Prehabilitation for Surgery in Urology, Urogynaecology, and Gynaecological Oncology

Abstract

Cancer prehabilitation is a process on the continuum of care that occurs between the time of a cancer diagnosis and the beginning of acute treatment. Preoperative optimization is important in preventing morbidity and mortality after surgery. Undergoing a major surgery puts enormous metabolic stress on the body and tilts it towards a catabolic phase. If not managed properly, the functional capacity of an individual can decline.

Prehabilitation in cancer surgery is expanding from the single physical intervention to multi-professional complex programs. Bringing all the field experts together with a common goal of prehabilitation helps to improve surgical outcomes.

In complex urological procedures like radical cystectomy, the role of prehabilitation is paramount. Physical strength optimization with help of a physiotherapist is crucial in getting a patient ready for surgery. Better functional capacity improves postoperative morbidity and improves surgical outcomes. Psychological health is often overlooked and optimizing psychological health requires identifying patients at risk of depression. Poor mental health and increased stress impair the immune system which leads to significant postoperative complications. Psychological evaluation is recommended in patients at risk of mental health deterioration. Nutrition optimization is well recognized to help patients withstand surgical stress and recover faster. Immunonutrition is a newer concept but has a strong effect in improving patients’ immune response to surgical stress.

One aspect that is quite specific to urology prehabilitation is sexual health optimization. As urologists deal with erectile/ejaculatory dysfunction on a regular basis, identifying patients at risk of postoperative sexual dysfunction is not difficult. Sexual counselling and discussing various treatment options with patients before surgery can help to alleviate fears of patients and their partners.

Prehabilitation in gynaecological oncology covers three major components of nutrition, physical, and psychological well-being. The unique and extensive nature of gynaecological cancer surgery must be appreciated and prehabilitation should be tailored accordingly. Endometrial cancers are often seen in affluent populations where malnutrition is not a major issue. However, endometrial cancer typically affects obese woman and weight management is crucial to reduce surgical morbidity. Cervical cancer is common in underprivileged society secondary to poor access to cervical cancer screening. In this population, malnutrition is a major issue and nutrition optimization is crucial. Despite limited time available between presentation and surgery in patients with ovarian cancer, every effort should be taken to prehabilitate these patients for improved surgical outcomes. In pelvic floor prolapse surgery, preoperative pelvic floor exercises and bladder training exercises should be offered to optimize the patient before the surgery.

Conclusion: Prehabilitation is yet to be embedded as a standard of care in patients undergoing surgical procedures for urological and gynaecological procedures. However, emerging evidence conducted in prehabilitation interventions appears to have merit. An evidence-based approach to prehabilitation can lead to improved, clinically significant surgical outcomes.