eISSN: 2299-0054
ISSN: 1895-4588
Videosurgery and Other Miniinvasive Techniques
Current issue Archive Manuscripts accepted About the journal Supplements Editorial board Reviewers Abstracting and indexing Subscription Contact Instructions for authors Ethical standards and procedures
Editorial System
Submit your Manuscript
SCImago Journal & Country Rank
2/2021
vol. 16
 
Share:
Share:
Original paper

Flexible cystoscopy can improve anxiety and subjective feelings of bladder cancer patients during follow-up

Jie Gao
1
,
Da-Wei Tian
1
,
Dian-Sheng Zhou
1
,
Chang-Li Wu
1

  1. Department of Urology, The Second Hospital of Tianjin Medical University, Hexi District, Tianjin, China
Videosurgery Miniinv 2021; 16 (2): 397–402
Online publish date: 2020/11/16
Article file
- Flexible cystoscopy.pdf  [0.08 MB]
Get citation
 
PlumX metrics:
 

Introduction

Bladder cancer (BC) is the most common genitourinary cancer worldwide [1]. Approximately 70–80% of newly diagnosed bladder cancers are classified as non-muscle-invasive bladder cancer (NMIBC) and are usually treated by transurethral resection of bladder tumor (TURBT). NMIBC has a high recurrence rate about 40–80%, so patients will accept regular cystoscopy over a long period of time. Patients with high-risk tumors will accept cystoscopy at 3 months after TURBT. If negative, subsequent cystoscopy should be repeated every 3 months for a period of 2 years, and every 6 months thereafter until 5 years, and then yearly. Patients with low-risk tumors should undergo cystoscopy according EAU guidelines [2]. As no noninvasive method can replace endoscopy [2], cystoscopy is the most common examination in the urology department. Patients with cancer are more prone to anxiety [3], and the impact of repeated cystoscopy on anxiety in BC patients deserve the attention of clinicians. The flexible cystoscope has a soft body, a smaller diameter, and is more convenient to observe, especially for the bladder neck. Many studies have shown that the two types are equal in detective effectiveness [4, 5]. But so far, the soft cystoscope has not completely replaced rigid ones, which have lower cost, clear vision and convenient performance [6]. Severe pain and discomfort affect the patient’s compliance with regular follow-up, and may cause some cystoscopy interruption after TURBT, so it is necessary to pay attention to the patients’ feelings during cystoscopy [7]. There has been rare research to observe the effect of different cystoscopes on patients’ comprehensive subjective feelings and anxiety status. This study mainly focused on patients’ anxiety situation, and analyzed the changes in lower urinary tract symptoms (LUTS), pain scores and the incidence of gross hematuria and pyuria during peri-examinations.

Aim

The aim of study was to compare the difference of patients’ anxiety and subjective feelings caused by different cystoscopes.

Material and methods

This was a single-institute study involving 192 NMIBC patients who accepted regular cystoscopy follow-up after TURBT. All patients who might be included needed to fill out the Core Lower Urinary Tract Symptom Score (CLSS) questionnaire, so that we could exclude patients with severe LUTS. Other exclusion criteria included gross hematuria, urinary tract infection and those who accepted biopsy. Patients with pyuria needed to undergo a urine culture to determine the presence of infection. The included patients were randomly divided into a rigid group and a flexible group. In the process of cystoscopy, lidocaine was used first to anesthetize the urethra for 5 min. The order of bladder examination remained consistent between the two groups. The day before the cystoscopy, patients were informed about the type of cystoscope, and then filled out the Amsterdam Preoperative Anxiety and Information Scale (APAIS), which has been proved as a reliable method for assessing preoperative anxiety [8]. Patients were asked to select the pain level and score immediately according to the visual analogue scale (VAS) after the cystoscopy. They filled in the CLSS questionnaire again and performed another urinalysis the day after the cystoscopy. Data on the incidence of pyuria and CLSS changes were collected. Meanwhile, it was recorded whether gross hematuria still existed 24 h after cystoscopy.

Statistical analysis

Continuous variables were displayed as mean ± standard deviation or median (interquartile range) based on the outcome of the normal distribution test. Categorical variables were presented as number and percentage. Statistical differences between groups were analyzed by Student’s t test or the Mann-Whitney U test for continuous variables, and the chi-square test and Fisher’s exact test for categorical variables. P-values under 0.05 indicate statistical significance. All data analyses were conducted using IBM SPSS Statistics (version 21.0; IBM Corp., New York, USA).

Results

One hundred ninety-two patients were included in this study, 93 (48.4%) patients in the flexible cystoscope group and 99 (51.6%) patients in the rigid cystoscope group. There was no difference in the ratio of males to females between the two groups. Demographic and clinical characteristics are shown in Table I.

Table I

Demographic and clinical characteristics

CharacteristicsFlexible group (n = 93)Rigid group (n = 99)P-value
Age66.2 ±15.066.4 ±11.90.927
Gender:0.865
 Male64 (68.8%)67 (66.7%)
 Female29 (31.2%)32 (33.3%)
Smoking history:0.248
 Yes62 (66.7%)58 (58.6%)
 No31 (33.3%)41 (41.4%)
Diabetes:0.228
 Yes28 (30.1%)38 (38.4%)
 No65 (69.9%)61 (61.6%)
Hypertension:0.535
 Yes40 (43.0%)47 (47.5%)
 No53 (57.0%)52 (52.5%)
Prostate volume [g]35.4 (29.8, 50.9)43.9 (30.5, 70.1)0.074
High grade:0.726
 Yes39 (41.9%)44 (44.4%)
 No54 (58.1%)55 (55.6%)

The main outcomes are shown in Table II. The median APAIS score of male patients undergoing flexible or rigid cystoscopy was 8 vs. 12 (p < 0.01), and this result in females was 8 vs. 9 (p = 0.048). Similar to the anxiety evaluation, the median pain scores for men in the two groups was 1 vs. 2 (p < 0.01), respectively, and this outcome in female patients was 0 vs. 1 (p < 0.01). Included male patients had higher CLSS scores than female patients. There was no difference in preoperative CLSS between male and female patients. After cystoscopy, patients who underwent the rigid test had a greater CLSS change (0 vs. 1, p < 0.01; 0 vs. 1, p = 0.001) and the main changes came from bladder pain and urethral pain. Items that changed in CLSS are shown in Table III. There was no difference in the pyuria rate after examination. Analysis in the respective groups showed that men have more severe pain than women, 1 vs. 0 (p = 0.001) in the flexible group and 2 vs. 1 (p = 0.009) in the rigid group. Included male patients have higher baseline CLSS scores than females. Other analyzed outcomes are shown in Table IV.

Table II

Main measure outcomes in male and female patients

GenderItemsFlexible groupRigid groupP-value
MaleAPAIS8 (6, 12)12 (8, 15)< 0.01
VAS1 (0, 1.75)2 (1, 3)< 0.01
CLSS3 (2, 4)3 (2, 4)0.397
CLSS change0 (0, 0)1 (0, 2)< 0.01
Gross hematuria1 (0.8%)5 (3.8%)0.231
WBC number per high-power field7.59 (3.60, 16.18)15.32 (5.19, 41.16)0.023
Pyuria40 (62.5%)50 (74.6%)0.135
FemaleAPAIS8 (6.5, 9)9 (7.25, 12)0.048
VAS0 (0, 1)1 (1, 2)< 0.01
CLSS2 (1,2.5)1 (0.25, 2.0)0.083
CLSS change0 (0, 0)1 (0, 2)0.001
Gross hematuria00
WBC number per high-power field6.42 (3.70, 13.30)8.28 (2.62, 19.63)0.355
Pyuria17 (58.6%)23 (71.9%)0.277

[i] APAIS – Amsterdam Preoperative Anxiety and Information Scale, VAS – visual analogue scale, CLSS – Core Lower Urinary Tract Symptom Score, WBC – white blood cell.

Table III

CLSS changed items after cystoscopy

GenderGroupUrethral pain (n)Bladder pain (n)Frequent urination (n)Urgency incontinence (n)
MaleRigid40 (53.3%)27 (36%)2 (2.67%)6 (8%)
Flexible9 (52.9%)6 (35.3%)02 (11.8%)
FemaleRigid20 (42.6%)27 (57.4%)00
Flexible2 (22.2%)7 (77.8%)00
Table IV

Main measure outcomes in flexible and rigid group

GroupItemsMaleFemaleP-value
FlexibleAPAIS8 (6, 12)6 (6.5, 9)0.507
VAS1 (0, 1.75)0 (0, 1)0.001
CLSS3 (2, 4)2 (1, 2.5)< 0.01
CLSS change0 (0, 0)0 (0, 0)0.386
Gross hematuria1 (1.1%)0 (0%)1.000
WBC number per high-power field7.59 (3.60, 16.18)6.42 (3.70, 13.30)0.245
Pyuria40 (43%)17 (18.3%)0.722
RigidAPAIS12 (8, 15)9 (7.25, 12)0.074
VAS2 (1, 3)1 (1, 2)0.009
CLSS3 (2, 4)1 (0.25, 2)< 0.01
CLSS change1 (0, 2)1 (0, 2)0.562
Gross hematuria5 (5.1%)0 (0%)0.286
WBC number per high-power field15.32 (5.19, 41.16)8.28 (2.62, 19.63)0.051
Pyuria50 (50.5%)23 (23.2%)0.771

[i] APAIS – Amsterdam Preoperative Anxiety and Information Scale, VAS – visual analogue scale, CLSS – Core Lower Urinary Tract Symptom Score, WBC – white blood cell.

Discussion

In this study, we firstly analyzed the different impact of the cystoscope on patients’ anxiety in BC patients, especially including female patients. At the same time, we studied several subjective indicators such as pain level, CLSS change and gross hematuria. The pyuria rate after cystoscopy was also studied. Prospective multi-institutional studies and meta-analyses have shown that men suffered more pain in cystoscopy [9, 10], but few studies have focused on women’s feelings, especially when it comes to anxiety during cystoscopy. We found that those patients who underwent rigid examination showed worse anxiety, more severe pain and changes in lower urinary tract symptoms (LUTS). Female patients showed the same tendency as male patients. Although the ratio of males to females with bladder cancer is approximately 4 : 1 [11], the number of female patients is large. Therefore, both genders of BC patients need to be concerned. The pyuria rate in the two groups showed no difference. After the cystoscopy, there will be an increase in urine white blood cells, but it usually does not mean a real urinary tract infection. The pyuria rate in another study was about 8% [12]; our result may be due to the urinalysis performed less than 24 h after examination. Strict aseptic performance merely caused severe urinary infections.

The Hospital Anxiety and Depression Scale (HADS) score was used to analyze the anxiety of patients undergoing cystoscopy [13]. Compared with the HADS, APAIS places more attention on anesthesia and the examination itself, which can better reflect the subjective feelings of patients [14]. The Chinese version of APAIS has been proved as an effective tool for assessing patients’ preoperative anxiety [8]. There is no research focusing on the change of LUTS caused by cystoscopy. Guidelines recommend IPSS (International Prostate Symptoms Score) to assess patients with LUTS. CLSS has a comprehensive assessment, especially suitable for addressing lower abdominal discomfort caused by the cystoscopy [15]. Most patients with bladder cancer are elderly, especially mostly male patients with benign prostate hyperplasia (BPH). Transurethral examination can cause trauma and affect the feeling of LUTS. Our research shows that female patients had lower CLSS scores than male patients and patients’ LUTS were less susceptible to flexible cystoscopy. Urethral and bladder pain were major change items in CLSS.

More than 10% of cancer patients suffer from depression [16]. There are two main reasons for the anxiety of cancer patients. On one hand, there are biological psychosocial causes, and on the other hand, it is attributed to the cancer itself and related treatments [17]. Now clinicians pay more and more attention to the physical and mental health of patients with BC. The anxiety, depression and suicide rates are higher in BC patients compared to healthy people [18]. Up to 70% of BC patients have varying degrees of anxiety and depression according to the Vartolomei et al. study [19]. Most studies focus on the impact of lifestyle changes after RC, and few studies have focused on patients with NMIBC. Compared with RC, patients with NMIBC have a better quality of life, but they need to be reviewed more frequently. Although NMIBC patients’ 5-year overall survival exceeds 90%, the high risk of recurrence and progression is an ongoing burden [20]. Anxiety is difficult to cure clinically. It is more practical to reduce patient anxiety as much as possible during the treatment process. Studies have shown that cystoscopy has a significant impact on the anxiety level of patients in a week, and elderly female patients are more likely to be anxious [14]. A flexible cystoscope has obvious advantages in this regard.

Anxiety is a complex feeling. During the cystoscopy period, it is affected by pain, fear of recurrence, hematuria, CLSS changes, etc. Poor compliance with regular cystoscopy in NMIBC is associated with even more than double the progression risk [21]. Severe anxiety can lead to interruption of follow-up, so these patients are more likely to suffer a worse prognosis [22]. In fact, few publications study the source of poor adherence and the relationship between compliance and anxiety.

The type of cystoscope can affect anxiety, pain and CLSS during examination. Our research shows that a rigid instrument significantly increases the psychological burden of BC patients and makes their subjective feelings worse. As we all know, BC has a high recurrence rate. Patients need to undergo cystoscopy routinely for several years or even for lifetime. Flexible cystoscopy has become a valuable instrument to detect bladder lesion. It has equal effectiveness in diagnosis or even better when using a special optical source and fluorescent dye [23, 24]. Regrettably, a traditional rigid cystoscope is still the most common way in bladder follow-up so far.

Our study is aimed at anxiety change in patients after TURBT. The impact of anxiety on patients is comprehensive. Although there is no evidence proving that anxiety is a risk factor for the recurrence and progression of BC, the physical and mental impact of invasive examinations should be minimized as much as possible. The cost of flexible cystoscopy is higher, about three times that of hard ones in our center. The inspection fee is one of the obstacles affecting the use of soft lenses. Soft lenses should be used instead of traditional hard lenses as much as possible. Single-center research is the limit in this study. We analyzed subjective items change just during cystoscopy but not throughout all the time of follow-up. The long-term effects of different types of cystoscope on patients’ anxiety and further effects on disease recurrence need to be verified. It is necessary to increase clinicians’ attention to the mental state of BC patients.

Our research shows that repeated cystoscopy can cause additional anxiety of BC patients. Attention should be paid to the increase in anxiety caused by cystoscopy. Clinicians have not observed this advantage of the flexible cystoscope in this regard. As the effectiveness of soft cystoscope in diagnosis is reliable, it should be used as much as possible to reduce patients’ pain, lower urinary tract symptoms, and most importantly, patient anxiety. This applies to both male and female patients.

Conclusions

Flexible cystoscopy can improve the anxiety and subjective feelings of BC patients during cystoscopy follow-up. Both genders can benefit from flexible examination.

Conflict of interest

The authors declare no conflict of interest.

References

1 

Siegel RL, Miller KD, Jemal A , authors. Cancer statistics, 2019. CA Cancer J Clin. 2019. 69:p. 7–34

2 

Babjuk M, Burger M, Comperat EM, et al. , authors. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) – 2019 Update. Eur Urol. 2019. 76:p. 639–57

3 

Yi JC, Syrjala KL , authors. Anxiety and depression in cancer survivors. Med Clin North Am. 2017. 101:p. 1099–113

4 

Lerner SP, Liu H, Wu MF, et al. , authors. Fluorescence and white light cystoscopy for detection of carcinoma in situ of the urinary bladder. Urol Oncol. 2012. 30:p. 285–9

5 

Kausch I, Sommerauer M, Montorsi F, et al. , authors. Photodynamic diagnosis in non-muscle-invasive bladder cancer: a systematic review and cumulative analysis of prospective studies. Eur Urol. 2010. 57:p. 595–606

6 

Lapini A, Minervini A, Masala A, et al. , authors. A comparison of hexaminolevulinate (Hexvix((R))) fluorescence cystoscopy and white-light cystoscopy for detection of bladder cancer: results of the HeRo observational study. Surg Endosc. 2012. 26:p. 3634–41

7 

Garfield SS, Gavaghan MB, Armstrong SO, et al. , authors. The cost-effectiveness of blue light cystoscopy in bladder cancer detection: United States projections based on clinical data showing 4.5 years of follow up after a single hexaminolevulinate hydrochloride instillation. Can J Urol. 2013. 20:p. 6682–9

8 

Wu H, Zhao X, Chu S, et al. , authors. Validation of the Chinese version of the Amsterdam Preoperative Anxiety and Information Scale (APAIS). Health Qual Life Outcomes. 2020. 18:p. 66

9 

Seklehner S, Remzi M, Fajkovic H, et al. , authors. Prospective multi-institutional study analyzing pain perception of flexible and rigid cystoscopy in men. Urology. 2015. 85:p. 737–41

10 

Raskolnikov D, Brown B, Holt SK, et al. , authors. Reduction of pain during flexible cystoscopy: a systematic review and meta-analysis. J Urol. 2019. 202:p. 1136–42

11 

Burger M, Catto JW, Dalbagni G, et al. , authors. Epidemiology and risk factors of urothelial bladder cancer. Eur Urol. 2013. 63:p. 234–41

12 

Turan H, Balci U, Erdinc FS, et al. , authors. Bacteriuria, pyuria and bacteremia frequency following outpatient cystoscopy. Int J Urol. 2006. 13:p. 25–8

13 

Krajewski W, Koscielska-Kasprzak K, Rymaszewska J, et al. , authors. How different cystoscopy methods influence patient sexual satisfaction, anxiety, and depression levels: a randomized prospective trial. Qual Life Res. 2017. 26:p. 625–34

14 

Seklehner S, Engelhardt PF, Remzi M, et al. , authors. Anxiety and depression analyses of patients undergoing diagnostic cystoscopy. Qual Life Res. 2016. 25:p. 2307–14

15 

Fujimura T, Kume H, Tsurumaki Y, et al. , authors. Core lower urinary tract symptom score (CLSS) for the assessment of female lower urinary tract symptoms: a comparative study. Int J Urol. 2011. 18:p. 778–84

16 

Smith HR , author. Depression in cancer patients: pathogenesis, implications and treatment. Oncol Lett. 2015. 9:p. 1509–14

17 

Pitman A, Suleman S, Hyde N, et al. , authors. Depression and anxiety in patients with cancer. BMJ. 2018. 361:p. k1415

18 

Vartolomei L, Vartolomei MD, Shariat SF , authors. Bladder cancer: depression, anxiety, and suicidality among the highest-risk oncology patients. Eur Urol Focus. 2019. 6:p. 1158–61

19 

Vartolomei L, Ferro M, Mirone V, et al. , authors. Systematic review: depression and anxiety prevalence in bladder cancer patients. Bladder Cancer. 2018. 4:p. 319–26

20 

Flaig TW, Spiess PE, Agarwal N, et al. , authors. NCCN Guidelines Insights: Bladder Cancer, Version 5.2018. J Natl Compr Canc Netw. 2018. 16:p. 1041–53

21 

Datovo JCF, Neto WA, Mendonca GB, et al. , authors. Prognostic impact of non-adherence to follow-up cystoscopy in non-muscle-invasive bladder cancer (NMIBC). World J Urol. 2019. 37:p. 2067–71

22 

Caruso R, Nanni MG, Riba M, et al. , authors. Depressive spectrum disorders in cancer: prevalence, risk factors and screening for depression: a critical review. Acta Oncol. 2017. 56:p. 146–55

23 

Daneshmand S, Patel S, Lotan Y, et al. , authors. Efficacy and safety of blue light flexible cystoscopy with hexaminolevulinate in the surveillance of bladder cancer: a phase iii, comparative, multicenter study. J Urol. 2018. 199:p. 1158–65

24 

Lotan Y, Bivalacqua TJ, Downs T, et al. , authors. Blue light flexible cystoscopy with hexaminolevulinate in non-muscle-invasive bladder cancer: review of the clinical evidence and consensus statement on optimal use in the USA – update 2018. Nat Rev Urol. 2019. 16:p. 377–86

Copyright: © 2020 Fundacja Videochirurgii This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
 
  
Quick links
© 2024 Termedia Sp. z o.o.
Developed by Bentus.