ELSEVIER
Ambulatory Surgery 5 (1997) 15 - 19
Australian men’s experiences of cystoscopic day surgery
Judith Donoghue *, Dianne Pelletier, Christine Duffield, Maria Torres
Fircult), of‘ %ursing, Unioersity of Technology, Sydney, PO Bou 222, Lin&eld,
XS W 2070, Austrtrlicc
Received 8 November 1996: accepted 18 November 1996
Abstract
The New South Waleshealth care systemis experiencingconsiderablegrowth in the numberof day surgery proceduresand in
all likelihood the complexity of thesewill increase.Urological procedureshave led the way for a variety of reasonsincluding the
rapid growth in technologicalinnovations in this field. An assessment
of the effect of decreasedcontact with medicaland nursing
professionals,particularly in the postoperativerecovery phase,and the experienceof home recovery speciallyfor the elderly and
potentially lesswell population, is warranted. Semi-structuredinterviewswereusedto investigatethe experienceof cystoscopicday
surgery and the recovery processof 21 men. In most casesno significantcomplicationswere recorded. Eight patients have had
previous experiencewith cystoscopicday surgery, and expectedthe sameuncomplicatedrecovery as they have had in the past.
Generally patientsfelt that they were adequatelypreparedfor their experience.However, somedid not know who to contact or
what to do in case of unexpected symptoms presenting postoperatively. 8 1997 Elsevier Science B.V.
Kqvwmds:
Day surgery; Cystoscopy; Outcomes;Recovery
1. Introduction
The 1983 Australian Health Minister’s Conference
defined day surgery as ‘a surgical operation or proce-
dure on a patient who can be admitted and discharged safely on the same day from a hospital or
from a free standing facility which is in close proximity to a hospital’ [l].
During the past decade in New South Wales
(NSW) day surgery has experienced a dramatic increase in numbers [2]. This growth has followed an
international
trend showing an increase in the numbers as well as in the variety and complexity of procedures being performed on an ambulatory basis [3,4].
It is the intention of the New South Wales government to continue to increase the number and range
of the procedures undertaken in day surgery units [5].
In New South Wales cystoscopic procedures account for an important percentage of the day surgery
case load [6]. Cystoscopic procedures are now well
established as a diagnostic and therapeutic procedure
in day surgery venues and are increasingly being performed in surgeon’s consulting rooms [73. They have
tended to be used for the generally healthier population [8] but there is clearly potential to expand the
population. It is likely that if numbers are to increase
older men and those with more co-morbidities
will
undergo day only cystoscopies.
There is very little research which discusses patients’ experiences with day surgery, in particular following cystoscopic procedures. The importance
of
establishing more comprehensive oumome measures
has been recognized by the NSW Department
of
Health [5].
This paper discusses the findings of a qualitative
study which analysed men’s experiences of cystoscopic
day surgery and the recovery process. These findings
*Corresponding
author. Tel.: + 61 2 95145129; fax: + 61 2
95145513; e-mail: j.donoghue@uts.edu.au.
0966-6532/97;$17.00 0 1997 Elsevier Science B.V. All rights reserved.
PIZ S0966-6~3’(96)00126-6
have implications
for pre- and postoperative
tion, community support services and aftercare.
educa-
J. Donoghue
16
2. Literature
et al. /Ambulatory
review
Day surgery is not new. The practice of performing
operations and discharging the patients on the same
day has existed for a long time [9]. The increase in
number and the variety of procedures being performed
results from technological advances, the availability of
new anaesthetic agents, the need to reduce health costs
and changing attitudes among health professionals [lo].
These developments have contributed to a reduction in
the time necessary to both perform and recover from a
variety of procedures, thereby increasing the likelihood
of them being performed on an ambulatory basis.
Day surgery has the potential to reduce hospital costs
and long waiting lists for surgery with no associated
decrease in quality of care [2,11,12]. Several studies
suggest that there is no difference in morbidity and
mortality
between day case surgery and inpatient
surgery, and in some cases outcomes have been improved with reduced incidence of hospital-acquired infections and of respiratory complications
[ 11- 141.
Studies have shown that a variety of urological procedures performed on an outpatient basis are 40-60%
cheaper than as an inpatient [lo].
The literature suggests that historically urology has
been a major contributor to the development of day
only and outpatient surgery [10,15,16]. Urological procedures, cystoscopic ones in particular, represent a high
percentage of day only procedures. In the United Kingdom, cystoscopies make up 15% of day surgery procedures, while in the USA it is the fourth most commonly
performed procedure [ 171.
According to Warden, a leading advocate of day
surgery, a variety of cystoscopic procedures, namely
cystoscopy and urethroscopy including dilatation, removal of foreign material, ureteric catheterisation,
treatment of warts, biopsy and resection of bladder
tumour figured among the 30 most frequent Australian
National Diagnostic Related Groups (AN DRG) for
same day separations in 1991/1992 in NSW [6]. Surgeons’ personal preferences are very important when
determining the setting where a particular procedure
will be performed [ 131. Technological
developments
also play an important role and seem to be having an
impact on urologic day surgery [lo].
There has been limited research in Australia on patients’ satisfaction with and recovery from, day surgery
procedures [18]. However, data suggesting that the type
of day surgery unit has an impact on patients’ recovery
experience have been presented [19]. Additionally,
evidence from overseas indicates that outcomes following
day surgery vary depending on previous experience of
day surgery, employment status, education, expectations and preparations for surgery [20].
In a qualitative study of 31 Sydney women experiencing gynaecological laparoscopy, it was found that pa-
Surgery
5 (1997)
15-19
tients and carers were unprepared for the longer than
anticipated duration of recovery [21]. Home support for
at least 24 h appears essential when day surgery involves a general anaesthesia and/or the patient is elderly, a combination particularly common in urological
surgery [ 131.
The need for further health outcomes research has
been recognized by the NSW Department of Health [5].
In addition, a recent publication [22] identified the need
for further research to determine the characteristics of
services to provide the ‘ideal patient encounter’.
3. Purpose of the research
The cystoscopy population
was considered sufficiently important to warrant at least preliminary study
for several reasons. Firstly, cystoscopy appears to be a
relatively ‘invisible’ procedure lacking even the small
incisions of laparoscopy or arthroscopy. There is no
external evidence and until micturition,
often little sensation to remind the patient that a procedure has been
carried out. Do these factors influence the patient’s
expectations, their experience or their process of recovery? Does this ‘invisibleness’ and relative non-invasiveness of the procedure influence health professionals in
their preparation of the patient and management of
their discharge or recovery?.
Secondly, the number of cystoscopic day surgery
patients is large (approximately
13 500 in 1992-1993
[6]) and the potential for this population to increase
further justifies the population selection.
The objective of the study was to report men’s experiences of cystoscopic day surgery. The project aimed
to:
l
l
l
l
Determine aspects of the post operative experience,
such as difficulties with urination, discomfort, pain;
emotional responses; limitations to normal activity;
and duration of recovery.
Investigate if there was any difference in the reported
experiences of men who had a cystoscopy in the day
surgery unit for the first time, compared to those
who have had previous day surgery cystoscopies.
Investigate patients’ perceptions of their preparation
for the procedure.
Investigate
patients satisfaction with their day
surgery experience.
4. Methods
4.1. Selection and recruitment
Twenty-one men were recruited by the research assistant from the cystoscopy population at a large teaching
J. Donoghue
et al. /Ambulatory
hospital day surgery unit during an eight month period.
Exclusion criteria were age under 18 years and insufficient English ability.
Patients were made aware of their right to refuse or
withdraw and confidentiality
was assured. Consenting
patients were then allocated at random to one of the
two interview times: between the third to sixth postoperative day (10 patients) called early (E), or between the
21st and 24th postoperative day (11 patients) called late
(L). These intervals were chosen because the onset of
complications would usually occur within the first 72 h.
In the laparoscopy study by Donoghue et al. [18] the
longest interval of recovery detected was 21 days. This
longer period allows for the development of complications such as infection.
4.2. Interviews
and instrument
Data were collected using a semi-structured interview
of 20-50 min depending on the length of free response
to open ended questions and the course of the participants’ recovery. Three researchers conducted interviews
to validate the semi-structured questions and to achieve
heuristic relevance. The interviews were conducted at a
time and place selected by the participant. Interviews
were recorded.
4.3. Transcription
und analysis
Transcribed tapes with identifying material removed
were read and coded by all researchers individually.
Minor differences emerged.
Surgery
5 (1997)
5.1. Patients’
15 - 19
recovery
The majority of patients perceived their recovery to
be uncomplicated, as shown in the comment “I just felt
like nothing had happened to me”. This was despite the
presence of bleeding and/or dysuria.
Eleven patients reported bleeding ranging from slight
bleeding on the first evening to profuse bleeding. Three
patients experienced clots and in one case this led to
obstruction. The length of bleeding in the other eight
patients ranged from a few hours to 3 days. Several first
timers were shocked on the first postoperative void to
see blood rather than urine. They had not been warned
or could not recall being warned on the amount of
bleeding and they did not expect this outcome.
Postoperative pain was not an issue for most of the
participants. Only four patients reported pain as a
problem for example:
I had maybe a day or a day and a half of pain, when
I urinated...it brings tears to your eyes. (E9)
The recovery period was complicated for two patients (L2 and L5), one of whom took 9 days to
recover. This respondent needed to visit his own doctor
because of his concern about the continued bleeding,
dizziness and dysuria.
Several patients recovered fully within hours of the
procedure. Two patients (aged 63 and 67) returned to
work the same day. The majority followed instructions
provided and had no adverse recovery experiences.
5.2. Educational
5. Results
The patients’ ages ranged from 29 to 81 years old,
with a mean of 56.8 and a median of 54. For 13
participants this had been their first cystoscopy. One
patient had experienced day surgery previously for a
different procedure. All patients with previous cystoscopic experience (eight) had at least one of their cystoscopies at a day surgery centre. Therefore, nine patients
had previous experience with day surgery of which
eight had uncomplicated recoveries (Table 1).
Table I
Distribution
day surgery
of patients
experience
Previous cystoscopic
experience
NO previous
cystoscopic experience
according
to their
previous
cystoscopic
Previous day
surgery experience
No previous
day
surgery experience
8
0
I
12
and
preparation
Another theme related to the preoperative information supplied. Only three of the total responses clearly
indicated that they did not know enough about the
procedure itself
I had no idea what cystoscopy was I had no idea
what prostatitis was (E8)
When I went in I knew nothing
(L?)
Generally, participants believed that they had received sufficient information,
although the characteristics of the information,
timing and provider varied
from one participant to another.
Participants were treated at a day surgery centre
whose practice was to provide each pa.tient having a
general anaesthetic with a booklet. This publication
provides an outline of day surgery plus valuable information about fasting, medication. the need to leave
with an escort, advice on what to do after surgery and
the geographical location of the unit. When questioned
about the information they had received three patients
18
J. Donoghue
mentioned
tion:
et al. : Ambulatory
this leaflet as the main source of informa-
They certainly give you instructions before you go,
quite a good outline of the day surgery and what you
ought to do and what you shouldn’t do and...the
procedure for going home...
(L3)
Others did not refer to the information
leaflet but
described the instructions and/or explanations given by
the urologist or the staff at the day surgery centre:
I wasn’t really given any idea of what to expect, I
sort of had my own ideas of what might happen....[After the operation] they gave me a whole lot
of instructions about what to do and all the rest of it,
for twenty-four hours, now I would have felt that I
didn’t need half of that information but of course it
would probably depend on what dose of anaesthetic
you got, I’d imagine
(E3)
The majority of patients knew who to contact if they
needed assistance during the recovery period, although
two patients were uncertain who to contact if problems
arose during the night. One had undergone 25 cystoscopies and it is surprising that he was not clear how to
proceed should he have needed help.
Information
provided after the operation was commented on by only six participants, three commented
on the intake of fluids and two on discharge instructions. Two patients sought information about the procedure and the process of recovery, and suggested a
possible format for urologists to provide information to
patients. One of these patients expressed his surprise
about not getting information in writing because of the
possibility of patients suing doctors and the occurrence
of misunderstandings:
Surgery
5 (1997)
15- 19
tions of the experience. Experienced patients who had
undergone urological or day surgery had preconceived
ideas which influenced their expectations and perceptions.
Oh well because I had it before I understood
was going on. (E4)
what
Another patient who had required medical assistance
for postoperative bleeding on another occasion felt
anxious because he was bleeding on his arrival home
from the unit (L3). One patient having his ninth cystoscopy (L8) expressed his apprehension before the
operation both about having a general anaesthetic and
the possibility of tumour regrowth. Two other patients
expressed their apprehension about the outcome of the
surgical procedure, e.g. tumour regrowth. This could be
expected as reasonable in light of the reason for cystoscopy.
Those who were novices also had preconceived ideas
“No there weren’t any surprises because I knew it was
day surgery so I knew it wouldn’t be anything of a
serious nature...” (L4). Three patients having their first
day surgery experience were in this group. Two of them
said that the anaesthetic was their main worry or that it
was “the least pleasant aspect of it [the day surgery
experience] that I could think of’ (E5).
Strong positive responses were expressed by the majority of the participants reflected in comments like:
“No trouble at all”, “could do it with my eyes closed”
or “no worries...as soon as he had finished the procedure I was ready to go, it was that easy”.
Eight were pleased with short waiting times or
prompt feedback from the surgeon. Many strongly
recommended the day surgery track for cystoscopy or
other procedures perceived to be minor: “...day surgery
is the way to go...the best place to recover is at home”
@3).
The specialist just said to me well we’ll have to have
a look, so that’s what I thought he was going to
do...So I knew nothing, about the operation...If he
had told me,...well...I would have been happier if he
had told me...and I would have agreed to have it
done...but when I went in I knew nothing...1 think it
probably would help people to know beforehand
what it will entail or may entail.
(L5)
One patient mentioned that he would like to see the
equipment used for the procedure, but he added that he
was in two minds about this as he was curious but at
the same time afraid of what he could find out.
5.3. Expectations
experience
of and satisfaction with the
Another theme identified related to patients’ expecta-
6. Conclusion
This study indicates that the cystoscopic day surgery
population appears to be well served, but the concerns
expressed by these patients need to be addressed. An
area worthy of attention is patient education, particularly for first timers. The majority responded positively
in terms of satisfaction with the information
received.
However, they demonstrated their lack of knowledge
when unexpected situations such as bleeding arose.
Ways of ensuring the consistency of information
supplied should be explored, as well as the provision of an
opportunity for patients to reflect on and discuss with a
health professional the information they have received.
Despite the fact that the postoperative symptoms are
J. Donoghue
et al. /Ambulatory
likely to be minor, the best educational preparation
critical to enhance patient outcomes irrespective
where the procedure is undertaken.
is
of
Acknowledgements
This research project was funded by a grant from the
NSW Health Department
~- Health Outcomes Program.
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