Preliminary evidence of the impact of social distancing on psychological status and functional outcomes of patients who underwent robot-assisted radical prostatectomy.

INTRODUCTION: Social distancing is considered the best strategy to prevent the spread of COVID-19 (COronaVIrus Disease 19). We aimed to analyse the effect of 'social distancing' on the emotional state, post-operative pain and functional outcomes of patients undergoing robot-assisted radical prostatectomy (RARP).
MATERIAL AND METHODS: We retrospectively reviewed data of male patients who underwent RARP within the study period (from March to April 2019 [Group A = 27 patients] and from March to April 2020 [Group B = 29 patients]). Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) results were collected on the first day of hospitalization. Post-operative pain was assessed using the numerical rating scale (NRS) and visual analogic scale (VAS) after surgery in the post-anesthesia care unit (PACU) and at 24 hours. Functional outcomes were evaluated at the one-month follow-up. Demographic, pathological and peri-operative data were collected for all patients.
RESULTS: There were no significant differences in demographics and pathological characteristics amongst the groups. We observed that patients in Group A had a statistically lower value on the PHQ-9 and GAD-7 questionnaires than patients of Group B. Moreover, Group A showed statistically significant better post-operative pain control in PACU and at 24 hours. At one-month follow-up, patients in Group B required more diapers for incontinence than Group A, showing poor early continence. Patients in Group A showed interest in sexual rehabilitation after 1.11 ±.320 months while patients in Group B after 2.59 ±.712 months (p <.001). Moreover, 17 out of 29 patients (58.62%) in Group B were referred to an andrologist, compared to 100% of patients from Group A (p = 0.0006).
CONCLUSIONS: Social distancing during the COVID-19 pandemic is associated with a poor pre-operative emotional state, as well as influencing post-operative pain, early urinary continence and desire for sexual rehabilitation. Copyright by Polish Urological Association.

INTRODUCTION

The COVID-19 pandemic has generated a revolution in outpatient and inpatient care management [1]. Social distancing is considered the best strategy to prevent the spread of COVID-19 (COronaVIrus Disease 19) [2]. Particularly, in our Department hospitalized patients are completely isolated and visits from relatives and friends are absolutely abolished. Moreover, all patients are admitted to a single room Literature data shows that depression is a common cause of morbidity in patients who undergo surgery. Depression can be considered an independent risk factor for postoperative delirium and may cause a long and incomplete recovery after surgery [3]. We aimed to analyse the effect of ‘social distancing’ on the emotional state, post-operative pain and functional outcomes of patients undergoing robot-assisted radical prostatectomy (RARP).

MATERIAL AND METHODS

We retrospectively reviewed data of male patients who underwent RARP [4] within the study period (from March to April 2019 [Group A = 27 patients] and from March to April 2020 [Group B = 29 patients]). Despite the continued debate on the performance of minimally invasive surgery during the COVID-19 pandemic due to the risk of viral diffusion in the operating theatre, all prostatic cancers were managed with a robot-assisted approach using the AirSeal Intelligent Flow System [5]. After orotracheal intubation, a bilateral Transversus Abdominis Plane (TAP)-block was performed according to Rafi’s technique [6]. Retropubic RARP and posterior musculofascial reconstruction according to Rocco’s technique was performed in all patients [7].

Since 2017 our Urology Department provides psychological support for all patients undergoing surgery for pelvic cancer and some questionnaires are administered to the patients. Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) results were collected on the first day of hospitalization [8]. Post-operative pain was assessed using the numerical rating scale (NRS) and visual analogic scale (VAS) after surgery in the post-anesthesia care unit (PACU) and at 24 hours. Functional outcomes were evaluated at the one-month follow-up. Demographic, pathological and peri-operative data were collected for all patients. All data was collected in a prospectively maintained database and retrospectively analysed. Descriptive statistics of categorical variables focused on frequencies and proportions. Mean values with standard deviations (±SD) were computed and reported for all items. Yates’ chi-square and Student's t-tests were used to compare the statistical significance of differences in proportions and means, respectively. Statistical significance was achieved if p-value was ≤0.05 (two-sides). Statistical analyses were performed using SPSS version 23.0 (Armonk, NY: IBM Corp.).

RESULTS

There were no significant differences in demographic characteristics amongst the groups. Moreover, rates of pelvic lymphadenectomy, nerve-sparing and bladder neck sparing techniques were similar across groups. Pathological stage and Gleason Score were also similar amongst the groups (Table 1). No urine leakage [9] and post-operative complications were detected.

Table 1

Differences between the two groups in demographic and pathological characteristics of patients, questionnaires, post-operative pain and functional outcomes

	Group A n = 27 (2019)	Group B n = 29 (2020)	p value
Age (years)	63.71 ±6.82	64.43 ±6.91	.6965
BMI	26.81 ±1.62	26.32 ±1.30	.2158
Diabetes	5/27 (18.52%)	6/29 (20.69%)	.8948
Prostate volume	45.07 ±20.59	47.7 ±16.15	.5956
Unilateral nerve-sparing technique	5/27 (18.52%)	6/29 (20.69%)	.8948
Bilateral nerve-sparing technique	10/27 (37.04%)	12/29 (41.38%)	.9532
Non-nerve-sparing technique	12/27 (44.44%)	11/29 (37.93%)	.8233
Bladder neck preservation	23/27 (85.19%)	26/29 (89.66%)	.9195
Pelvic lymphadenectomy	13/27 (48.15%)	14/29 (48.28%)	.7964
Duration of indwelling catheter	6.86 ±1.04	7.07 ±1.11	.4690
Gleason Score 6 (ISUP grade 1)	5/27 (18.52%)	6/29 (20.69%)	.8948
Gleason Score 7 (ISUP grade 2)	10/27 (37.04%)	9/29 (31.03%)	.8480
Gleason Score 7 (ISUP grade 3)	9/27 (33.33%)	11/29 (37.93%)	.9364
Gleason Score 8 (ISUP grade 4)	3/27 (11.11%)	3/29 (10.34%)	.7341
Pathological stage pT2	16/27 (59.26%)	19/29 (65.52%)	.8359
Pathological stage pT3a	8/27 (29.63%)	7/29 (24.14%)	.8715
Pathological stage pT3b	3/27 (11.11%)	3/29 (10.34%)	.7341
Pathologically positive lymph nodes	1/13 (7.69%)	1/14 (7.14%)	.4959
GAD-7	7.37 ±1.11	8.48 ±1.36	.002
PHQ-9	9.59 ±1.65	11.21 ±3.26	.024
NRS-PACU	1.37 ±.49	1.83 ±.71	.007
NRS-24 hours	.22 ±.42	.59 ±.63	.015
VAS-PACU	2.93 ±.87	3.72 ±1.16	.006
VAS-24 hours	.48 ±.58	1.24 ±1.15	.003
N°diapers/day	.48 ±.51	1.07 ±.80	.002
Months to sexual rehabilitation	1.11 ±.32	2.59 ±.71	<.001

BMI – body mass index; GAD-7 – Generalized Anxiety Disorder-7; PHQ-9 – Patient Health Questionnaire-9; NRS – Numerical Rating Scale; PACU – Post-Anesthesia Care Unit; VAS – Visual Analogic Scale

Table 1 summarizes the differences in questionnaires, post-operative pain and functional outcomes between the two groups. We observed that patients in Group A had a statistically lower value on the PHQ-9 and GAD-7 questionnaires than patients in Group B. Moreover, Group A showed statistically significant better post-operative pain control in PACU and at 24 hours. At the one-month follow-up, patients in Group B required more diapers for incontinence than Group A, showing poor early continence. Patients in Group A showed interest in sexual rehabilitation after 1.11 ±.320 months while patients in Group B after 2.59 ±.712 months (p <.001). Moreover, 17 out of 29 patients (58.62%) in Group B were referred to an andrologist, compared to 100% of patients from Group A (p = 0.0006).

DISCUSSION

Stress, anxiety, depressive symptoms, and insomnia have been documented during the COVID-19 outbreak [1]. Literature data reports that pre-operative depression can predict post-operative pain in patients who underwent open radical prostatectomy [10]. Our results highlight how the pre-operative psychological status of patients who underwent minimally invasive surgery affects post-operative pain.

Moreover, depression and anxiety are shown to be risk factors for developing urinary incontinence with a dose-dependent trend [11]. Particularly, pre-operative depression or anxiety were associated with worse urinary continence status in a retrospective analysis of 5862 patients who underwent radical surgery for prostate cancer [12]. Depression was also found to be significantly associated with sexual functioning in men with a medical or surgical comorbidity, substance use, or other comorbid psychiatric disorders [13].

In our Department, outpatient visits were reserved only for oncological patients during the COVID-19 pandemic [4]. Despite this, all patients of Group B were consulted over the telephone about their desire for sexual rehabilitation.

In our experience, during the COVID-19 pandemic, a lot of patients refused recommended sexual rehabilitation protocols. The missed or late sexual rehabilitation will possibly have an influence on future sexual function [14]. Moreover, sexual activity is considered by patients to a lesser degree because sexual needs are composed of a biological, psychological and social component [15]. Our results provide a further demonstration of the need of psychosexual counselling in patients who underwent pelvic surgery [16]. However, other large-scale prospective studies are needed to evaluate post-operative and functional outcomes of ‘social distancing’ on patients undergoing pelvic surgery. In particular, a multivariate analysis of factors influencing continence and sexual rehabilitation should be evaluated. Some home-based programs could expand to accommodate patients who are displaced from on-site care, enabling uninterrupted care while both patients and providers can remain at home [17].

CONCLUSIONS

Social distancing during COVID-19 pandemic is associated with a poor pre-operative emotional state, influencing post-operative pain, early urinary continence and desire for sexual rehabilitation.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.