Life?”
patients selected 1 from 4 answers.
Fig. 2B Did urinary diversion meet patients’ satisfaction as pre-
operational expectations?: Patients selected 1 from 4 answers.
if possible, other methods
Fig. 2C Which urinary diversion method would be selected if it
could be?: Patients selected 1 from 5 answers.
Regarding satisfaction with urinary diversion, more
patients in the OUR sub-group felt disappointment
than those in ileal conduit or cutaneostomy sub-groups
(Fig. 2B). However, a questionnaire which asked
which diversion method would be preferable showed a
trend that more patients in the OUR subgroup would
have chosen the same one (Fig. 2C).
It is commonly held by urological surgeons that
there are quality of life diff erences between various
diversions after radical cystectomy for bladder cancer.
While we had concluded that neobladder recon-
struction following cystectomy for bladder cancer is
indicated in elderly patients, because age is not a
critical factor in the selection of urinary diversion
method , no study conclusively documents that
one form of diversion is superior to another in terms
of HRQOL in elderly patients.
In the current results of functional scoring in
QLQ-C30, physical functioning of the OUR group
showed a better trend (p＝0.08) than that of the
cutaneostomy group. OUR construction may maintain
better physical functioning in elderly patients in
comparison to urinary stoma formation. One possible
reason is that stoma management is diffi cult for elderly
patients. However, since our study does not have
baseline or pre-operative data, the possibility of
baseline diff erences between sub-groups cannot be
ignored. The lack of baseline assessment of HRQOL
would need to be estimated before cystectomy and take
place in a prospective study.
Despite the relatively high pain score in all sub-
groups, the results of the symptom scores in
QLQ-C30 showed good scoring in all patients. Radical
cystectomy and urinary diversion may not cause
symptomatic disturbance, even in elderly patients.
There was no signifi cant diff erence in the
QLQ-C30 scores among the urinary diversion
methods. A similar trend has been reported in some
comparative studies of post-operative QOL between
OUR and ileal conduit in relatively younger patients,
although incontinent urinary diversions compromised
physical and psychological status [1ﾝ12]. The authors
were unable to detect any diff erence in QOL between
ileal conduit and OUR, with both groups younger than
our patients having high scores despite urinary
incontinence being more common after OUR
reconstruction. One possible reason discussed in the
reports was that the instruments used were
insuffi ciently sensitive to pertinent diff erences between
the groups, especially if the eff ects were small.
Although questionnaires have been previously used
in QOL studies of patients with bladder cancer,
neither instrument was substituted for the other, so
direct comparison of the results obtained with each is
impossible . Our results, therefore, can not be
compared with prior reports with younger patients,
especially, in terms aging.
In general, the limitation of this type of study
design is selection bias, e.g., the patient’s preoperative
health status may have been diff erent prior to
cystectomy which may in turn have aff ected the choice
of diversion. However, since most functional/
symptomatic factors of QLQ-C30 in the current
results are relatively good and similar in all sub-
groups, preoperative health status may have been
similar between sub-groups.
Some patients in the ileal conduit and
cutaneostomy sub-groups felt severe disturbance
although no one in the OUR sub-group felt any. Fewer
patients with OUR (14ｵ) felt moderately severe
disturbance than patients with stoma (25ｵ moderately
severe or severe). Stoma formation therefore might
lead to some disturbance due to lost body shape or
On the other hand, lower satisfaction than pre-
operative expectations in many patients with OUR
might be the result of excessive positive expectations
about OUR, such as “bladder substitution must be a
brand-new bladder”. The surgeon should inform
patients about the merits and demerits of OUR. Our
current results can provide additional information.
More patients in the OUR subgroup would chose
the same urinary diversion than in other sub-groups.
From these results, OUR construction can be one
strong candidate for urinary diversion even in elderly
patients with bladder cancer.
In conclusion, health-related quality of life
appeared relatively good in these 3 groups. Although
no obvious diff erences were recognized in functional
and symptomatic QOL between the 3 urinary diversion
methods, demands and expectations may be so
diff erent that the details of each urinary diversion
method should be explained to elderly patients
Acta Med. Okayama Vol. 61, No. 4
Saika et al.
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Quality of Life after Radical Cystectomy August 2007