The psychological distress symptoms, specifically depression and anxiety remain an inherent part of oncological surgery. This is particularly true for RC patients in whom the prevalence of psychological distress is higher than in those affected with other cancers [6]. The emotional response may be a function of different factors such as diagnosis of an aggressive tumor with uncertain long-term prognosis, large extent of the imminent surgical procedure and the need for an alternative urinary diversion, frequently leading to a permanent deterioration of body image. Bearing in mind the complexity of emotional response preoperative support and psychological preparation to RC is likely to play a substantial role, particularly given that patient reported mental health has been independently associated with incidence of high-grade complications after cystectomy [7].
Most studies investigating emotional response to surgery have demonstrated an elevated risk of anxiety and depression before surgery, followed by a significant decrease thereafter. This phenomenon was described amongst patients subjected to emergency and major elective surgeries, including RC [6, 8]. In our study more than one third of patients who were scheduled to RC had anxiety and depression symptoms within the mild to severe range (HADS score ≥ 8). Interestingly, the overall proportion of patients at risk has not decreased significantly on the day of discharge. This is in line with findings from Benner et al., who observed an increase in depression symptoms during follow-up after RC. In aforementioned study, pre-cystectomy average HADS scores for anxiety and depression were within normal range, whereas at 4 and 6 months after RC increased to borderline abnormal level [9]. It may indicate that in certain groups of patients with MIBC treated with RC distress may continue to accumulate after surgery, a phenomenon possibly related to urinary diversion type and supportive undertakings. Taking above into account, establishing mechanisms to preemptively moderate the emotional response of cystectomy patients seems a very attractive pathway.
There is now general understanding that educational and psychological preparation for surgery is advantageous for most patients, however there is a paucity of outcomes for patients who were scheduled for elective RC [10]. The effects of psychological preparation have mostly been measured after non-urological surgeries [11, 12]. Moreover, the influence of preoperative psychological preparation was usually measured 3 months or later after surgery [12]. These outcomes may in greater extent represent the preparation for the long-term sequelae of the procedure, rather than preparation to handle procedure-related stress itself. Taking this into account, in our study we restricted assessment of anxiety and depression to the immediate perioperative period. Consequently, we chose the Hospital Anxiety and Depression Scale, designed primarily for hospital use and despite its subsequent validation in different clinical settings, we decided to use it only for inpatients [13]. This study design enabled us to investigate direct association between preoperative supportive and psychological intervention and early emotional response to RC.
It remains undetermined which preparation techniques would bring most benefit to population of patients with MIBC undergoing RC. To date, several forms of preoperative supportive and educational interventions have been proposed, and some proven effective in improving physical performance, emotional functioning and self-caring of patients after cystectomy [14, 15]. Our study revealed a significant reduction in postoperative depression within a subgroup of patients who joined Cystocare meetings and followed the prehabilitation program during preparation for surgery. Effects of psychotherapy on depressive symptoms in cancer patients have been summarized in recent systematic review which demonstrated that cognitive behavioral therapy (CBT) brings the best outcome [16]. However, this review included only incurable cancer patients and the number of those with BC was limited. Effectiveness of CBT after surgery for early-stage cancer patients was reported by Stagl et al. Women with stage 0 to IIIb breast cancer were recruited after surgery and randomized to cognitive-behavioral stress management or control group. Participants assigned to intervention group reported significantly lower depressive symptoms OR 0.63 (95%CI: 0.56–0.70) [12]. The abovementioned findings are obviously difficult to translate into perioperative settings and associated depressive symptoms of a cystectomy patient. We believe our study contributes to the scarce evidence on the effectiveness of preemptive supportive and psychotherapeutic intervention in alleviating perioperative psychological distress symptoms amongst cystectomy patients.
Our study also showed a beneficial influence of minimally invasive surgical technique on preoperative anxiety. Patients due to undergo a laparoscopic RC suffered significantly less anxiety than those planned for an open procedure. Interestingly, conflicting results were presented by recent comparison of laparoscopic and open cholecystectomy. Patients, who underwent laparoscopic cholecystectomy more frequently presented moderate to high level of anxiety preoperatively [17]. These surprising results may suggest difficulties in patients’ adaptation to rapid technical developments in surgery. Some patients may find it difficult to believe that surgery can safely be performed through a small incision, a phenomenon which emphasizes the importance of a thorough patient information. Therefore, patients who are operated in a high-volume center with extensive experience in laparoscopic surgery may experience lower anxiety before surgery. It may be one of plausible explanations of our results. Our department is a pioneer and one of the highest volume centers for laparoscopic RC in Poland, and closely follows all developments in this field. Nevertheless, up to our knowledge our study is the first one to demonstrate such benefit of laparoscopic approach to RC.
Our study also revealed the association between abnormal level of postoperative anxiety and hospital stay longer than a week, even in absence of high-grade complications. This finding has some plausible explanations. Patients with an increased anxiety level are more often reluctant to leave the hospital earlier, as they may worry about being challenged with new everyday reality after the surgery at home [18, 19]. At the same time, a prolonged hospital stay may represent a source of anxiety itself, when patients are becoming increasingly concerned about the postoperative course not going exactly according to plan.
We are aware of certain limitations of this study. None of patients from our cohort received an orthotopic bladder substitution. Patients from the intervention arm were also significantly younger than those who received standard preparation, which may represent their more proactive approach to treatment and more positive attitude towards impending surgery, nonetheless patients’ age has not been independently associated with any of the HADS domain sub-scores.