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. References [l) Day Procedure Task Force: Reports and Recommendations. Health Department Victoria. 1987. [2] Sibbritt DW. Trends and projections for day only admissions in NSW acute hospitals. Aust Clin Rev 1992; 12 (3): 1155124. [3] Caldwell LM. Surgical outpatient concerns: what every perioperative nurse should know. AORN J 1991; 53 (3): 761-767. [4] lcenhour ML. Quality interpersonal care, a study of ambulatory surgery patient’s perspective. AORN J 1988; 47 (6): 1414-1419. [5] Department of Health. Performance audit report: same day admission. The Audit Office of New South Wales, 1995. [6] Warden JC. 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