Månsson A, Christensson P, Johnson G, Colleen S
Department of Urology, University Hospital, Lund, Sweden.
Br J Urol. 1998 Sep;82(3):348-56. doi: 10.1046/j.1464-410x.1998.00763.x.
To assess if there is relationship between: (i) preoperative psychological defensive strategies, mood and type of lower urinary tract reconstruction, and (ii) psychosocial adaptation after radical cystectomy for bladder cancer.
Fifty-seven consecutive patients (44 men and 13 women, mean age 62 years, range 34-81) undergoing radical cystectomy (ileal conduit urinary diversion in 17, continent cutaneous diversion in 22 and orthotopic bladder replacement in 18) were assessed preoperatively using the meta-contrast technique (MCT), a projective test to reveal individual defensive strategies. From the results the patients were classified as hypothetical 'at risk' or 'no risk' patients for postoperative psychosocial complications. An 'at risk' patient was designated as one who showed neurotic defensive strategies in coping with threats, i.e. primitive, immature or regressive strategies or even lack of defence in connection with pronounced anxiety. All patients completed a questionnaire and were interviewed; 10 questions dealt with mood, five reflecting anxiety and five the depressive states. The questionnaire and the interview were repeated 3 and 12 months, and 5 years after surgery.
The remembered difficulties during the first month after discharge from hospital differed between the 'risk' and 'no risk' groups after 1 and 5 years. On a visual analogue scale (VAS) the 'risk' patients had very low scores (less difficulty) or very high, while the 'no risk' patients had intermediate scores. VAS score were also higher, although not significantly so, in patients using primitive defence strategies. The psychosocial situation did not differ between the groups in the first year, but at 5 years there were differences in self-esteem and interpersonal contact-seeking. High depression scores before surgery were associated with high VAS scores at 3 months when recalling the first month after discharge, but the anxiety score was not predictive. Men with orthotopic bladder replacement adapted less well throughout the 5 year follow-up. Elderly patients with stereotypy (the commonest defensive strategy at these ages) adapted relatively well to ileal conduit diversion. About 20% of patients had difficulty in accepting the postoperative situation, regardless of urinary diversion modes.
The combination of defensive strategies assessed using the MCT and selected on hypothetical grounds was less discriminatory than expected for those at risk of postoperative psychosocial problems. However, those with primitive strategies apparently had a long-term risk of poor adaptation. The search for an optimal instrument for the identification of patients at risk is warranted. In this study, patients with a 'wet' stoma did not seem to fare less well than those with a continent reconstruction.
评估以下两者之间是否存在关联：（i）术前心理防御策略、情绪与下尿路重建类型；（ii）膀胱癌根治性膀胱切除术后的心理社会适应情况。
连续纳入57例患者（44例男性和13例女性，平均年龄62岁，范围34 - 81岁），这些患者均接受了根治性膀胱切除术（17例行回肠膀胱术，22例行可控性皮肤造口术，18例行原位膀胱替代术）。术前采用元对比技术（MCT）对患者进行评估，这是一种用于揭示个体防御策略的投射测试。根据测试结果，将患者分为术后心理社会并发症的假设性“有风险”或“无风险”患者。“有风险”患者被定义为在应对威胁时表现出神经质防御策略的患者，即原始、不成熟或退行性策略，甚至在明显焦虑时缺乏防御。所有患者均完成一份问卷并接受访谈；10个问题涉及情绪，5个反映焦虑，5个反映抑郁状态。在术后3个月、12个月及5年时重复进行问卷和访谈。
出院后第一个月内记忆中的困难在1年和5年后“有风险”组与“无风险”组之间存在差异。在视觉模拟量表（VAS）上，“有风险”患者得分很低（困难较少）或很高，而“无风险”患者得分中等。采用原始防御策略的患者VAS得分也较高，尽管差异不显著。两组在第一年的心理社会状况无差异，但在5年时，自尊和寻求人际接触方面存在差异。术前抑郁得分高与出院后第一个月回忆时3个月的高VAS得分相关，但焦虑得分无预测价值。在整个5年随访期间，原位膀胱替代术的男性患者适应较差。采用刻板模式（这些年龄段最常见的防御策略）的老年患者对回肠膀胱术的适应相对较好。无论尿路改道方式如何，约20%的患者难以接受术后状况。
使用MCT评估并基于假设选择的防御策略组合，对于术后心理社会问题有风险的患者，其区分度低于预期。然而，采用原始策略的患者显然存在长期适应不良的风险。有必要寻找一种识别有风险患者的最佳工具。在本研究中，有“湿性”造口的患者似乎并不比可控性重建患者的情况更差。
