Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy

Abstract

Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.

Abstract

Incontinence is a common complication of radical prostatectomy and can have a considerable effect on quality of life for men who have survived prostate cancer. In the past, management of postoperative incontinence has focused on rehabilitation and postsurgical management, but prehabilitation, in the form of pelvic floor muscle exercises and training, has the potential to improve postprostatectomy continence outcomes, provide patients with agency for their own health and improve quality of life in men who have been treated for prostate cancer.

Key points

• The oncological curative effectiveness of radical prostatectomy can be diminished by treatment-related adverse effects that include urinary incontinence, reduced physiological functional capacity and psychosocial well-being.

• The increasing survival of men following radical prostatectomy has resulted in the development of preoperative interventions that can improve the patients’ preoperative and postoperative experience and optimize health-related quality-of-life outcomes.

• Preoperative exercise interventions comprising a combination of aerobic exercise, resistance training and specific pelvic floor muscle training programmes are designed to enhance the patients’ physiological functional capacity and mitigate the treatment-related adverse effects of radical prostatectomy including urinary incontinence.

• Transperineal ultrasonography can provide a non-invasive and validated method to improve the quality and specificity of the delivery of pelvic floor muscle training interventions in men before and after they undergo radical prostatectomy.

• A structured and coordinated prehabilitation model of care can be initiated by the surgeon and delivered through their multidisciplinary team to extend the surgical care provided to patients and optimize preoperative and postoperative functional outcomes.