Preparedness for Prostatectomy

Bradley Gill, MD, MS; Abhinav Khanna, MD, MPH; Anna Zampini, MD, MBA

Radical prostatectomy is a commonly performed and effective surgical treatment for prostate cancer. However, men undergoing the procedure often experience postoperative quality of life issues, in particular changes in urinary function and sexual function.

Advancements in surgical technique and increased surgeon experience over the years have reduced the rate of long-term or permanent postprostatectomy urinary incontinence, broadly defined as an undesired leakage of urine. However, all men experience at least temporary incontinence following prostatectomy.

Group education for prostatectomy preparedness

Glickman Urological & Kidney Institute’s Department of Urology began offering group education sessions to men considering radical prostatectomy to treat their prostate cancer in 2015.

The education sessions, hosted at various Cleveland Clinic locations, last roughly one hour and are facilitated by nurses, nurse practitioners and physician assistant members of the urology team. Topics addressed include:

• Anticipated perioperative course.
• What to expect in the hospital and during recovering at home.
• Expected outcomes of surgery.
• Postoperative pain and activity limitations.
• Catheter care.
• Other elements of recovery, including urinary incontinence and erectile dysfunction.
• Expected time course of recovery following surgery.
• Follow-up plans.

Is education effective?

The urology team wanted to know whether being prepared for prostate surgery helped men deal with incontinence issues and whether preparedness impacts patient-reported outcomes. They assessed men participating in the program from 2015 through its first couple of years.

The initial insights from this study were presented at the 2018 annual meeting of the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction.

A previous Cleveland Clinic study in women treated for urinary incontinence demonstrated that those who reported higher levels of preparedness for surgery also reported better outcomes of their treatment. The higher levels of preparedness in that study were achieved by preoperative group education, where multiple patients considering treatment met together with a member of the surgical team to learn about the procedure, recovery and potential outcomes.

Interestingly, despite similar numerical measures of urinary incontinence between women who underwent group education and those who had standard in-office counseling, those in the group-based sessions felt better after the procedure and were more satisfied with their outcomes. These were also the women who had higher levels of preparedness before surgery.

To assess levels of preparedness for prostatectomy, a survey was administered at the conclusion of each prostatectomy group education session. The survey was designed to assess understanding of the goals of surgery, potential outcomes, potential side effects and satisfaction with respondents’ current functional status.

Participants were surveyed again by telephone at three weeks, three months and six months following surgery. During these calls, surveyors assessed participants’ satisfaction with surgical experience, progress in recovery and progress in recovery relative to where they expected to be.

Education yields better patient-reported outcomes

A total of 175 men completed the initial survey. Overall, they reported high levels of preparedness for prostatectomy. Ninety-three percent felt the class was helpful and 97 percent noted they would recommend group education to a family member or friend in need of prostatectomy. Approximately 83 percent felt highly prepared for surgery, 90 percent felt they knew what to expect in recovery, and 93 percent reported understanding potential side effects of surgery.

When asked about urinary outcomes after prostatectomy, 96 percent of men agreed or strongly agreed that they “would have a catheter after surgery,” 98 percent agreed or strongly agreed that they “can leak urine after prostatectomy,” and 94 percent agreed or strongly agreed that “it can take up to one year for urinary function to recover maximally.”

Most men found the class helpful in preparing for surgery, and they displayed high rates of understanding the processes surrounding recovery from prostatectomy.

At three months after surgery, men with greater baseline understanding of side effects were significantly more likely (P < 0.03) to have felt they were more prepared for surgery. Men with higher preparedness also had better expectations of hospitalization and recovery at home. At six months postoperatively, men who knew what to expect following surgery were significantly more likely (P = 0.04) to report they felt well prepared for surgery.

Overall, men who were more prepared noted higher rates of satisfaction with treatment and recovery compared to those who were less prepared.

In follow-up assessments, many men responded affirmatively to the question, “Is your urinary control good enough to complete the activities you wish to perform?” At three weeks, 45 percent felt this; at three months and extending to six months, 81 percent responded yes.

At the three-week time point, men who felt more prepared for surgery at baseline were significantly more likely (P = 0.013) to rate their urinary control as good enough to perform the activities they wished to perform. This strongly suggests that group education classes helped accurately prepare men for the postoperative period and recovery of their urinary function.

In a similar question, men were asked to rate their urinary function “compared to what you expected at this time after surgery” using a Likert scale. High proportions of men felt their urinary function was “better” or “much better” than expected at three weeks (72 percent), three months (81 percent), and six months (84 percent) postoperatively. Men who had greater preparedness at baseline were also significantly more likely (P < 0.001) to rate their overall recovery process as better than expected at that time.

Daily pad use to manage incontinence improved with time from surgery. An average of 3.0 pads were used at three weeks, 1.5 pads at three months, and 1.1 pad by six months. Interestingly, despite no difference in amounts of daily pad use, men with greater preparedness for surgery were significantly (P = 0.03) more likely to view their urinary control as satisfactory, compared to those with lower levels of preparedness.

Preparedness classes increase satisfaction

This study utilized a comprehensive questionnaire to gain insight into how preparing men for prostatectomy influences their reported outcomes and satisfaction with the procedure. Using a multifaceted analysis, it was clear that greater preparedness for prostatectomy was associated with improved patient-reported outcomes.

This study highlights the importance of ensuring that men understand what to expect following prostatectomy, as being better prepared for surgery translated into better patient-reported outcomes. The most prepared men were the most satisfied with recovery of their postoperative urinary function, experiences surrounding surgery, and feeling that their expectations had been met.

Though our study was conducted with a heterogeneous group of prostate cancer patients, these results may be generalizable to other practices.

Dr. Gill is a faculty member in the Department of Urology. Both Dr. Khanna and Dr. Zampini are residents in the Department of Urology. Urologists Hadley Wood, MD, and Edmund Sabanegh, MD, also participated in this study.