Time to Return to Work and Physical Activity Following Open Radical Retropubic Prostatectomy

Time to Return to Work and Physical Activity Following Open Radical Retropubic Prostatectomy Raymond Sultan, Denisa Slova, Bob Thiel and Herbert Lepor*,† From the Department of Urology, New York University School of Medicine, New York, New York

Purpose: We identified factors that predict return to part-time and full-time work and resumption of unlimited physical activity following open radical retropubic prostatectomy. Materials and Methods: Between July 1, 2002 and February 28, 2005, 537 men with clinically localized prostate cancer underwent open radical retropubic prostatectomy, as performed by a single surgeon. Intraoperative, perioperative and postoperative parameters were recorded in real time and entered into a database. An assessment was made 1 and 3 months postoperatively regarding time to return to work and unrestricted physical activity. Results: Of the men 50% returned to part-time and full-time work, and unrestricted activity within 14, 21 and 30 days after discharge home, respectively. Patient age and hematocrit at hospital discharge significantly predicted return to part-time and full-time work, and unlimited physical activity. The number of days that the urinary catheter was indwelling was also associated with return to part-time work. Occupation (blue vs white collar) and marital status were also associated with return to full-time work. In the multivariate model a unit increase in hematocrit decreased the time to return to part-time and full-time work, and unrestricted physical activity by 0.50, 0.60 and 0.59 days, respectively. Men with discharge hematocrit greater than 32% were 1.57 (p ⫽ 0.059), 1.65 (p ⫽ 0.041) and 2.03 (p ⫽ 0.002) times more likely to return to part-time and full-time work, and unlimited activity before 14, 21 and 30 days, respectively. Overall models were developed that accounted for 9.4%, 14.0% and 4.0% of the time to return to part-time work, full-time work and unrestricted physical activity, respectively. Conclusions: Efforts to increase discharge hematocrit by minimizing intraoperative blood loss or using preoperative blood management strategies and earlier removal of the urinary catheter have a favorable impact on the return to work and physical activity. Key Words: prostate, prostatic neoplasms, quality of life, outcomes research (health care), hematocrit

igh volume uro-oncological surgeons recently reported exceedingly low intraoperative and perioperative complications rates following open1,2 and laparoscopic3 radical prostatectomy. In the last decade experienced surgeons have directed their efforts to decrease transfusion rates, decrease hospital stay, shorten the time requirement for the urinary catheter, and improve continence and potency rates following radical prostatectomy.4 The rationale for laparoscopic radical prostatectomy with or without robotic assistance is to expedite recovery by eliminating a lower abdominal incision and improve quality of life outcomes by enhancing visualization during dissection of the apex and neurovascular bundles. Except for higher postoperative HCT there appears to be no advantage of laparoscopic over open radical prostatectomy as it relates to transfusion rates, hospital stay, time requirement for the urethral catheter, or the continence or potency rate.5 Many men are

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Submitted for publication October 28, 2005. Study received New York University School of Medicine Institutional Board approval. * Correspondence: Department of Urology, New York University School of Medicine, 150 East 32nd St., 2nd Floor, New York, New York 10016 (telephone: 646-825-6340; FAX: 646-825-6397; e-mail: [email protected]). † Financial interest and/or other relationship with MedReviews, Threshold, Zentaris and Watson.

0022-5347/06/1764-1420/0 THE JOURNAL OF UROLOGY® Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION

concerned how long they will be unable to work or engage in physical activity following radical prostatectomy. In this prospective study we determined when men return to activity and employment following open radical prostatectomy as well as the parameters influencing these outcomes.

METHODS Between July 1, 2002 and February 28, 2005, 537 men with clinically localized prostate cancer underwent open radical retropubic prostatectomy, as performed by a single surgeon (HL) at our institution using a previously described surgical technique.6 Limited pelvic lymphadenectomy was performed in cases with a biopsy Gleason score of 7 or greater. All men with a baseline HCT of 48% or less were encouraged to receive 2 preoperative subcutaneous injections of recombinant erythropoietin at a dose of 300 IU/kg. HCT was measured immediately before anesthesia induction, upon arrival to the recovery room, on the day of hospital discharge and when otherwise clinically indicated. Gravity cystograms were routinely performed on postoperative day 8 using a previously described technique.7 Indwelling urinary catheters were removed only if there was no observed extravasation. In cases with mild extravasation on the initial cystogram urinary catheters were removed on postoperative day 15 without repeat cystography. Repeat cystograms were per-

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Vol. 176, 1420-1423, October 2006 Printed in U.S.A. DOI:10.1016/j.juro.2006.06.011

RETURN TO WORK AND PHYSICAL ACTIVITY AFTER PROSTATECTOMY formed in all men with moderate or marked extravasation on the initial cystogram and the catheters were removed only in the absence of extravasation. The New York University continence index was used to access continence at catheter removal. The continence score of between 0 and 18 is assigned by the nurse specialists or radiologist. A score of 18 represents total observed continence, and the ability to volitionally start and stop the urinary stream. This index has been shown to be an early indicator of time to continence.8 Time to return to work was left to the discretion of the individual. Men were counseled that they could resume unrestricted physical activity on postoperative day 21. All 537 men were interviewed on postoperative day 30 by a urology nurse specialist via telephone to determine whether they had returned to part-time or full-time work and unlimited physical activity and, if so, how many days postoperatively they had achieved these milestones. The 3 questions regarding return to work and activity were included as part of the 3-month self-reported evaluation. In patients who had not returned to work or activity by the telephone interview on postoperative day 30 the information captured at the 3-month evaluation was used. All data points were entered prospectively into a database (FileMaker, Santa Clara, California). The database was maintained by a full-time data manager (DS) who was not directly involved in surgical management or followup care. Data acquisition and entry were done completely independent of the primary surgeon. The current study was reviewed and approved by the New York University School of Medicine Institutional Board. Statistical Analysis The original database was exported to an Excel™ spreadsheet and then converted to a SPSS© data set using DBMS/ Copy, version 8 (DataFlux Corp., Cary, North Carolina). All analyses were performed using SPSS® for Windows™, version 11. All data transformations and analyses were performed by one of us (RT). To facilitate the regression analyses binary (0, 1) dummy variables were created from categorical variables when necessary. All univariate models considered each predictor without regard for other predictors. Multivariate models were developed using a stepwise inclusion criteria that maximized the R2 for the model. If a variable on a patient was missing, the patient was withdrawn from that analysis. No imputation of missing values was performed. RESULTS Table 1 lists the relevant baseline characteristics and outcomes in the 537 men. These baseline characteristics were evaluated as potential factors influencing return to work and activity following open radical prostatectomy. Table 2 lists sample statistics for time to return to parttime and full-time work, and unrestricted activity. Of the men 50% returned to part-time and full-time work, and unrestricted activity within 14, 21 and 30 days after hospital discharge. Table 3 lists the parameters significantly influencing return to part-time and full-time work based on univariate analysis. Patient age, discharge HCT and the time that the

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TABLE 1. Study population characteristics Characteristic Age: Mean ⫾ SEM Range Occupation: White collar Blue collar Retired Marital status: Married Unmarried Clinical stage: T1 T2 T3 PSA (ng/ml): Mean ⫾ SEM Range Gleason score: 2–6 7 8–10 PLND: No Yes Inguinal herniorrhaphy: No Yes Preop erythropoietin: No Yes Indwelling catheter (days): Mean ⫾ SEM Range Continence score: Mean ⫾ SEM Range Pathological stage: pT2 pT3 Surgical margins: Neg Pos Mean % HCT ⫾ SEM: Induction Discharge

Value

% Pts

58.0 ⫾ 0.3 38–79 348 60 82

71 12.3 16.7

478 49

90.7 9.3

458 74 1

85.9 13.9 0.2

6.7 ⫾ 0.2 0.36–70 349 150 23

66.8 28.7 4.5

354 179

66.4 33.6

456 76

85.7 14.3

49 479

9.3 90.7

10.1 ⫾ 0.3 2–42 16.7 ⫾ 0.1 3–18 433 97

81.7 18.3

490 42

92.1 7.9

48.5 ⫾ 0.2 34.4 ⫾ 0.2

urinary catheter was indwelling were related to time to return to part-time work. Based on univariate results a model was developed to predict time to return to part-time work that included patient age, discharge HCT and the time that the urinary catheter was indwelling. The final model had the form, days ⫽ 50.5 – 0.3 ⫻ age – 0.5 ⫻ discharge HCT ⫹ 6.5 (6.5 days were added if a urinary catheter was indwelling more than 15 days). The interpretation of this model is that for every year increase in age the number of days to return to part-time work decreased by 0.30 days. For every unit increase in discharge HCT the number of days to return to part-time work decreased by 0.50 day. Men in whom the urinary catheter was indwelling more than 15 days returned to part-time work an average 15 days later. Overall our model accounted for 9.4% of the variation in the days to return to part-time work. Age, martial status, occupation and discharge HCT significantly predicted time to return to full-time work. Based on univariate results a model was established that included age, discharge HCT, martial status and occupation. The complete model yielded the equation, days ⫽ 75.2 – 0.64 ⫻ age – 0.6 ⫻ discharge HCT ⫹ 8.5 ⫹ 6.7 (8.5 days were added

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RETURN TO WORK AND PHYSICAL ACTIVITY AFTER PROSTATECTOMY

TABLE 2. Sample return to work or unrestricted activity statistics Work (days) Statistic

Part Time

Full Time

Activity (days)

Mean SD Minimum 25th Percentile Median 75th Percentile Max

17 12.6 1 7 14 21 84

25 16.6 3 14 21 30 112

34 19.8 2 21 30 42 120

if employment was blue collar and 6.7 days were added if the patient was unmarried). The interpretation of this model is that for every year increase in age the number of days to return to full-time work decreased by 0.64 days. For every unit increase in discharge HCT the number of days to return to full-time work decreased by 0.6 days. Married men returned to fulltime work an average of 6.7 days earlier than unmarried men and white collar men returned to full-time work an average of 8.5 days earlier than blue collar workers. This model accounted for 14% of the variation in days to return to full-time work. Table 3 also lists the parameters significantly influencing return to unrestricted physical activity based on univariate analysis. The 2 variables, patient age and discharge HCT, were associated with return to unrestricted activity. The multivariate model yielded the equation, days ⫽ 80.7 – 0.46 ⫻ age ⫺0.59 ⫻ discharge HCT. The model accounted for 4% of the variation in the number of days to return to unrestricted activity. The odds of returning to work in less than 14 days if HCT is greater than 32% are 1.5 times as great as the odds of returning to work in less than 14 days if HCT is less than 33% (p ⫽ 0.059). The odds of returning to full-time work in less than 21 days if HCT is greater than 32% are 1.65 times as great as the odds of turning to work in less than 21 days if HCT is less than 32% (p ⫽ 0.041). The odds of returning to unrestricted activity in less than 30 days if HCT is greater than 32% are twice as great as the odds of returning to unrestricted activity in less than 30 days if HCT is less than 32% (p ⫽ 0.002). DISCUSSION There is no consensus regarding the optimal time to return to work or physical activity following open radical prostatectomy. Recommendations regarding the time to return to work or physical activity following open and laparoscopic radical prostatectomy are currently based only on surgeon discretion. Men are often discouraged from resuming physical activity for a given period, presumably to avoid interfering with the healing of the lower abdominal incision and urethrovesical anastomosis, and prevent bleeding and clot urinary retention. None of these assumptions are evidence based. In the last 12 years we have arbitrarily encouraged men to resume unrestricted physical activity by 3 weeks following open radical prostatectomy. Of the 500 men undergoing radical retropubic prostatectomy between 2002 and 2004 none had an incisional hernia and 6 (1.2%) had clot urinary retention.1 We do not believe that our early recommenda-

tions for return to activity impacted the anastomosis since our reported stricture rate9 is comparable to that in other large series.2 Our recommendations regarding return to work were influenced by the degree of physical activity associated with employment and access to bathroom facilities to change protective pads. Men whose occupations required no strenuous activity were encouraged to return to part-time work when they felt capable of resuming their responsibilities. Men in our series returned to part-time and full-time work, and unrestricted activity an average of 17, 25 and 34 days following open radical prostatectomy. It is conceivable that men would have safely resumed physical activity earlier if encouraged to do so. Sved et al have previously reported that men returned to normal preoperative activity an average of 19.4 days following open radical retropubic prostatectomy.10 Our longer time to resumption of activity may be attributed to our emphasis on return to unrestricted rather than normal activity. We investigated factors that influenced time to return to work and physical activity in a contemporary cohort of men undergoing open radical prostatectomy, as performed by a single surgeon. Patient age, occupation, marital status, HCT at hospital discharge and the time that the indwelling catheter was indwelling significantly influenced these collective outcomes. HCT at hospital discharge significantly influenced time to return to part-time and full-time work, and unrestricted activity. In the multivariate model a unit increase in HCT decreased time to return to part-time and full-time work, and unrestricted physical activity by 0.63, 0.50 and 0.59 days, respectively. Increasing discharge HCT above 32% increased the odds of returning to part-time and full-time work, and unrestricted activity by 50%, 65% and 100% within 14, 21 and 30 days, respectively. We have previously recommended using recombinant erythropoietin as a strategy to decrease the risk of allogeneic transfusion.11 Two injections of 300 IU/ks recombinant erythropoietin have been shown to increase preoperative HCT an average of 4%. The current study supports using recombinant erythropoietin not only to decrease the risk of allogeneic transfusion, but also to facilitate recovery. Age was another factor that significantly influenced return to part-time and full-time work, and unrestricted activity, although as an inverse relationship. Younger men are presumably engaged in more physically demanding employment and activity, which might explain why it takes longer

TABLE 3. Univariate regression analysis of return to part-time and full-time work, and unrestricted activity Variable Part-time work: Age Discharge HCT No. days catheter indwelling Full-time work: Age Discharge HCT Marital status Occupation Activity: Age Discharge HCT

Regression Coefficient

SE

t

p Value

⫺0.282 ⫺0.566 0.437

0.114 0.174 0.132

⫺2.486 ⫺3.262 3.308

0.014 0.001 0.001

⫺0.634 ⫺0.434 6.757 10.820

0.135 0.203 2.867 2.625

⫺4.688 ⫺2.145 2.356 4.123

0.000 0.033 0.019 0.000

⫺0.394 ⫺0.553

0.148 0.222

⫺2.670 ⫺2.498

0.008 0.013

RETURN TO WORK AND PHYSICAL ACTIVITY AFTER PROSTATECTOMY to return to work or recover to baseline physical activity levels. Older patients may also have a higher degree of control over working condition because of senior status with their employers. The nature of employment significantly influenced only return to full-time work. White collar workers returned to full-time work an average of 11 days earlier than blue collar workers. White collar workers presumably have less physically demanding responsibilities and are likely to have better access to bathroom facilities to manage incontinence. Married men returned to full-time work an average of 6 days earlier than unmarried men. It is unclear why marital status did not influence return to part-time work or activity. It is conceivable that the financial responsibility of a family explains the earlier return to full-time work. Overall 83%, 90% and 100% of catheters were removed by days 8, 15 and 42, respectively. The timing of the catheter removal influenced only return to part-time work. It is likely that the discomfort of the urinary catheter is an impediment to any level of employment. Most urinary catheters were removed by 15 days postoperatively. Most men returned to part-time work but not to full-time work or unrestricted activity by postoperative day 15. Therefore, the urinary catheter had little impact on return to full-time work or unrestricted activity in our patients following radical prostatectomy. It is likely that if urinary catheters were routinely left indwelling for 3 weeks, as some experts recommend, the urinary catheter would have impacted return to full-time employment or unrestricted activity. Sved et al reported that the pain score at hospital discharge correlates with time to the resumption of normal activity following radical retropubic prostatectomy.10 We did not assess the impact of postoperative pain control on time to return to work or activity in our study. Overall we developed models that accounted for 9.4%, 14.0% and 4.0% of the time to return to part-time work, full-time work and unrestricted physical activity, respectively. There are obviously many other factors that influence return to employment, such as patient motivation and financial incentives, overall satisfaction with the work environment and demands of employment, that were not captured in this study. There is a paucity of studies examining return to work and activity following radical prostatectomy or other urological procedures. We identified factors influencing return to work and activity in our cohort of men undergoing open radical retropubic prostatectomy. Our study did not address the optimal time for patients to safely return to work and activity since all men in our series received the same recommendations based on surgeon experience. An evidence based approach is needed to determine the optimal time for patients to return to work and unrestricted physical activity.

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CONCLUSION Our study suggests that efforts to increase discharge HCT by minimizing intraoperative blood loss or increasing erythropoiesis preoperatively and earlier urinary catheter removal have a favorable impact on returning to work and physical activity. Age, marital status and occupation had varying impacts on these patient outcomes. It is likely that patient expectation, and other socioeconomic and demographic factors have important roles in determining when patients return to work or activity following radical prostatectomy.

Abbreviations and Acronyms HCT ⫽ hematocrit PLND ⫽ pelvic lymph node dissection PSA ⫽ prostate specific antigen REFERENCES 1.

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4. 5. 6. 7.

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