Efficacy of pre and rehabilitation in radical cystectomy on health related quality of life and physical function: A systematic review

Effect of Prehabilitation Interventions in People Affected by Bladder Cancer on Long-Term Physical, Clinical, and Patient-Reported Outcome Measures: A Systematic Review

PURPOSE

To understand the effect of prehabilitation interventions on ≥30 days post-treatment outcomes including physical functioning, clinical, and patient-reported outcomes in people affected by bladder cancer.

METHODS

This systematic review included all randomized, quasi-randomized, or single-arm studies in patients affected by bladder cancer (irrespective of stage or treatment modality) that compared prehabilitation intervention(s) with standard care. A range of key terms related to bladder cancer and prehabilitation were developed to search the four electronic databases. Articles were assessed according to predetermined inclusion and exclusion criteria. A methodological quality assessment was performed.

RESULTS

Of the 932 studies identified, 14 studies were included and represented 1,034 participants. The interventions included multimodality prehabilitation (n = 5), exercise-only programs (n = 3), nutrition-focused interventions (n = 2), educational support (n = 3), and smoking/alcohol cessation counseling (n = 1). All of the studies were conducted in patients treated by surgery, therefore clinical and research gaps exist in the prehabilitation interventions among patients treated by intravesical therapy (ie, BCG) or radiotherapy. The key findings highlighted that multimodal program mainly showed improvements in physical function outcomes. Exercise-only interventions demonstrated some benefits in physical function. Nutrition-only interventions did not show any statistically significant improvements. Education programs showed improvements in patient-reported outcomes. Smoking and alcohol cessation counseling achieved notable abstinence rates, which were associated with fewer postoperative complications.

CONCLUSION

This review suggests that prehabilitation interventions may benefit patients with bladder cancer, particularly exercise and education programs, which showed improvements in physical function and patient-reported outcomes. However, the evidence remains inconclusive, with no clear impact on clinical outcomes such as complications or hospital stay. More robust studies are needed to determine the most effective prehabilitation strategies for patients with bladder cancer.

Enhanced Recovery After Surgery for patients undergoing radical cystectomy: Surgeons' perspectives and recommendations ten years after its implementation

BACKGROUND AND OBJECTIVES

Enhanced Recovery After Surgery (ERAS) guidelines for Radical Cystectomy (RC) were published over ten years ago. Aim of this systematic review is to update ERAS recommendations for patients undergoing RC and to give an expert opinion on the relevance of each single ERAS item.

METHODS

A systematic review was performed to identify the impact of each single ERAS item on RC outcomes. Embase and Medline (through Pubmed) were searched systematically. Relevant articles were selected and graded. For each ERAS item, a level of evidence was determined. An e-Delphi consensus was then performed amongst an international panel with renowned experience in RC to provide recommendations based on expert opinion.

KEY FINDINGS AND LIMITATIONS

Preoperative medical optimization and avoiding bowel preparation are highly recommended. Robotic-assisted RC with intracorporeal urinary diversion is moderately recommended and can help in applying other ERAS items, such as early mobilization. Medical thromboprophylaxis should be administered and nasogastric tube should be removed at the end of surgery. Perioperative fluid restriction as well as opioid-sparing anesthesia protocols should be implemented. Generally, consensus was reached on most ERAS items, with the exception of epidural anesthesia (no consensus), resection site drainage (consensus against), and type of urinary drainage. Limitations include the lack of a multidisciplinary approach to the present consensus, giving however a highly specialized surgical opinion on ERAS.

CONCLUSIONS

and clinical implications: The current study updates ERAS recommendations for patients undergoing RC and suggests application of ERAS by a panel of experts in the field.

The inequalities and challenges of prehabilitation before cancer surgery: a narrative review

INTRODUCTION

Prehabilitation seeks to enhance functional capacity and preparedness before surgery with the aim of improving outcomes; it is generally based on exercise, diet and psychological interventions. While there is obvious appeal to this approach in terms of patient experience and resource use, the interventions are complex and the evidence base for prehabilitation before cancer surgery is heterogeneous. Prehabilitation requires patient understanding and motivation as well as commitment of resources. Programmes are challenging to design and implement, and can generate 'intervention-based inequalities' based on the capacity of patients to engage. We present a narrative review on the inequalities and challenges of prehabilitation before cancer surgery.

METHODS

We searched databases of peer-reviewed research to identify appropriate articles. We used the results in combination with iterative searches based on citation tracking, grey literature (e.g. patient information resources) and articles from personal libraries, to develop our discussion.

RESULTS

We describe the uncertainties in the evidence base for prehabilitation before cancer surgery, and the challenges and barriers for healthcare providers, systems and patients. Key findings include that prehabilitation is under-researched in many cancers and that people with lower health literacy, from minority ethnic groups and socio-economically disadvantaged backgrounds, are less likely to engage, despite often having worse peri-operative outcomes.

DISCUSSION

Prehabilitation must be implemented carefully to avoid widening inequalities. More research is needed, both in terms of the impact of interventions and to understand how prehabilitation should account for the social determinants of health.

Prehabilitative/rehabilitative exercise, nutrition, and psychological support for bladder cancer: A scoping review of randomized clinical trials

The study of prehabilitation and rehabilitation ([p]rehabilitation) to alleviate the sequelae of bladder cancer and its treatment has generated numerous opportunities to improve the quality of life of bladder cancer survivors. The authors conducted a scoping review of randomized clinical trials (RCTs) to identify knowledge gaps in and research directions for (p)rehabilitative support for those affected by bladder cancer. The authors systematically searched six databases and synthesized key findings from RCTs conducted from January 1, 2004, through March 15, 2022, that enrolled participants with bladder cancer, survivors, or caregivers in outpatient (p)rehabilitative programs (e.g., exercise, nutrition, or psychological support). Outcomes were characterized according to eight prespecified, clinically relevant categories. The search retrieved 10,968 records, 27 of which met the inclusion criteria, and 24 described unique RCTs with 2471 enrolled participants. Of 24 interventions, 17 (71%) yielded statistically significant results for the outcome of interest. Only one RCT included a cost-effectiveness analysis, and only two characterized the efficacy of interventions for caregivers. Of 11 RCTs involving psychological support, eight yielded statistically significant results, as did nine of 11 RCTs with physical exercise interventions, three of four RCTs with educational interventions, three of four RCTs with nutritional support interventions, one of two RCTs with pharmacologic medications, and zero of one RCT with physical therapy. The most promising interventions for inclusion in multimodal, personalized (p)rehabilitation programs included exercise, stress management training, cognitive training, smoking and alcohol cessation counseling, immunonutrition, stoma education, and penile rehabilitation. Further studies of the cost effectiveness and efficacy for caregivers of such interventions are needed. PLAIN LANGUAGE SUMMARY: In a scoping review of all randomized clinical trials involving prehabilitative or rehabilitative diet, exercise, and psychological support interventions for patients with bladder cancer, survivors, and their caregivers, 17 of 24 (71%) interventions yielded statistically significant improvements in the outcome of interest. Clinicians should consider implementing such interventions for those affected by bladder cancer.

Co-developing a theory of change for a personalised multimodal cancer prehabilitation programme in South Wales

BACKGROUND

Evidence suggests that prehabilitation interventions, which optimise physical and mental health prior to treatment, can improve outcomes for surgical cancer patients and save costs to the health system through faster recovery and fewer complications. However, robust, theory-based evaluations of these programmes are needed. Using a theory of change (ToC) approach can guide evaluation plans by describing how and why a programme is expected to work. Theories of Change have not been developed for cancer prehabilitation programmes in the literature to date. This paper aims to provide an overview of the methodological steps we used to retrospectively construct a ToC for Prehab2Rehab (P2R), a cancer prehabilitation programme being implemented by the Cardiff and Vale University Health Board.

METHODS

We used an iterative, participatory approach to develop the ToC. Following a literature review and document analysis, we facilitated a workshop with fourteen stakeholders from across the programme using a 'backwards mapping' approach. After the workshop, stakeholders had three additional opportunities to refine and validate a final working version of the ToC.

RESULTS

Our process resulted in the effective and timely development of a ToC. The ToC captures how P2R's interventions or activities are expected to bring about short, medium and long-term outcomes that, collectively, should result in the overarching desired impacts of the programme, which were improved patient flow and reduced costs to the health system. The process of developing a ToC also enabled us to have a better understanding of the programme and build rapport with key stakeholders.

CONCLUSIONS

The ToC has guided the design of an evaluation that covers the complexity of P2R and will generate lessons for policy and clinical practice on supporting surgical cancer patients in Wales and beyond. We recommend that evaluators apply a ToC development process at the outset of evaluations to bring together stakeholders and enhance the utilisation of the findings. This paper details a pragmatic, efficient and replicable process that evaluators could adopt to develop a ToC. Theory-informed evaluations may provide better evidence to develop and refine cancer prehabilitation interventions and other complex public health interventions.

Classification and Risk Factors for Surgical Site Infections in Radical Cystectomy: A 16-Year Analysis

Introduction: Surgical site infection (SSI) is a substantial cause of peri-operative morbidity among patients undergoing radical cystectomy (RC). The purpose of this study was to identify the risk factors of SSI after RC and to classify and characterize treatment of SSIs. Methods: We retrospectively analyzed peri-operative characteristics and SSI, for patients undergoing RC from 2007 to 2022. Patients were stratified by SSI versus no SSI and differences were assessed. Uni-variable/multi-variable logistic regression analyses were performed to identify factors associated with SSI. SSIs were categorized by the Centers for Disease Control and Prevention (CDC) type: Superficial incisional, deep incisional, and organ/space confined. Results: Three hundred and ninety-eight patients had RC, 279 open, and 119 robotic; 78 (19.6%) developed SSI. Cohorts were similar demographically. Length of stay (LOS) was longer in the SSI cohort (8.8 d versus 12.4 d, p < 0.001), and body mass index (BMI) was greater in patients with SSI (24.34 vs. 25.39, p = 0.0003). On uni-variable analysis, age, gender, Charlson Comorbidity Index, diabetes mellitus, diversion, odds ratio (OR) time, blood loss, and open versus robotic technique were not substantial SSI predictors. BMI was an independent risk factor for SSI on both uni-variable (OR: 1.07, 95% confidence interval [CI]: 1.018-1.115, p = 0.0061) and multi-variable analysis (OR: 1.06, 95% CI: 1.009-1.109, p = 0.02) for 10 (12.8%) and 24 (30.8%) superficial and deep-incisional SSIs, respectively. Superficial wound SSI was treated conservatively with 60% receiving antibiotic agents and no procedural intervention. Deep SSIs received antibiotic agents and 50% required surgical intervention. There were 44 (56.4%) organ/space SSIs, and the most common treatment was antibiotic agents (100%) and IR drain placement (30, 68.2%). Conclusion: In patients undergoing RC, BMI was an independent risk factor for SSI. Type of the surgical procedure, robotic versus open, was not predictive of SSI. LOS was longer for patients with SSI. SSI was managed differently depending on CDC classification.

Effects of an exercise intervention in primary care after robot-assisted radical cystectomy for urinary bladder cancer: a randomised controlled trial

INTRODUCTION

After radical cystectomy physical activity is important to reduce risk of complications, but patients with urinary bladder cancer have difficulties in achieving general recommendations on physical activity and exercise. The aim of this randomised controlled trial was therefore to evaluate the effects of a physical exercise programme in primary care, following discharge from hospital after robot-assisted radical cystectomy for urinary bladder cancer.

MATERIALS AND METHODS

Patients with urinary bladder cancer scheduled for robot-assisted radical cystectomy at Karolinska University Hospital, Sweden between September 2019 and October 2022 were invited to join the study. At discharge, they were randomised to intervention or active control group. The intervention group was planned to start exercise with physiotherapist in primary care during the third week; the programme included aerobic and strengthening exercises, twice a week for 12 weeks, and daily walks. The control group received unsupervised home-based exercise with daily walks and a sit-to-stand exercise. Assessments were conducted before surgery, at discharge and after four months regarding the primary outcome physical function (Six-minute walk test), and secondary outcomes physical activity, pain, health-related quality of life, fatigue, and psychological wellbeing.

RESULTS

Ninety patients were included, mean (sd) age 71.5 (8.5) years. An intention-to-treat analysis showed no intervention effect on the primary outcome physical function, or on pain or psychological wellbeing, but effect on physical activity with a difference from discharge to four months with a median (IQR) of 4790 (3000) and 2670 (4340) daily steps in the intervention and control group, respectively (p = 0.046), and for fatigue, and health-related quality of life, in favour of the intervention group.

CONCLUSION

Both the intervention and control groups improved physical function, but the patients who exercised in primary care experienced additional positive effects on physical activity, fatigue, and health-related quality of life. Hence, exercise in primary care after discharge from hospital could be a promising method after radical cystectomy for urinary bladder cancer.

TRIAL REGISTRATION

The study was registered in Clinical Trials with registration number NCT03998579, 20,190,607.

Clinical updates on the effects of high intensity interval training (HIIT) exercise in people diagnosed with cancer. A systematic review and meta-analysis

OBJECTIVES

To provide an updated critical evaluation on the effectiveness of high intensity interval training (HIIT) on health outcomes amongst cancer survivors.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search was conducted using databases CINAHL and Medline (via EBSCOhost platform), Scopus, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials. Randomised, controlled, exercise trials involving cancer survivors were eligible. Data on the effects of HIIT amongst individuals diagnosed with cancer at any stage were included. Risk of bias was assessed with the Mixed Methods Appraisal Tool (MMAT). Standardised mean differences (SMD) were calculated to compare differences between exercise and usual care. Meta-analyses (including subgroup analyses) were undertaken on the primary outcome of interest, which was aerobic fitness. Secondary outcomes were fatigue, quality of life, physical function, muscle strength, pain, anxiety, depression, upper-body strength, lower-body strength, systolic and diastolic blood pressure.

RESULTS

Thirty-five trials from forty-seven publications were included, with intervention durations ranging between 4 and 18 weeks. Breast cancer participants were represented in the highest number of trials (n = 13, 37 %). Significant effects in favour of HIIT exercise for improving aerobic fitness, quality of life, pain and diastolic blood pressure were observed (SMD range: 0.25-0.58, all p < 0.01).

CONCLUSIONS

Participation in HIIT exercise was associated with higher retention and improvements in aerobic fitness, quality of life, pain and diastolic blood pressure. The present results provide updated contemporary evidence for clinicians (e.g., exercise physiologists and physiotherapists) to prescribe HIIT exercise for cancer survivors to improve health before, during and following treatment.

Wound dehiscence in enhanced recovery after open radical cystectomy: A meta-analysis

A meta-analysis study to assess the outcome of enhanced recovery (ER) after radical cystectomy (RC) on wound dehiscence was performed. A comprehensive literature examination till January 2023 was implemented and 1457 linked studies were appraised. The picked studies contained 772 open RC subjects in the picked studies' baseline, 436 of them were enhanced recovery after RC, and 336 were open RC. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of enhanced recovery after RC on wound dehiscence after open RC by the dichotomous styles and a fixed or random model. The ER after RC caused significantly lower wound dehiscence (OR, 0.51; 95% CI, 0.30-0.89, P = .02) with low heterogeneity (I2  = 46%) compared with open RC. The ER after RC caused significantly lower wound dehiscence compared with open RC. Thorough precaution should be taken when commerce with the consequences because a limited number of studies were found and selected for this meta-analysis.

Future Perspectives on Prehabilitation Interventions in Cancer Surgery

OBJECTIVE

This article provides a map of key knowledge gaps regarding the evidence supporting prehabilitation and its integration with enhanced recovery after surgery (ERAS) programs. Filling this lack of knowledge with future research will further establish the effectiveness of prehabilitation.

DATA SOURCES

These are electronic databases including PubMed and CINAHL.

CONCLUSION

Future efforts must embrace the elderly frail or cognitively impaired patient with specific needs to further promote restoration of postoperative function throughout the surgical pathway. Prehabilitation should be coupled and integrated within the existent concept of the ERAS framework, to facilitate the continuous evolution of screening, assessment, and optimization of high-risk surgical patients who are at risk of not being restored to physical and psychological function after surgery, including independence.

IMPLICATIONS FOR NURSING PRACTICE

In the future, the ERAS nurse will be an essential figure of the prehabilitation program, proactively coordinating the assessment, optimization, and adjustment of perioperative comorbidity and guiding the rehabilitation process to improve patients' outcomes. These skills and characteristics will be required to provide optimal nursing care in the context of an integrated prehabilitation ERAS pathway.