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Preoperative Exercise Interventions to Optimize Continence Outcomes Following Radical Prostatectomy

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Preoperative Exercise Interventions to Optimize Continence Outcomes Following Radical Prostatectomy REVIEWS Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy Sean F. Mungovan 1,2,3 ✉ , Sigrid V. Carlsson4,5,6, Gregory C. Gass2,7, Petra L. Graham 8, Jaspreet S. Sandhu4, Oguz Akin 9, Peter T. Scardino4, James A. Eastham4 and Manish I. Patel 10,11 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. Prostate cancer is a common malignancy and, as the can be successfully managed and treated6. Accurate fifth most common cause of cancer deaths in men, is a tumour grading remains the cornerstone for diagnosis, global public health problem1,2. GLOBOCAN 2020 esti- risk stratification and clinical management decisions. mates reported 1,414,259 new cases of prostate cancer Classification methods that guide the clinical manage- globally in 2020, with a higher prevalence in developed ment of prostate cancer incorporate tumour grade, the countries1. Despite geographical and ethnic variations in tumour, node, metastasis stage and PSA level. Patients the incidence rate, prostate cancer is one of the most fre- with prostate cancer can be stratified into low- risk, quently diagnosed non- cutaneous cancers. The highest intermediate- risk and high- risk disease groups7. In estimated incidence rates per 100,000 males have been developed countries, most men who receive a diagno- reported in Australia and New Zealand, North America, sis of prostate cancer present with organ- confined and Western and Northern Europe and the Caribbean2. The potentially curable disease7,8. incidence rate of prostate cancer has been reported to be The high incidence rate and need for effective treat- 2 ✉e- mail: sean.mungovan@ on an upward trajectory in Eastern Europe , the Middle ment options has led to extensive efforts to improve 3 4 5 crinstitute.com.au East , North Africa and in Central and South America . the assessment and clinical management of patients https://doi.org/10.1038/ Not all prostate cancer diagnoses are terminal. The with prostate cancer. Treatment options continue to s41585-021-00445-5 indolent nature of the disease is widely recognized and evolve to support patient-centred models of care, which NATURE REVIEWS | UROLOGY VOLUME 18 | MAY 2021 | 259 0123456789();: REVIEWS Key points adds to the complexity of informed and shared clinical decision- making for patients with localized prostate • The oncological curative effectiveness of radical prostatectomy can be diminished cancer. by treatment- related adverse effects that include urinary incontinence, reduced Low- risk localized prostate cancer, which includes physiological functional capacity and psychosocial well- being. most men with Gleason Grade Group 1 disease, can be • The increasing survival of men following radical prostatectomy has resulted in the carefully monitored and managed using active surveil- development of preoperative interventions that can improve the patients’ preoperative lance protocols, delaying the need for curative interven- and postoperative experience and optimize health- related quality-of- life outcomes. tions until evidence of disease progression is seen. Active • Preoperative exercise interventions comprising a combination of aerobic exercise, surveillance was developed to personalize the need for resistance training and specific pelvic floor muscle training programmes are designed early intervention, potentially circumventing the risk to enhance the patients’ physiological functional capacity and mitigate the treatment-related adverse effects of radical prostatectomy including urinary of functional impairments and other negative conse- 14 incontinence. quences of definitive curative treatment options . For • Transperineal ultrasonography can provide a non- invasive and validated method men with prostate cancer who require definitive curative to improve the quality and specificity of the delivery of pelvic floor muscle training treatment, the management options for localized pros- interventions in men before and after they undergo radical prostatectomy. tate cancer include radical prostatectomy, radiotherapy, • A structured and coordinated prehabilitation model of care can be initiated by the focal therapy and/or ADT, low- dose- rate brachyther- 15,16 surgeon and delivered through their multidisciplinary team to extend the surgical care apy and focal therapy alone . Men who present with provided to patients and optimize preoperative and postoperative functional outcomes. locally advanced prostate cancer typically receive ADT as the primary intervention in conjunction with radio- therapy or, in some instances, surgery17. Although met- are based on informed and shared decision- making astatic prostate cancer disease is primarily treated with between the patient and their clinicians9. Prostate can- ADT, clinical trials have reported the benefit of includ- cer encompasses a wide spectrum of disease, ranging ing docetaxel chemotherapy18,19 or abiraterone acetate to from indolent to highly aggressive tumours. The range improve survival20,21. Evidence suggests that radiother- of treatment options available to successfully manage apy and radical prostatectomy reduces disease burden clinically localized prostate cancer has evolved because and the need for palliative treatment, even in patients of the significant variation in the potential clinical with metastatic disease22. course of the disease and a better understanding of the genetic and molecular profile of the disease10–12. Radical prostatectomy These treatment options include active surveillance The surgical technique of prostatectomy has changed and definitive curative interventions including surgi- considerably over time from simple prostatectomy, cal resection, radiotherapy including external- beam which removed only parts of the prostate, to removal of and interstitial radiation, energy ablative technolo- the entire prostate using radical prostatectomy23 (Fig. 1). gies and/or androgen deprivation therapy (ADT)13. The radical approach to prostatectomy was first reported Although each treatment option has a unique efficacy in 1905 by Hugh Hampton Young24 and remains the profile, including treatment- related risks, benefits and mainstay of surgical curative treatment for men with adverse effects, the lack of robust comparative effec- localized prostate cancer. Randomized controlled tri- tiveness trials mean that, as yet, no single treatment als (RCTs) have confirmed that radical prostatectomy option has emerged as the most appropriate for patients improves prostate cancer survival and reduces the inci- with prostate cancer. In a patient- centred model of dence of metastasis compared with observation25,26. care, achieving the optimal balance of potential bene- The growing number of men who survive prostate fits, risks and adverse effects for each treatment option cancer has widened the focus of clinical management to improve the patients’ preoperative and postoperative Author addresses experience, reduce the impact and hasten the recov- ery of treatment- related adverse effects and improve 1Westmead Private Physiotherapy Services, Westmead Private Hospital, Westmead, New health- related quality of life. South Wales, Australia. 2The Clinical Research Institute, Westmead, New South Wales, Australia. Radical prostatectomy is a substantial life event for 27 3Department of Professions, Faculty of Health, Arts and Design, Swinburne University the patient . The majority of men who undergo radical of Technology, Hawthorn, Victoria, Australia. prostatectomy experience predictable functional impair- 4Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, ments including urinary incontinence and erectile dys- New York, NY, USA.
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