Effectiveness of Video-Based Instructions on Urostomy Self-Care in Patients Undergoing Radical Cystectomy with Ileal Conduit Urinary Diversion

By Arshad Maqbool, Wajahat Aziz, Shahid Iqbal, M. Hammad Ather

Affiliations

1. Section of Urology, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan

doi: 10.29271/jcpsp.2025.10.1345

ABSTRACT
Objective: To evaluate the effectiveness of video-assisted stoma-care teaching in improving patients' confidence and skills in stoma management.
Study Design: Quasi-experimental study.
Place and Duration of the Study: Section of Urology, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from December 2023 to May 2024.
Methodology: Nineteen patients underwent radical cystectomy with ileal conduit, of whom 15 met the eligibility criteria. On the third postoperative day, patients received verbal stoma-care instructions, followed by video-assisted teaching at their first clinic visit. A self-efficacy questionnaire was administered pre- and post-intervention. The Wilcoxon signed-rank test compared the scores, with p <0.05 deemed statistically significant.
Results: The median self-efficacy score improved significantly from 24/65 before the video intervention to 61/65 afterwards (p <0.05). Improvements were observed across stoma-care, application, and confidence domains. Pre-intervention, only one patient demonstrated high confidence, whereas post-intervention, all patients achieved high self-efficacy.
Conclusion: Video-assisted stoma-care teaching significantly improved patients' confidence and skills in managing their stoma after radical cystectomy. This method provides a valuable, repeatable tool to enhance patient outcomes and quality of life.

Key Words: Radical cystectomy, Urinary diversion, Ileal conduit, Stoma management, Video-assisted teaching, Self-efficacy, Confidence, Patient confidence, Learning tool, Quality of life.

INTRODUCTION

Radical cystectomy with urinary diversion is the treatment of choice for muscle-invasive bladder cancer and selective non- muscle-invasive bladder cancers.¹ Urinary diversion is either an incontinent diversion (conduits) or a continent diversion (orthotopic neobladder and cutaneous urinary diversion). Ileal conduit is the most common diversion performed around the world in view of its safety.² The major issue faced by the patients, particularly in the initial phase, is handling the stoma and changing the flange and bag. Patients must understand how to maintain their urostomy after radical cystectomy.³

Undergoing a radical cystectomy and urinary diversion significantly alters a patient's life, often leaving them unprepared for the adjustments required after an ostomy.

This lack of preparation can result in avoidable medical visits, stoma-related issues such as rashes and stomal stenosis, and feelings of inadequacy in handling new physical changes, all of which can negatively impact their quality of life (QoL).^3-5

Performing daily stoma care, learning how to manage clothing, external looks, daily activities, and coping with the impact on a patients’ self-esteem are common challenges faced by patients living with a stoma.^6,7 Brown and Randle reported that patients frequently experience feelings of disgust, shock, or disconnection from their bodies upon first seeing their stoma.⁷ These feelings can hinder the development of skills and confidence needed for effective ostomy self-care, which is essential for their QoL and adjustment to life after stoma surgery.³

Patients undergoing radical cystectomy with an ileal conduit and urostomy are referred to a stoma-care nurse for preoperative counselling. Postoperatively, nurse-led, hospital-based instruction on urostomy self-management continues to be the primary component of urostomy education.^6,8 However, patients often struggle to maintain self-management practices and may not retain postoperative education as effectively as required.^5,9,10 The stoma-care nurse and the operating surgical team are typically more concerned with the immediate physical needs, medical and surgical issues. Stoma care can become a secondary issue. Caregiver support cannot consistently overcome all challenges that arise postoperatively.

Many ostomy educational programmes, such as stoma boot camp and ostomy self-management telehealth, have been developed for patients and their caregivers to improve under- standing of stomas, their complications, and their manage- ment.^10,11

However, not every patient with a stoma is able to join or benefit from such programmes. Post-cystectomy patients often call the hospital helpline or visit nearby hospitals for advice on stoma care, ostomy adjustment, and skincare.^5,10,12

Online videos have become a valuable resource for interaction, sharing experiences, and education. Accessing medical information online’s growing in popularity, providing an easy way for individuals to learn how to manage long-term health conditions such as urostomy. However, while these educational videos are well-intentioned, many are not regulated and may present confusing or misleading information.¹³

Although many studies have examined video-assisted teach- ing of stoma care in patients with colostomy, it is less well- studied in patients undergoing radical cystectomy with ileal conduit.¹⁴ The study aimed to evaluate the effectiveness of video-assisted stoma-care teaching for patients with urostomy and  their  caregivers.

METHODOLOGY

This study was conducted prospectively at the Section of Urology, Department of Surgery, the Aga Khan University Hospital, Karachi, Pakistan, from December 2023 to May 2024. The sample size was calculated using a feasibility sampling method, considering the number of patients undergoing radical cystectomy within the study duration. Based on the annual surgical volume and study timeframe, a total of 15 patients were deemed appropriate for this pilot study. The study protocol was approved by the Institutional Ethical Review Committee (ERC) with ref# 2023-9248-27450.

Patients over 18 years of age who underwent radical cystectomy with ileal conduit, along with their caregivers, were included in this study if they were able to communicate, willing to participate, and had normal cognitive function. Patients who were not willing to participate, had history of psychiatric illness, or if either the patient or their caregiver who had previously attended any stoma-care educational programme, were excluded.

All patients planned for radical cystectomy underwent stoma- site marking one day prior to surgery. A stoma bag was applied one day before surgery to acclimatise the patient to the stoma. This study was carried out in two steps. In the first step, on postoperative day three, once the patient was fully awake and pain-free, a verbal demonstration was given to the patient and their caregivers on stoma care. A questionnaire adapted from Bekkers et al. was filled by patients or their caregivers at their first clinic visit.¹⁵ For its Urdu-translated version, content validation was performed by a panel of five experts, and the content validation index was calculated. A content validation index ≥0.8 was considered acceptable. The video-assisted stoma teaching was given at the first visit to the clinic by the primary investigator or co-investigator. This video contained instructions on stoma care, the steps for changing the stoma bag, and potential problems patients might face after surgery (httpss:// youtu.be/nUE1ZZtHBi0). This video was in the Urdu language with English subtitles, recorded via a standard device, and was shown to the patients on a standard 17-inch screen with a resolution of 1920 x 1080. The same questionnaire was filled out after  one  month  postoperatively.

Patients’ responses were categorised as follows: 1–very sure I cannot do it, 2–somewhat sure I cannot do it, 3–not sure I cannot do it, 4–somewhat sure I can do it, and 5–very sure I can do it. Out of a total score of 65, patients achieving a score of ≥32 were considered to have high self-efficacy.

Data were analysed using SPSS version 22.0 (SPSS Inc., Chicago). Quantitative variables, such as age, were represented as mean and standard deviation, meanwhile qualitative variables were represented as frequency and percentage. Pre- and post-self-efficacy outcome scores were reported as median and interquartile range (IQR). The Wilcoxon signed-rank test was used to assess these outcomes. A p-value of <0.05 was considered significant for both primary and secondary objectives.

RESULTS

Nineteen patients underwent radical cystectomy during the study period. Fifteen patients met the inclusion criteria and were included in the study. Twelve out of fifteen (80%) of these patients were male with at least secondary / high school education. Baseline demographics and clinical parameters are given in Table I.

Table   I:   Baseline   demographics   and   clinical   parameters.

Demographics	n	Percentages (%)
Age (mean)	64 ± 10.5
Gender
Male	12	80
Female	3	20
BMI
Healthy	9	60
Overweight	4	26.7
Obese	2	13.3
Education level
Secondary	5	33.3
Graduated	10	66.7
Occupation
Student	1	6.7
Professional	6	40.0
Not working	8	53.3
Marital status
Married	15	100
Unmarried	0	0
Smoking status
Smoker	7	46.7
Non-smoker	8	53.3

Table II: Comparison of pre- and post-intervention median scores in stoma care self-efficacy domains.

Parameters	Pre-test median (IQR)	Post-test median (IQR)	Median difference	p-values
Overall score	24 (22-27)	61 (56-61.5)	37	0.001*
Stoma care	8 (7-10)	15 (14-15)	7	0.001*
Stoma application	8 (7-9)	20 (18-20)	12	0.001*
Urostomy confidence	8 (7-10)	26 (22.5-26.5)	18	0.001*
*p-value of <0.05 was considered as significant.

Following the video discharge instructions, the overall scores demonstrated substantial improvement. The median stoma- care self-efficacy score was 24/65, whereas after video discharge instructions, the median score increased to 61/65, showing a difference of 37 (p = 0.001).

The self-efficacy questionnaire was further categorised into three distinct domains: stoma care, stoma application, and urostomy confidence.

In subdomain analysis, the stoma care showed a median pre-test score of 8/15. Post-intervention, this median score increased to 15/15. The median difference of 7, with a narrow IQR, indicates consistent improvement among participants.

For the stoma application category, the pre-test median score was initially 8/20, with an IQR of 7 to 9. After the intervention, the median score significantly increased to 20/20, with an IQR of 18 to 20, with a median difference of 12 reflecting significant advancement in participants' abilities.

In the urostomy confidence category, the pre-test median score was 8/30, with an IQR of 7 to 10. Post-test, the median score improved to 26/30, with an IQR of 22.5 to 26.5, with a median difference of 18, highlighting a substantial boost in participants' confidence.

Overall, the results (Table II) indicate significant improvements in the general median scores and the specific subcategories of stoma care, application, and confidence after the intervention. Especially, the patients showed remarkable improvement in urostomy confidence and application.

Self-efficacy scores showed that only one patient had high self-efficacy before video teaching, while fourteen had low efficacy. After the intervention, all patients had high self- efficacy.

DISCUSSION

Stoma formation profoundly affects patients' QoL, encompassing significant challenges in daily management, psychological well-being, and social adjustment. This study aimed to assess the effectiveness of video-assisted stoma-care teaching for patients undergoing radical cystectomy and their caregivers. The mean age of the participants was 64.1 years. This is consistent with a study conducted by Villa et al., where the mean age was 69 years.¹⁶

The study demonstrated significant improvements in overall stoma care, application, and confidence in stoma management. The median difference of 37 in pre- and post-video care indicates that the patients who initially felt unprepared and less confident became more effective and confident afterwards. These results align with those of Halemani et al., who evaluated the effectiveness of a video-assisted teaching module on the knowledge and practice in home-based colostomy care.¹⁷ The pre- and post-test mean peristomal care were 7.03 ± 2.251 and 14 ± 1.365, respectively. Similarly, a study conducted by Abouelela et al. on the effectiveness of video-assisted colostomy care demonstrated that post-video awareness increased to 66.7% from 26.7%, while low self- efficacy levels dropped from 63.4% to 21%, and high self- efficacy levels rose to 78.9% from 36.6%.¹⁴

Video-assisted urostomy care is an accessible and repeatable method that effectively addresses many challenges faced by patients. As reported by Cengiz et al., patients often forget multiple steps of stoma care taught during preoperative sessions, and many expressed a desire for more home visits from healthcare providers.¹⁸ A large number of patients turn to the internet for additional knowledge. Furthermore, shorter post-surgery hospital stays limit the time available for patients to acquire sufficient knowledge and master essential skills.¹⁷ A systematic review by Liu et al. suggested that effective stoma self-care reduces the risk of hospital readmission.¹⁹ In addition, urostomy self- care is essential to maintain patients’ psychological stability and QoL.^17,20 Video-assisted urostomy management is a valuable resource because it is readily available and can be watched repeatedly, allowing patients to reinforce their understanding and skills at home.

This study holds significant strengths and certain limitations. It represents the first exploration specifically focused on patients with urostomies, addressing a critical gap in the current literature. The positive findings pave the way for larger-scale studies involving a more diverse patient cohort, with the potential to influence clinical practice and patient outcomes on a broader scale. However, this study was conducted at a single centre in Pakistan, where radical cystectomy was performed in limited specialised centres, potentially limiting the generalisability of these results. Additionally, due to the smaller patient population and the lack of previous research on this specific topic, a randomised study design was not feasible, highlighting the need for future multicentre randomised trials to enhance the validity and applicability of the findings. Moreover, the pilot nature of the study, with its smaller sample size, highlights the preliminary character of the findings. Further research with larger cohorts is necessary to strengthen the evidence and validate the conclusion effectively. Future research and interventions should prioritise the development of tailored educational strategies to enhance patient confidence, promote effective self-care practices, and foster psychological resilience in navigating the complexities of life with a stoma. These efforts ultimately aim to improve patients' overall well-being and facilitate their successful adaptation to long-term stoma management.

CONCLUSION

Radical cystectomy with urinary diversion is the treatment of choice for muscle-invasive bladder cancer and selective non- muscle-invasive bladder cancers. Stoma formation negatively affects a patient’s QoL, and its proper management is crucial in reducing stoma-related complications. Many patients are not fully prepared to deal with stoma care. Patients and their caregivers cannot retain pre- and postoperative education as effectively as required. The current study showed significant improvements in overall stoma care effectiveness, application, and confidence in stoma management. This is the first study that focuses specifically on patients with urostomies. While the results can lay the groundwork for large-scale studies, the small sample size highlights the preliminary nature of findings, necessitating further research with a larger sample size.

ETHICAL APPROVAL:
Ethical approval was obtained from the Institutional Ethical Review Committee of the Aga Khan University Hospital, Karachi, Pakistan (ERC No. 2023-9248-27450).

PATIENTS’ CONSENT:
Informed written consent was taken from the patients.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
AM, WA, SI, MHA: Conception and design of the study, data analysis and interpretation, and revision of the intellectual content.
All authors approved the final version of the manuscript to be published.
 

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