Introduction

Exercise can improve physical function, quality of life (QoL) and alleviate adverse effects as a result of prostatectomy. However, there is no consensus on the timing of exercise intervention. Although the physical condition of patients is better before prostatectomy, it is not known if commencing the exercises before surgery would be beneficial to patients as compared to postoperative rehabilitation. Initiating exercise before surgery might mitigate surgery-related declines in physical function of QoL.

Aim

The objective and patient-reported outcomes, hospital length of stay, and urinary incontinence in men with prostate cancer who initiated supervised exercise before prostatectomy have been compared to postoperative rehabilitation.

Method

Study Design

• Randomized controlled trial

  Patient Profile

• Men with localised prostate cancer
• Minimum 7 weeks between baseline assessment and surgery
• Completed 6 weeks of exercise

Treatment Strategy

• A total of 41 men were randomized to a 6-week supervised multimodal exercise program before surgery (prehabilitation) or identical exercise program post-surgery (rehabilitation)
• Prehabilitation comprised combined resistance and aerobic exercise thrice weekly pre-surgery, while rehabilitation exercises were started 6-weeks post-surgery
• all the patients were instructed not to do exercises for atleast 6 weeks post-surgery for recovery
• the time between baseline to pre-surgery is defined as pre-surgery phase, period from discharge to 6 weeks post-surgery as the early post-surgery phase, between 6-12 weeks post-surgery as the late post-surgery phase
• the patients were evaluated for various outcomes at baseline, pre-surgery, 6 weeks, 12 weeks and post-surgery
• Assessments included strength, function (repeated chair rise, stair climb, 400-m, 6-m usual, fast, and backwards walk), body composition, fatigue and QoL, undertaken at pre-surgery, early post-surgery and late post-surgery phase, with urinary incontinence assessed at 2, 6, and 12-weeks post-surgery

Endpoints

Primary Endpoint

• Dynamic muscle strength for chest press and leg press

  Secondary Endpoints

• Physical function
• Body composition
• Urinary incontinence, assessed using 24-hr pad test
• Hospital length of stay
• Fatigue
• QoL

Results

• A total of 29 men out of 38 completed the study
• 92.1% underwent robotic-assisted laparoscopic prostatectomy
• In the pre-surgery phase, prehabilitation significantly improved muscle strength (leg press: 17.2 kg; chest press: 2.9 kg; p ≤ 0.001) while rehabilitation also resulted in a remarkable increase of 6.7 kg (p<0.001)
• In the early post-surgery phase, both groups demonstrated significant reductions in chest (4.8 kg vs 3.9 kg) and leg press (8.9 vs 8.7 kg) in prehabilitation and rehabilitation groups respectively
• Late post-surgery phase showed significant improvements in leg press in both groups; whereas chest press strength improved only in rehabilitation group
• In the pre-surgery phase, prehabilitation group showed improvements in 400-m, chair rise, 6-m fast and backward walk tests (p ≤ 0.001-0.028)
• Strength and function declines in the early post-surgery phase were maintained late post-surgery
• Rehabilitation group demonstrated declines of these outcomes after surgery with improvement late post-surgery (400-m walk: -12.0 s, p = 0.005), resulting in no difference between groups at 12 weeks
• Patient-reported outcomes, hospital length of stay or urinary incontinence were comparable

Conclusion

• Exercise before prostatectomy resulted in enhanced muscle strength and physical function, protecting against post-surgery declines.
• In cases where pre-surgical exercises are not possible, commencing supervised exercise program postoperatively will be beneficial for recouping strength and function.
• Clinicians should advise exercises pre-surgery or as soon as possible after surgery to help in the recovery.

J Cancer Res Clin Oncol. 2023 Dec;149(18):16563-16573.