Efficacy of a multiprofessional rehabilitation programme in radical cystectomy pathways: A prospective randomized controlled trial

What is the role of physical exercise in the era of cancer prehabilitation? A systematic review

PURPOSE

Exercise before surgery, as part of prehabilitation, aiming to enhance patients' functional and physiological capacity, has become widespread, necessitating an in-depth understanding.

METHODS

A systematic search was conducted on Pubmed, Cochrane, and Scopus to examine the effect of exercise as prehabilitation, alone or in combination with other interventions, in patients with cancer. Interventional studies applying a single-arm, randomized controlled, or nonrandomized design were included.

RESULTS

A total of 96 studies were included, and categorized according to cancer types, i.e., gynecological, breast, urological, gastrointestinal and lung cancer. For each cancer site, the effect of exercise, on physical fitness parameters and postoperative outcomes, including length of hospital stay and postoperative complications, was reported.

CONCLUSION

Exercise as prehabilitation may have an important role in improving physical fitness, postoperative outcomes, and accelerating recovery, especially in certain types of malignancies.

Towards a common definition of surgical prehabilitation: a scoping review of randomised trials

BACKGROUND

There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition.

METHODS

The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis.

RESULTS

We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.'

CONCLUSIONS

A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.

The effect of physical therapy and mechanical stimulation on dysfunction of lower extremities after total pelvic exenteration in cervical carcinoma patient with rectovesicovaginal fistula induced by radiotherapy: a case report

BACKGROUND

Total pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes intraoperative complications and postoperative complications. These complications are responsible for the dysfunction of lower extremities, impaired quality of life, and even the high long-term morbidity rate, thus multidisciplinary cooperation and early intervention for prevention of complications are necessary. Physical therapy was found to reduce the postoperative complications and promote rehabilitation, yet the effect on how physiotherapy prevents and treats complications after total pelvic exenteration and pelvic lymphadenectomy remains unclear.

CASE PRESENTATION

A 50-year-old Chinese woman gradually developed perianal and pelvic floor pain and discomfort, right lower limb numbness, and involuntary vaginal discharge owing to recurrence and metastasis of cervical cancer more than half a year ago. Diagnosed as rectovesicovaginal fistula caused by radiation, she received total pelvic exenteration and subsequently developed severe lower limb edema, swelling pain, obturator nerve injury, and motor dysfunction. The patient was referred to a physiotherapist who performed rehabilitation evaluation and found edema in both lower extremities, right inguinal region pain (numeric pain rate scale 5/10), decreased temperature sensation and light touch in the medial thigh of the right lower limb, decreased right hip adductor muscle strength (manual muscle test 1/5) and right hip flexor muscle strength (manual muscle test 1/5), inability actively to adduct and flex the right hip with knee extension, low de Morton mobility Index score (0/100), and low Modified Barthel Index score (35/100). Routine physiotherapy was performed in 2 weeks, including therapeutic exercises, mechanical stimulation and electrical stimulation as well as manual therapy. The outcomes showed that physiotherapy significantly reduced lower limb pain and swelling, and improved hip range of motion, motor function, and activities of daily living, but still did not prevent thrombosis.

CONCLUSION

Standardized physical therapy demonstrates the effect on postoperative complications after total pelvic exenteration and pelvic lymphadenectomy. This supports the necessity of multidisciplinary cooperation and early physiotherapy intervention. Further research is needed to determine the causes of thrombosis after standardized intervention, and more randomized controlled trials are needed to investigate the efficacy of physical therapy after total pelvic exenteration.

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review

BACKGROUND

Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation.

METHODS

MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework.

RESULTS

We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein.

CONCLUSIONS

There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.

Physical Prehabilitation in Patients who Underwent Major Abdominal Surgery: A Comprehensive Systematic Review and Component Network Meta-Analysis Using GRADE and CINeMA Approach

BACKGROUND

Physical prehabilitation is recommended before major abdominal surgery to ameliorate short-term outcomes.

METHODS

A frequentist, random-effects network meta-analysis (NMA) was performed to clarify which type of preoperative physical activity among aerobic exercise (AE), inspiratory muscle training (IMT), and resistance training produces benefits in patients who underwent major abdominal surgery. The surface under the P-score, odds ratio (OR), or mean difference (MD) with a 95% confidence interval (CI) were reported. The results were adjusted by using the component network approach. The critical endpoints were overall and major morbidity rate and mortality rate. The important but not critical endpoints were the length of stay (LOS) and pneumonia.

RESULTS

The meta-analysis included 25 studies. The best approaches for overall morbidity rate were AE and AE + IMT (OR = 0.61, p-score = 0.76, and OR = 0.66, p-score = 0.68). The best approaches for pneumonia were AE + IMT and AE (OR = 0.21, p-score = 0.91, and OR = 0.52, p-score = 0.68). The component analysis confirmed that the best incremental OR (0.30; 95% CI 0.12-0.74) could be obtained using AE + IMT. The best approach for LOS was AE alone (MD - 1.63 days; 95% CI - 3.43 to 0.18). The best combination of components was AE + IMT (MD - 1.70; 95% CI - 2.06 to - 1.27).

CONCLUSIONS

Physical prehabilitation reduces the overall morbidity rate, pneumonia, and length of stay. The most relevant effect of prehabilitation requires the simultaneous use of AE and IMT.

Preoperative optimization of the radical cystectomy patient: Current state and future directions

Radical cystectomy (RC) is associated with high rates of morbidity and mortality despite adoption of robotics and implementation of enhanced recovery after surgery protocols. There have been increased efforts to investigate preoperative optimization through comprehensive nutritional evaluation, preoperative supplementation, and prehabilitation outside of previously described enhanced recovery after surgery protocols to reduce mortality and morbidity from RC. In this review, we summarize and evaluate the current literature on preoperative assessment and optimization in RC.

One-Year Follow-Up after Multimodal Prehabilitation Interventions in Radical Cystectomy

Multimodal prehabilitation is the process of enhancing physiological, nutritional, and psychological resilience to increase patients' functional capacity before major cancer surgery and aims to empower the patient to withstand the pending stress of major surgery and ultimately to improve long-term outcomes. The effect of physical prehabilitation to counteract the physical decline in surgical cancer patients has been documented; however, long-term results have not yet been published. This follow-up study aims to evaluate 1-year results on the efficacy of physical prehabilitation after bladder cancer surgery. The efficacy of prehabilitation was measured over the course of 1 year in 107 patients randomized to (1) pre- and rehabilitation or (2) standard care divided by n = 50 in the intervention (I) and n = 57 in the standard group (S). Physical function was measured by muscle leg power, and nutritional status was expressed with handgrip strength. Prehabilitation in major bladder cancer surgery can significantly improve physical function with 19.8 Watt/kg (p = 0.04), lean body mass (p = 0.047) and body cell mass (p = 0.03), and regained nutritional status one year after surgery. The results demonstrate that the restoration of physical function is vital to a full recovery.

Home-based prehabilitation improves physical conditions measured by ergospirometry and 6MWT in colorectal cancer patients: a randomized controlled pilot study

PURPOSE/BACKGROUND

Prehabilitation aims to improve physical condition in the preoperative period and, therefore, decrease the loss of cardiopulmonary capacity postoperatively, with the aim of reducing complications and promoting an early recovery. This study aims to evaluate the impact of home-based prehabilitation on the physical condition of patients treated surgically for colorectal cancer.

METHODS

A prospective and randomized clinical study was conducted on 60 patients during two periods from October 2018 to February 2019 and from September 2019 to September 2020, in a single university hospital. Patients were randomized into two study groups (30 per group): prehabilitation vs. standard care. Changes in physical condition, measured at diagnosis, the day before surgery, and at 6-8 weeks after surgery using the cardiopulmonary exercise testing (CPET) and the 6-minute walk test (6MWT) were evaluated.

RESULTS

Prehabilitation reduced postoperative complications (17.4% vs. 33.3%, p = 0.22) and hospital stay (5.74 vs. 6.67 days, p = 0.30). 6MWT showed a significant improvement in the prehabilitation group (+78.9 m). Six weeks after surgery, prehabilitation showed a significant improvement in the 6MWT (+68.9 m vs. -27.2 m, p = 0.01). Significant differences were also observed in the ergospirometry between the diagnosis and postoperative study (+0.79 METs vs. -0.84 METs, p = 0.001). A strong correlation was observed between CPET and 6MWT (0.767 (p < 0.001)).

CONCLUSION

Home prehabilitation achieved lower overall postoperative complications than standard care and reached significant improvements in 6MWT and CET. A strong correlation was observed between CET and 6MWT, which allows validation of 6MWT as a valid and reliable measure of functional exercise capacity in colorectal patients when other, more specific and expensive tests are not available.

TRIAL REGISTRATION

Registered in ClinicalTrials.gov in August 2018 with registration number https://clinicaltrials.gov/study/NCT03618329?cond=Prehabilitation%20cancer&term=arroyo&distance=50&rank=1  (NCT03618329). Initial results published in Supportive Care in Cancer: Effect of home-based prehabilitation in an enhanced recovery after surgery program for patients undergoing colorectal cancer surgery during the COVID-19 pandemic. DOI: https://doi.org/10.1007/s00520-021-06343-1 .

Complications After Radical Cystectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials with a Meta-regression Analysis

CONTEXT

Radical cystectomy is considered a procedure of high complexity with a relative high complication rate.

OBJECTIVE

To systematically summarize the literature regarding the complications of radical cystectomy and the factors that contribute to them.

EVIDENCE ACQUISITION

We searched MEDLINE/PubMed, ClinicalTrials.gov, and Cochrane Library, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for randomized controlled trials (RCTs) on complications related to radical cystectomy.

EVIDENCE SYNTHESIS

A total of 3766 studies were screened, and 44 studies were included in this systematic review and meta-analysis. Complications following radical cystectomy are quite common. The most common complications were gastrointestinal complications (20%), infectious complications (17%), and ileus (14%). The majority of complications occurring were Clavien I-II (45%). Specific measurable patient factors are related to certain complications and can be used to stratify risk and assist in preoperative counseling, while proper design of high-quality RCTs may better reflect real-life complication rates.

CONCLUSIONS

In our study, RCTs with a low risk of bias had higher complication rates than studies with a high risk of bias, underlining the need for further improvement on complication reporting in order to refine surgical outcomes.

PATIENT SUMMARY

Radical cystectomy is usually followed by high complication rates, which affect patients and are, in turn, strongly associated with patients' preoperative health status.

Reporting quality of randomized controlled trials in prehabilitation: a scoping review

BACKGROUND

Inadequate study reporting precludes interpretation of findings, pooling of results in meta-analyses, and delays knowledge translation. While prehabilitation interventions aim to enhance candidacy for surgery, to our knowledge, a review of the quality of reporting in prehabilitation has yet to be conducted. Our objective was to determine the extent to which randomized controlled trials (RCTs) of prehabilitation are reported according to methodological and intervention reporting checklists.

METHODS

Eligibility criteria: RCTs of unimodal or multimodal prehabilitation interventions.

SOURCES OF EVIDENCE

search was conducted in March 2022 using MEDLINE, Embase, PsychINFO, Web of Science, CINAHL, and Cochrane.

CHARTING METHODS

identified studies were compared to CONSORT, CERT & Modified CERT, TIDieR, PRESENT, and CONSORT-SPI. An agreement ratio (AR) was defined to evaluate if applicable guideline items were correctly reported. Data were analyzed as frequency (n, %) and mean with standard deviation (SD).

RESULTS

We identified 935 unique articles and included 70 trials published from 1994 to 2022. Most prehabilitation programs comprised exercise-only interventions (n = 40, 57%) and were applied before oncologic surgery (n = 32, 46%). The overall mean AR was 57% (SD: 20.9%). The specific mean ARs were as follows: CONSORT: 71% (SD: 16.3%); TIDieR: 62% (SD:17.7%); CERT: 54% (SD: 16.6%); Modified-CERT: 40% (SD:17.8%); PRESENT: 78% (SD: 8.9); and CONSORT-SPI: 47% (SD: 22.1).

CONCLUSION

Altogether, existing prehabilitation trials report approximately half of the checklist items recommended by methodological and intervention reporting guidelines. Reporting practices may improve with the development of a reporting checklist specific to prehabilitation interventions.

Efficacy and Feasibility of Presurgical Exercise in Bladder Cancer Patients Scheduled for Open Radical Cystectomy

PURPOSE

This study aimed to examine the feasibility and potential efficacy of presurgical exercise in patients with bladder cancer scheduled for open radical cystectomy with follow-up postsurgery.

METHODS

Prospective single-group design with assessments at baseline, presurgery, and 3 months postsurgery was used in this study. Multimodal supervised resistance and aerobic exercise was undertaken 2-3 d·wk -1 at moderate intensity for a median of 3.5 wk (interquartile range [IQR] = 1.3-5.6). Feasibility was assessed by recruitment and completion rates, patient safety, program tolerance, adherence, and compliance. Lean and fat mass were assessed by dual-energy x-ray absorptiometry, physical function by a battery of tests (chest press and leg press strength, 6-min walk test [6MWT], timed up-and-go, repeated chair rise), and quality of life (QoL), psychological distress, and body image by questionnaire. Hospital length of stay (LOS) and complications were assessed by medical records.

RESULTS

Thirty-seven patients were referred with 20 recruited (67.3 ± 12.2 yr) and a presurgery intervention completion rate of 80% (16 of 20). The individual median program adherence was 100.0% (IQR = 89.4-100.0) with compliance of 100.0% (IQR = 90.5-100.0) for resistance exercise and 81.8% (IQR = 55.0-99.5) for aerobic exercise. There were no exercise-related adverse events. Body composition did not change presurgery; however, there were improvements ( P < 0.05) in leg press strength (16%), 6MWT distance (8%), timed up-and-go (12%), chair rise (10%), and multiple QoL domains including mental health. Median LOS was 8.0 d (IQR = 7.0, 15.0). Postsurgery, there were declines in components of QoL and apparent body image dissatisfaction.

CONCLUSIONS

A preradical cystectomy exercise program is feasible, safe, and well tolerated with improvements in physical function and QoL. Supervised multimodal exercise in bladder cancer patients before cystectomy can enhance physical and mental health potentially buffering the effects of surgery.

The effect of the enhanced recovery after surgery program on radical cystectomy: a meta-analysis and systematic review

Background

Bladder cancer is the ninth most common malignant tumor worldwide. As an effective evidence-based multidisciplinary protocol, the enhanced recovery after surgery (ERAS) program is practiced in many surgical disciplines. However, the function of ERAS after radical cystectomy remains controversial. This systematic review and meta-analysis aims to research the impact of ERAS on radical cystectomy.

Methods

A systematic literature search on PubMed, EMBASE, SCOPUS, and the Cochrane Library databases was conducted in April 2022 to identify the studies that performed the ERAS program in radical cystectomy. Studies were selected, data extraction was performed independently by two reviewers, and quality was assessed using a random effects model to calculate the overall effect size. The odds ratio and standardized mean difference (SMD) with a 95% confidence interval (CI) served as the summary statistics for the meta-analysis. A sensitivity analysis was subsequently performed.

Results

A total of 25 studies with 4,083 patients were enrolled. The meta-analysis showed that the complications (OR = 0.76; 95% CI: 0.63-0.90), transfusion rate (OR = 0.59; 95% CI: 0.39-0.90), readmission rate (OR = 0.79; 95% CI: 0.64-0.96), length of stay (SMD = -0.79; 95% CI: -1.41 to -0.17), and time to first flatus (SMD = -1.16; 95% CI: -1.58 to -0.74) were significantly reduced in the ERAS group. However, no significance was found in 90-day mortality and urine leakage.

Conclusion

The ERAS program for radical cystectomy can effectively decrease the risk of overall complications, postoperative ileus, readmission rate, transfusion rate, length of stay, and time to first flatus in patients who underwent radical cystectomy with relative safety.

Systematic Review Registration

https://inplasy.com/, identifier INPLASY202250075.

Barriers and facilitators to physical activity prehabilitation in patients with kidney cancer

PURPOSE

Timely and effective physical activity (PA) prehabilitation is an evidence-based approach for improving a patient's health status preoperatively. Identifying barriers and facilitators to PA prehabilitation can help inform best practices for exercise prehabilitation program implementation. We explore the barriers and facilitators to PA prehabilitation in patients undergoing nephrectomy.

METHODS

A qualitative exploratory study was conducted by interviewing 20 patients scheduled for nephrectomy. Interviewees were selected via convenience sampling strategy. The interviews were semi-structured and discussed experienced and perceived barriers/facilitators to PA prehabilitation. Interview transcripts were imported to Nvivo 12 for coding and semantic content analysis. A codebook was independently created and collectively validated. Themes of barriers and facilitators were identified and summarized in descriptive findings based on frequency of themes.

RESULTS

Five relevant themes of barriers to PA prehabilitation emerged: 1) mental factors, 2) personal responsibilities, 3) physical capacity, 4) health conditions, and 5) lack of exercise facilities. Contrarily, facilitators potentially contributing to PA prehabilitation adherence in kidney cancer included 1) holistic health, 2) social and professional support, 3) acknowledgment of health benefits, 4) exercise type and guidance, and 5) Communication channels.

CONCLUSION AND KEY FINDINGS

Kidney cancer patient's adherence to physical activity prehabilitation is influenced by multiple biopsychosocial barriers and facilitators. Hence, adherence to physical activity prehabilitation requires timely adaptation of health beliefs and behavior embedded in the reported barriers and facilitators. For this reason, prehabilitation strategies should strive to be patient-centered and include health behavioral change theories as underlying frameworks for sustaining patient engagement and self-efficacy.

EffectiveNess of a multimodal preHAbilitation program in patieNts with bladder canCEr undergoing radical cystectomy: protocol of the ENHANCE multicentre randomised controlled trial

INTRODUCTION

Radical cystectomy (RC) is the standard treatment for patients with non-metastatic muscle-invasive bladder cancer, as well as for patients with therapy refractory high-risk non-muscle invasive bladder cancer. However, 50-65% of patients undergoing RC experience perioperative complications. The risk, severity and impact of these complications is associated with a patient's preoperative cardiorespiratory fitness, nutritional and smoking status and presence of anxiety and depression. There is emerging evidence supporting multimodal prehabilitation as a strategy to reduce the risk of complications and improve functional recovery after major cancer surgery. However, for bladder cancer the evidence is still limited. The aim of this study is to investigate the superiority of a multimodal prehabilitation programme versus standard-of-care in terms of reducing perioperative complications in patients with bladder cancer undergoing RC.

METHODS AND ANALYSIS

This multicentre, open label, prospective, randomised controlled trial, will include 154 patients with bladder cancer undergoing RC. Patients are recruited from eight hospitals in The Netherlands and will be randomly (1:1) allocated to the intervention group receiving a structured multimodal prehabilitation programme of approximately 3-6 weeks, or to the control group receiving standard-of-care. The primary outcome is the proportion of patients who develop one or more grade ≥2 complications (according to the Clavien-Dindo classification) within 90 days of surgery. Secondary outcomes include cardiorespiratory fitness, length of hospital stay, health-related quality of life, tumour tissue biomarkers of hypoxia, immune cell infiltration and cost-effectiveness. Data collection will take place at baseline, before surgery and 4 and 12 weeks after surgery.

ETHICS AND DISSEMINATION

Ethical approval for this study was granted by the Medical Ethics Committee NedMec (Amsterdam, The Netherlands) under reference number 22-595/NL78792.031.22. Results of the study will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05480735.

Implementation of a comprehensive prehabilitation program for patients undergoing radical cystectomy

BACKGROUND

Coordinated preoperative optimization programs for radical cystectomy (RC) are limited and non-comprehensive. We evaluated the feasibility and acceptability of a coordinated, multi-faceted prehabilitation program for RC patients at a high-volume bladder cancer referral center.

METHODS

We performed a narrative literature review for prehabilitation in bladder cancer management as of December 1, 2020, with specific emphasis on examining higher-level evidence sources. We selected domains with the highest level of evidence and recruited a multidisciplinary team of experts to design our program. We implemented a comprehensive prehabilitation program with a pre-defined order set as standard of care for all patients undergoing RC beginning February 1, 2021. Demographic and clinicopathologic data were collected prospectively. Rates of adherence to the prehabilitation program services were analyzed using Stata version 13.

RESULTS

A total of 82 patients were enrolled between February - December 2021, of which 67 (81%) had undergone RC at data cutoff. Mean age was 68 years (SD 11) and 63 (76%) identified as male. Neoadjuvant chemotherapy (NAC) was utilized in 48 (59%) patients. The mean Charlson Comorbidity Index was 3.8 (SD 2.3). 100% of patients were screened for malnutrition, with 82% consuming nutritional supplements. Fifty-two percent of patients attended physical therapy pre-op. The 30-day and 30- to 90-day rates of complications were 56% and 40%, respectively. Resource length of stay (RLOS) declined after implementation of prehabilitation.

CONCLUSIONS

Implementation of a comprehensive prehabilitation program at a high-volume bladder cancer referral center is feasible and has a modest effect on resource consumption and complications in our early experience.

The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis

BACKGROUND

For patients undergoing abdominal surgery, multimodal prehabilitation, including nutrition and exercise interventions, aims to optimize their preoperative physical and physiological capacity. This meta-analysis aims to explore the impact of multimodal prehabilitation on surgical and functional outcomes of abdominal surgery.

METHODS

Medline, Embase and CENTRAL were searched for articles about multimodal prehabilitation in major abdominal surgery. Primary outcomes were postoperative complications with a Clavien-Dindo score ≥3, and functional outcomes, measured by the 6-Minute Walking Test (6MWT). Secondary outcome measures included the quality-of-life measures. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated, with DerSimonian and Laird random effects used to account for heterogeneity.

RESULTS

Twenty-five studies were included, analysing 4,210 patients across 13 trials and 12 observational studies. Patients undergoing prehabilitation had significantly fewer overall complications (RR = 0.879, 95% CI 0.781-0.989, p = 0.034). There were no significant differences in the rates of wound infection, anastomotic leak and duration of hospitalization. The 6MWT improved preoperatively in patients undergoing prehabilitation (SMD = 33.174, 95% CI 12.674-53.673, p = 0.005), but there were no significant differences in the 6MWT at 4 weeks (SMD = 30.342, 95% CI - 2.707-63.391, p = 0.066) and 8 weeks (SMD = 24.563, 95% CI - 6.77-55.900, p = 0.104) postoperatively.

CONCLUSIONS

As preoperative patient optimization shifts towards an interdisciplinary approach, evidence from this meta-analysis shows that multimodal prehabilitation improves the preoperative functional capacity and reduces postoperative complication rates, suggesting its potential in effectively optimizing the abdominal surgery patient. However, there is a large degree of heterogenicity between the prehabilitation interventions between included articles; hence results should be interpreted with caution.

Role of prehabilitation following major uro-oncologic surgery: a narrative review

PURPOSE

Functional status and physical independence play a key role in terms of quality of life, access to treatment, and continuity of care. Surgery, a central component of cancer treatments, leads to detrimental effects on functional capacity, which can be peculiarly relevant in vulnerable patients undergoing major procedures. Prehabilitation is a multidisciplinary intervention that uses the preoperative period to prevent or attenuate treatment-related functional decline and its subsequent consequences. This paper narratively reviews the rationale and the evidence of prehabilitation for uro-oncologic surgery.

METHODS

A narrative review was conducted in August 2020, aiming to: (1) identify and discuss the impact of modifiable determinants of postoperative outcomes in urology and (2) review randomized controlled trials (RCT) exploring the role of preoperative exercise, nutrition, and psychological interventions in uro-oncologic surgery.

RESULTS

Eight RCTs on preoperative conditioning interventions met the inclusion criteria, focusing on radical cystectomy for bladder cancer (RC) and radical prostatectomy for prostate cancer (RP). There is strong evidence that poor physical, nutritional and psychosocial status negatively impacts on surgical outcomes. Single modality interventions, such as preoperative exercise or nutrition alone, had no effect on 'traditional' surgical outcomes as length of stay or complication. However, multimodal approaches targeting postoperative functional status have shown to be effective and safe.

CONCLUSION

There is initial evidence on the effectiveness and safety of multimodal prehabilitation in preserving functional capacity following RC and RP. However, to date, outcomes such as complications and length of stay seem to be not affected by prehabilitation.

STRONG for Surgery & Strong for Life - against all odds: intensive prehabilitation including smoking, nutrition, alcohol and physical activity for risk reduction in cancer surgery - a protocol for an RCT with nested interview study (STRONG-Cancer)

Background

There is a large unused potential for risk reduction in the preoperative period via effective lifestyle intervention targeting co-existing risky lifestyles: Smoking, malNutrition, obesity, risky Alcohol intake and insufficient Physical activity (SNAP).

This trial compares the efficacy of the integrated STRONG programme with standard care on preoperative risk reduction and secondly on SNAP factor improvement and frailty, postoperative complications and quality of life. A nested interview study explores the patient preferences and the multi-perspective view of patients, relatives and health professionals.

Methods

In total, 42 surgical patients with ≥1 SNAP factor are allocated to individually tailored STRONG programme or usual care during adjuvant chemotherapy prior to radical bladder cancer surgery. The STRONG programme has ≥6 weekly sessions with patient education, motivational and pharmaceutical support. It is based on intensive smoking and alcohol cessation interventions reporting perioperative quit rates > 50%.

Surgical risk reduction is measured as ≥1 step for 1 or more risky lifestyles on the ASA-score, secondly as having no risky SNAP factors, and as any SNAP improvement. The outcomes are validated by measurements and biomarkers. Postoperative complications are categorised according to the Clavien-Dindo classification. Health-related quality of life is measured by EQ-5D.

The patients are followed up after 6 weeks at surgery and 6 weeks and 6 months postoperatively.

A representative sample of the participants, their relatives and the clinical staff are interviewed until data saturation. Transcription, triangulated analyses and data management are conducted using NVivo computer software.

Discussion

The surgical agenda is characterised by fixed dates for surgery focusing on clear risk reduction within a short time. This requires a clinical useful lifestyle intervention programme with a high effect and coverage as well as containing all SNAP factors and tailored to individual needs.

The STRONG programme seems to meet these requirements. After development in multi-professional collaboration, STRONG is delivered by a specially trained nurse as part of the surgical patient journey.

Overall, this study will bring important new knowledge about risk reduction in a frail patient group undergoing major cancer surgery.

Trial registration

Registration at www.clintrials.gov (NCT04088968)

The manuscript form from https://trialsjournal.biomedcentral.com/bmc/journal and the SPIRIT guidelines are followed.

Efficacy of Pre and Rehabilitation in Radical Cystectomy on Health Related Quality of Life and Physical Function, A Systematic Review

Objective

Methods

Results

Conclusions

•

There is no significant association between pre and/ or rehabilitation interventions and global HRQoL.

•

Physical prehabilitation interventions can improve physical function before radical cystectomy.

•

Enteral nutrition reduces risk such as sarcopenia, frailty and increase benefits to the patient.

•

Pre- and postoperative stoma education is effective and impacts significantly on self-efficacy.

•

Cognitive interventions focusing on depression and anxiety should be addressed in future research.

Updates on enhanced recovery after surgery for radical cystectomy

Enhanced Recovery after Surgery (ERAS) is a multimodal pathway that provides evidence-based guidance for improving perioperative care and outcomes in patients undergoing surgery. In 2013, the ERAS society released its original guidelines for radical cystectomy (RC) for bladder cancer (BC), adopting much of its supporting data from colorectal literature. In the last decade, growing interest in ERAS has increased RC-specific ERAS research, including prospective randomized controlled trials (RCTs). Collective data suggest ERAS contributes to improved complication rates, decreased hospital length-of-stay, and/or time to bowel recovery. Various institutions have adopted modified versions of the ERAS pathway, yet there remains a lack of consensus on the efficacy of specific ERAS items and standardization of the protocol. In this review, we summarize updated evidence and practice patterns of ERAS pathways for RC since the introduction of the original 2013 guidelines. Novel target interventions, including use of immunonutrition, prehabilitation, alvimopan, and methods of local analgesia are reviewed. Finally, we discuss barriers to implementing and future steps in advancing the ERAS movement.

Bladder cancer and exeRcise trAining during intraVesical thErapy-the BRAVE trial: a study protocol for a prospective, single-centre, phase II randomised controlled trial

INTRODUCTION

Non-muscle invasive bladder cancer (NMIBC) accounts for about 75% of newly diagnosed bladder cancers. The treatment for NMIBC involves surgical removal of the tumour followed by 6 weekly instillations of immunotherapy or chemotherapy directly into the bladder (ie, intravesical therapy). NMIBC has a high rate of recurrence (31%-78%) and progression (15%). Moreover, bladder cancer and its treatment may affect patient functioning and quality of life. Exercise is a safe and effective intervention for many patient with cancer groups, however, no studies have examined exercise during intravesical therapy for NMIBC. The primary objective of the Bladder cancer and exeRcise trAining during intraVesical thErapy (BRAVE) trial is to examine the safety and feasibility of an exercise intervention in patients with bladder cancer undergoing intravesical therapy. The secondary objectives are to investigate the preliminary efficacy of exercise on health-related fitness and patient-reported outcomes; examine the social cognitive predictors of exercise adherence; and explore the potential effects of exercise on tumour recurrence and progression.

METHODS AND ANALYSIS

BRAVE is a phase II randomised controlled trial that aims to include 66 patients with NMIBC scheduled to receive intravesical therapy. Participants will be randomly assigned to the exercise intervention or usual care. The intervention consists of three supervised, high-intensity interval training sessions per week for 12 weeks. Feasibility will be evaluated by eligibility, recruitment, adherence and attrition rates. Preliminary efficacy will focus on changes in cardiorespiratory fitness and patient-reported outcomes from baseline (prior to intravesical therapy) to pre-cystoscopy (3 months). Cancer outcomes will be tracked at 3 months, and 1-year follow-up by cystoscopy. Analysis of covariance will compare between-group differences at post-intervention (pre-cystoscopy) for all health-related fitness and patient-reported outcomes.

ETHICS AND DISSEMINATION

The study was approved by the Health Research Ethics Board of Alberta-Cancer Committee (#20-0184). Dissemination will include publication and presentations at scientific conferences and public channels.

TRIAL REGISTRATION NUMBER

NCT04593862; Pre-results.

The Impact of Physical Activity on Risk and Health-Related Quality of Life in Bladder Cancer

BACKGROUND: Sedentarism is an important modifiable risk factor in the struggle against cancer. In the last decades, the relationship between physical activity and different types of cancer has been investigated in depth. OBJECTIVE: To provide an overview of the literature on the effectiveness of physical activity in reducing the risk to develop bladder cancer and improving health-related quality of life in patients. METHODS: A systematic review was conducted through a search of the Embase, Cochrane, PubMed, Scopus, and Web of Science (WOS) databases to seek information and PRISMA system to delimitate the research. Outcomes included in searches were physical activity, tobacco consumption, obesity, body mass index, and metabolic syndrome, associated with bladder cancer and quality of life. RESULTS: Database searches identified 394 records, of which 75 were duplicated. A total of 280 articles were excluded based on abstract screening. An additional 16 full-text articles were excluded because they did not meet the eligibility criteria. Overall, 21 of the 23 studies included in the review reported beneficial effects of physical activity in bladder cancer. The majority of papers found that physical activity is a significant factor in reducing the risk of bladder cancer. Moreover, physical activity improves health-related quality of life in bladder cancer survivors, and diminishes both recurrence and mortality in those who engage in regular activity. Lastly, physical inactivity is associated with increased body mass index, obesity, metabolic syndrome, type 2 diabetes and unfavourable energy balance, which led to a greater probability of suffering from bladder cancer. CONCLUSIONS: These data reinforce the importance of promoting a healthy lifestyle to reduce the risk of bladder cancer and to improve survivorship and health-related quality of life of patients.

Supportive care needs and utilization of bladder cancer patients undergoing radical cystectomy: A longitudinal study

OBJECTIVES

Investigating supportive care (SC) needs and utilization/willingness to use SC services from diagnosis to one year after radical cystectomy in bladder cancer (BC) patients. MATERIALS & METHODS: A longitudinal cohort study was conducted in 90 BC patients at Ghent/Leuven University Hospitals between April 2017 and December 2020. The Supportive Care Needs Survey-short form (SCNS-SF34) was used before radical cystectomy, one, three, six and 12 months after radical cystectomy. Additional questions assessed utilization/willingness to use SC services. Linear mixed models were performed.

RESULTS

The majority of BC patients report at least one moderate or high SC need at diagnosis (82%), month 1 (84%), month 3 (86%), month 6 (64%), and month 12 (60%). Significant decreases over time were seen for all domains (p < 0.001), except for sexuality (p = 0.275). From baseline to month 1, physical needs first significantly increased (p = 0.001) after which they decreased. Psychological (e.g. fears about the future) and informational (e.g. information on how to get better) needs were most common at baseline whereas physical (e.g. lack of energy) and informational needs were more common in the early postoperative phases. The majority of patients (ranging from 81% (month 1) to 91% (month 12)) did not make use of SC services and the majority of the patients (ranging from 81% (month 1) to 88% (month 12)) did not wish to talk about their problems to someone. Those willing to talk to someone preferred their physician.

CONCLUSIONS

A clear gap exists between the large proportion of SC needs experienced by BC patients undergoing radical cystectomy and the low use of SC services.

Psoas Muscle Mass can Predict Postsurgical Outcomes in Patients Who Undergo Radical Cystectomy and Urinary Diversion Reconstruction

OBJECTIVE

To morphometrically measure to muscle mass which may reflect physical components of frailty. Hence, we evaluated the association between L4 total psoas area (TPA) and operative outcome after radical cystectomy (RC) for bladder cancer.

METHODS

In a retrospective single-center study, bladder cancer patients who underwent RC and urinary diversion between 2007 and 2012 were enrolled. TPA was evaluated in the cross-sectional imaging. The psoas muscles were normalized with the height. Male patients with a psoas mass index ≤7.4 cm²/m² and female patients with a psoas mass index ≤5.2 cm²/m² were classified as sarcopenic. Outcome measures were 30- and 90-day readmission and complications, and survival. Multivariable logistic and Cox proportional-hazards regression models were used to determine relevant predictors.

RESULTS

The median age of the 441 participants and follow up time was 68 years (IQR 59-75) and 1.2 years (IQR 0.5-1.9), respectively. One hundred forty-three patients (32.4%) were sarcopenic. The 30-day readmission and the complication rates were 13.8% and 44.7%, respectively. The 90-day readmission and complication rates were 23.9% and 53.1%, respectively. The 1-year mortality rate was 11.6% (95%CI 8.7-15.4). Multivariable logistic regression analysis revealed an association between increased TPA and lower odds of 30-day complications after RC (OR 0.95, 95%CI 0.92-0.99, P = .02); similarly, an increase in TPA was of prognostic value, although not statistically significant in the multivariable model (P = .05) once adjusting for other patient factors.

CONCLUSION

Sarcopenia predicted early complications and showed an informative trend for overall survival after RC, and thus may inform models predicting postsurgical outcomes.

Prehabilitation for Bariatric Surgery: A Randomized, Controlled Trial Protocol and Pilot Study

Bariatric surgery is the most efficacious treatment for obesity, though it is not free from complications. Preoperative conditioning has proved beneficial in various clinical contexts, but the evidence is scarce on the role of prehabilitation in bariatric surgery. We describe the protocol and pilot study of a randomized (ratio 1:1), parallel, controlled trial assessing the effect of a physical conditioning and respiratory muscle training programme, added to a standard 8-week group intervention based on therapeutical education and cognitive-behavioural therapy, in patients awaiting bariatric surgery. The primary outcome is preoperative weight-loss. Secondary outcomes include associated comorbidity, eating behaviour, physical activity, quality of life, and short-term postoperative complications. A pilot sample of 15 participants has been randomized to the intervention or control groups and their baseline features and results are described. Only 5 patients completed the group programme and returned for assessment. Measures to improve adherence will be implemented and once the COVID-19 pandemic allows, the clinical trial will start. This is the first randomized, clinical trial assessing the effect of physical and respiratory prehabilitation, added to standard group education and cognitive-behavioural intervention in obese patients on the waiting list for bariatric surgery. Clinical Trial Registration: NCT0404636.

A preliminary outcome of modified enhanced recovery protocol versus standard of care in radical cystectomy: an Indonesian experience

Background

This study aimed to evaluate the outcomes of modified Enhanced Recovery After Surgery (ERAS) protocol and standard of care (SC) in bladder cancer patients who underwent radical cystectomy (RC). The length of stay and complications rates were the primary outcomes. Time functional recovery, bowel movement, mobilization, drain removal, and other perioperative outcomes were the secondary outcomes.

Methods

A cohort retrospective study was conducted to investigate the effectiveness of the modified ERAS protocol compared to SC in 61 patients who underwent RC (36 ERAS vs. 25 SC).

Results

The modified ERAS protocol was associated with shorter length of stay (9.3 ± 5.0 days vs. 12.6 ± 6.7 days, P = 0.032) and reduction in important postoperative milestones, including days to first solid diet (3.5 ± 1.6 vs. 5.5 ± 1.5, P = 0.000), days to first defecation (4.8 ± 2.4 vs. 7.2 ± 2.4, P = 0.001), days to first walking (4.7 ± 2.2 vs. 7.9 ± 2.4, P = 0.000), and days to drain removal (3.9 ± 1.3 vs. 5.9 ± 2.5 P = 0.001). Postoperative complications rates were lower in the modified ERAS groups, but the result was not statistically significant (P = 0.282). Also, there were no significant differences between transfusion requiring, intensive care monitoring, re-operation, and re-admission between groups.

Conclusion

This study demonstrated that the modified ERAS protocol for RC can accelerate postoperative recovery without any adverse effects on morbidity and mortality.

Enhanced Recovery After Surgery and Radical Cystectomy: A Systematic Review and Meta-Analysis

Introduction

Enhanced recovery after surgery (ERAS) protocols aim to optimize patient recovery after major surgery. Our study was to examine the evidence of the effectiveness of interventions designed to improve patient outcomes after radical cystectomy.

Design

Systematic review and meta-analysis.

Data Sources

PubMed, Medline, Embase, Cochrane from January 2005 to January 2021 without language restrictions.

Eligibility Criteria

Randomized and non-randomized controlled studies implementing ERAS measuring its interventions on rates of postoperative complications, 30-day readmission, length of stay (LOS) and bowel function after radical cystectomy.

Data Extraction and Synthesis

Two members of the investigating team independently selected studies and evaluated bias using the Cochrane collaboration tool. Meta-analysis of all comparative studies used inversed-weighted, fixed- effects models and random effects models to pool results. Publication bias was graphically assessed using contour-enhanced funnel plots and the Egger’s test of funnel plot symmetry.

Results

Fifteen studies were included in our meta-analysis; we observed that ERAS decreased the time for the first bowel movement (standardized mean difference [SMD]: –1.30, 95% CI −1.90 to −0.70, P<0.00001) and shortened the length of stay (LOS) ([SMD]: –0.49, 95% CI −0.77 to −0.20, (P < 0.00001)); however, 30-day readmission (risk ratio [RR]: 0.97,95% [CI] 0.73 to 1.28, P=0.52) and the overall postoperative complication rate (risk ratio [RR]: 0.98,95% confidence interval [CI]: 0.88 to 1.09, P= 0.41) showed no significant difference.

Prehabilitation Exercise Before Urologic Cancer Surgery: A Systematic and Interdisciplinary Review

CONTEXT

The Consensus on Therapeutic Exercise Training (CONTENT) scale assesses the therapeutic validity of exercise programs. To date, prehabilitation exercise programs for heath optimization before urologic cancer surgeries have not been assessed for therapeutic validity or efficacy.

OBJECTIVE

To systematically assess prehabilitation exercise programs before urologic cancer surgery for therapeutic validity and efficacy, informing discussion of best practices for future intervention.

EVIDENCE ACQUISITION

A systematic review was performed using Ovid, Embase, Web of Science, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases through June 2020. The review included prospective (randomized controlled and uncontrolled) trials where patients were enrolled in prehabilitation exercise programs before urologic cancer surgery. The primary outcomes of interest included therapeutic validity and efficacy (measures of cardiorespiratory fitness and postsurgical outcomes). Studies were evaluated for the risk of bias. A narrative synthesis was carried out given heterogeneity in populations, interventions, and outcomes across studies.

EVIDENCE SYNTHESIS

Ten unique studies and two associated post hoc analyses met the inclusion criteria. Seven studies demonstrated therapeutic validity. Eight demonstrated a high risk of bias. All demonstrated significant improvement in cardiorespiratory fitness. Four of five studies evaluating quality of life observed significant improvements. To date, zero trials have demonstrated reduction in postsurgical complications, mortality, length of stay, or readmission rates following prehabilitation exercise interventions.

CONCLUSIONS

While prehabilitation exercise may result in improved cardiorespiratory fitness and quality of life, current studies have yet to demonstrate impact on surgical outcomes. When designing prehabilitation exercise programs for use before urologic cancer surgery, the therapeutic validity of the intervention should be considered. Future prehabilitation studies should employ standardized content rubrics to ensure therapeutic validity. Consensus is needed regarding the appropriate outcomes to adjudicate prehabilitation efficacy.

PATIENT SUMMARY

In this report, we looked at the effectiveness and quality of prehabilitation exercise programs before urologic cancer surgery. We found that these programs effectively improve presurgical fitness, but may benefit from the use of structured methodology and outcome assessment to understand their potential to improve surgical outcomes.

A multimodal prehabilitation program in high-risk patients undergoing elective resection for colorectal cancer: A retrospective cohort study

AIM

Up to 50% of the patients experience complications after colorectal cancer (CRC) surgery. Improved preoperative physical and nutritional status can enhance clinical outcomes and reduce postoperative complications. This retrospective, single-center, observational cohort study assessed the impact of a four-week multimodal prehabilitation program on postoperative complications, unplanned readmissions, length of stay, and mortality in elective high-risk CRC patients.

METHOD

Elective high-risk CRC patients, defined as ASA ≥3 or ≥65yr, who attended the multimodal prehabilitation program (prehabilitation-group) were compared to a historical cohort receiving standard care (control-group). Differences in outcomes between these groups were tested using Fisher's Exact and Mann-Whitney U test. To adjust for confounding, multivariate logistic regression analysis was performed. The main study outcome was the occurrence of postoperative complications. Secondary outcomes included unplanned readmissions, length of hospital stay, and mortality.

RESULTS

351 patients were included (n = 275 control-group, n = 76 prehabilitation-group). The complication rate was lower in the prehabilitation group compared to the control group, 26.3% (n = 20) versus 40% (n = 110) (p = .032). There were fewer unplanned readmissions in the prehabilitation group compared to the control group, 5.3% (n = 4) versus 16.4% (n = 45), p = .014. Median hospital days of stay was 1 day shorter for the prehabilitation-group (p = .004), mortality did not significantly differ between the groups.

CONCLUSION

This study shows that the used multimodal prehabilitation program leads to a reduction of medical postoperative complications, unplanned readmissions, and shortens the median hospital stay compared with standard care in high-risk CRC patients undergoing elective CRC surgery.

Efficacy of Prehabilitation Including Exercise on Postoperative Outcomes Following Abdominal Cancer Surgery: A Systematic Review and Meta-Analysis

Objectives: This systematic review set out to identify, evaluate and synthesise the evidence examining the effect of prehabilitation including exercise on postoperative outcomes following abdominal cancer surgery. Methods: Five electronic databases (MEDLINE 1946-2020, EMBASE 1947-2020, CINAHL 1937-2020, PEDro 1999-2020, and Cochrane Central Registry of Controlled Trials 1991-2020) were systematically searched (until August 2020) for randomised controlled trials (RCTs) that investigated the effects of prehabilitation interventions in patients undergoing abdominal cancer surgery. This review included any form of prehabilitation either unimodal or multimodal that included whole body and/or respiratory exercises as a stand-alone intervention or in addition to other prehabilitation interventions (such as nutrition and psychology) compared to standard care. Results: Twenty-two studies were included in the systematic review and 21 studies in the meta-analysis. There was moderate quality of evidence that multimodal prehabilitation improves pre-operative functional capacity as measured by 6 min walk distance (Mean difference [MD] 33.09 metres, 95% CI 17.69-48.50; p = <0.01) but improvement in cardiorespiratory fitness such as preoperative oxygen consumption at peak exercise (VO2 peak; MD 1.74 mL/kg/min, 95% CI -0.03-3.50; p = 0.05) and anaerobic threshold (AT; MD 1.21 mL/kg/min, 95% CI -0.34-2.76; p = 0.13) were not significant. A reduction in hospital length of stay (MD 3.68 days, 95% CI 0.92-6.44; p = 0.009) was observed but no effect was observed for postoperative complications (Odds Ratio [OR] 0.81, 95% CI 0.55-1.18; p = 0.27), pulmonary complications (OR 0.53, 95% CI 0.28-1.01; p = 0.05), hospital re-admission (OR 1.07, 95% CI 0.61-1.90; p = 0.81) or postoperative mortality (OR 0.95, 95% CI 0.43-2.09, p = 0.90). Conclusion: Multimodal prehabilitation improves preoperative functional capacity with reduction in hospital length of stay. This supports the need for ongoing research on innovative cost-effective prehabilitation approaches, research within large multicentre studies to verify this effect and to explore implementation strategies within clinical practise.

The Use of Theory to Develop Physical Activity Interventions in Urological Cancer Survivors: A Narrative Review

OBJECTIVES

To summarize the current available evidence on the use of behavior change theories to explain and change physical activity behavior in urological cancer survivors.

DATA SOURCES

Five electronic databases including Medline, Web of Science, Embase, Cochrane, and Psych INFO and reference lists of key studies were searched between database inception and November 2020. Peer-reviewed articles on the use of behavior change theories to understand or change physical activity in urological cancer survivors were included.

CONCLUSION

The theory of planned behavior and the social cognitive theory were the most used theories to explain and change physical activity behavior in urological cancers, respectively. However, the use of behavior change theories in physical activity interventions for urological cancers is still low across all urological tumor groups. Planning frameworks such as the intervention mapping approach should be used to enhance the systematic use of behavior change theories during every phase of intervention development. In addition, more research is needed to identity which behavior change techniques are most effective to change physical activity behavior in urological cancer survivors.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a key role in the urological cancer patients' clinical pathway and should be able to motivate patients to engage in sufficient physical activity levels. Therefore, it is important that nurses understand the underlying reasons why patients (do not) engage in physical activity and which behavior change techniques are most effective in changing a patients' behavior.

The Potential of Prehabilitation in Radical Cystectomy Pathways: Where Are We Now?

OBJECTIVE

The growing recognition of prehabilitation has caused an emerging paradigm shift in surgical cancer care and an integrated component of the cancer care continuum. This narrative review aims to update and inform the urological community of the potential of prehabilitation before radical cystectomy.

DATA SOURCES

A nonsystematic narrative review was performed through a database search in PubMed, and CINAHL using the following search terms: enhanced recovery after surgery (ERAS); Frailty; Prehabilitation and/or Rehabilitation; Physical Activity and/or exercises; Nutrition; Nutritional Care; Smoking cessation; Alcohol cessation; Prevention; Supportive Care; and combined with Radical Cystectomy.

CONCLUSION

A multimodal and multi-professional approach during the preoperative period may offer an opportunity to preserve or enhance physiological integrity and optimize surgical recovery. Studies indicate a positive effect of prehabilitation on postoperative functional capacity and earlier return to daily activities and health related quality of life. Meaningful outcomes that reflect recovery from a patient's perspective and clinical outcome measures, as well as validating metrics, are necessary to establish whether prehabilitation diminish the risk of developing long-term disability in high-risk patients.

IMPLICATIONS FOR NURSING PRACTICE

Uro-oncology nurses are at the forefront in every ERAS program and vital in screening patients ahead of surgery for common risk factors, current impairments, and limitations that can compromise baseline functional capacity. The growing movement to standardize clinical implementation of prehabilitation, indicate there is a clear need for further investigation, optimization of a multimodal approach and an open discussion between health care providers from different areas of expertise who might best support and promote these initiatives.

Nursing Implication of People Treated by Radical Cystectomy Postsurgery and Rehabilitation

OBJECTIVE

The purpose of this paper is to summarize existing evidence about nursing interventions to selected symptoms experienced by patients undergoing radical cystectomy (RC) to maintain or return to their daily life activities.

DATA SOURCES

A non-systematic narrative review was conducted. A search in PubMed and CINAHL was conducted eliciting evidence about frequent symptoms experienced after RC. The following search terms were used: radical cystectomy and/or nursing interventions, pain, distress, fatigue, urinary dysfunction, sexual dysfunction, loss of appetite, sleep disturbance, and enhanced recovery after surgery (ERAS).

CONCLUSION

Evidence in the ERAS pathway is still lacking regarding the effect of preoperative education and counseling of the patient and the most difficult part to implement is related to preoperative optimization of the patient such as lifestyle changes. Most nursing interventions to alleviate symptoms in the rehabilitation period after RC are still practice based.

IMPLICATIONS FOR NURSING PRACTICE

Priority should be given to implementation of the ERAS protocol. To improve the management of symptoms experienced by patients in the RC rehabilitation period it is essential that validated screening tools to identify the symptoms be used. Accepted and effective strategies for treating the individual symptoms should be initiated and clear treatment outcomes should be defined. Urology nurse researchers should investigate the concept of symptom clusters to clarify whether there are more efficient methods to identify symptoms or symptom clusters and if so would the use of symptom clusters knowledge improve patient care.

Enhanced recovery after surgery of patients undergoing radical cystectomy for bladder cancer

Radical cystectomy (RC) is the standard treatment for patients diagnosed with muscle invasive bladder cancer, but is associated with significant morbidity and long hospital stays. Enhanced recovery after surgery (ERAS) is based on a variety of interventions during the peri-treatment stage. It is designed to improve morbidity, enhance recovery, and reduce hospital stays after RC. The study provides an overview of the key elements of the ERAS protocol recommended for patients undergoing RC and directions for further research. We have analyzed the rationale for 15 key elements related to the ERAS protocol: preoperative patient counseling and education, preoperative medical optimization and nutrition, mechanical bowel preparation, preoperative fasting and carbohydrate loading, pre-anesthetic medication, thromboembolic prophylaxis, minimally invasive surgical approach, resection-site drainage, preventing intraoperative hypothermia, perioperative fluid management, perioperative analgesia, urinary drainage, prevention of postoperative ileus, nausea and vomiting, early oral feeding, and early mobilization. Several studies have shown that ERAS improves the recovery of RC patients. Evidence suggests that ERAS facilitates the recovery of RC patients. However, additional randomized controlled studies or large prospective studies are needed to demonstrate the effectiveness of ERAS in RC patients.

Optimal Delivery of Follow-Up Care After Radical Cystectomy for Bladder Cancer

Purpose of Review

To identify components representing optimal delivery of follow-up care after radical cystectomy because of bladder cancer and report the current level of evidence.

Methods

We conducted a systematic literature search of the following databases: Cochrane, MEDLINE, Embase, CINAHL, Web of Science, Physiotherapy Evidence Database and ClinicalTrials.gov. The search results were managed in Covidence Reference Manager and abstracts were screened by title. Articles relevant to the subject of interest were included and the results are reported narratively.

Results

Several studies have evaluated the positive impact of enhanced recovery after surgery (ERAS) on length of stay, albeit not on the further impact on 90-day postoperative complication rate, functional recovery, or mortality. Minimally invasive surgery may result in a slighter shorter length of stay compared to open surgery. Physical training combined with nutritional intervention can improve functional recovery up to one year after surgery. Nutritional supplements can preserve muscle and bone mass, and potentially improve recovery. Patient education in stoma care and prevention of infection can significantly improve self-efficacy and avoid symptoms of infection postoperatively. Moreover, specific devices like applications (apps) can support these efforts. Continued smoking increases the risk of developing postoperative complications while no evidence was found on the impact of continued alcohol drinking. Currently, there is no evidence on psychological well-being, sexual health, or shared decision making interventions with an impact on rehabilitation after radical cystectomy.

Conclusion

Data are scarce but indicate that peri- and postoperative multi-professional interventions can reduce prevalence of sarcopenia, and improve functional recovery, physical capacity, nutritional status, and self-efficacy in stoma care (level 1 evidence). Continued smoking increases the risk of complications, but the effects of a smoking and alcohol intervention remain unclear (level 3 evidence). The results of this review provide guidance for future directions in research and further attempts to develop and test an evidence-based program for follow-up care after radical cystectomy.

Systematic Review and Meta-Analysis of the Efficacy and Safety of Enhanced Recovery After Surgery vs. Conventional Recovery After Surgery on Perioperative Outcomes of Radical Cystectomy

Background and objective: Radical cystectomy has been characterized as the most difficult operation in urology because of the complex surgical procedures and postoperative complications. Enhanced recovery after surgery (ERAS), which reduces the incidence of perioperative complications, has been widely used in clinical surgery. Herein, we performed a meta-analysis to evaluate the efficacy and safety of ERAS vs. conventional recovery after surgery (CRAS) on perioperative outcomes of radical cystectomy. Methods: We performed a systematic search of randomized controlled trials (RCTs) in the following databases: Medline, Embase, and the Cochrane Controlled Trials Register, based on the PICOS strategy. The reference lists of the retrieved studies were further surveyed for relevant publications. Results: Our search yielded seven RCTs containing 813 patients. The ERAS group was found to have better performance in the following parameters: length of hospital stay [mean difference (MD) = -1.12, 95% confidence interval (CI): -1.80 to -0.45, P = 0.001], time to first flatus (MD = -0.70, 95% CI: -0.98 to 0.41, P < 0.00001), and time to regular diet (MD = -0.12, 95% CI: -1.76 to -0.28, P = 0.007). However, there were no significant differences between the two groups in major complications [odds ratio (OR) = 0.91, 95% CI: 0.63 to 1.34, P = 0.64], readmission (OR = 1.15, 95% CI: 0.65 to 2.01, P = 0.63), ileus (OR = 0.75, 95% CI: 0.44 to 1.28, P = 0.29), wound infection (OR = 0.56, 95% CI: 0.31 to 1.01, P = 0.05), mortality (OR = 0.69, 95% CI: 0.24 to 1.99, P = 0.49), or time to first bowel movement (MD = -0.55, 95% CI: -1.62 to 0.53, P = 0.32). Conclusion: ERAS reduced the length of hospital stay, time to first flatus, and time to regular diet after cystectomy. Compared to CRAS protocols, ERAS protocols do not increase the risk of adverse events.

Impact of Perioperative Multidisciplinary Rehabilitation Pathway on Early Outcomes after Robot-assisted Radical Cystectomy: A Matched Analysis

OBJECTIVE

To investigate the effect of incorporating physical rehabilitation, nutrition and psychosocial care as part of the "NEEW" (Nutrition, Exercise, patient Education and Wellness) on perioperative outcomes after robot-assisted radical cystectomy.

METHODS

Patients were divided into 2 groups: pathway group (NEEW in addition to enhanced recovery after surgery), vs prepathway group, before NEEW initiation (enhanced recovery after surgery only). Propensity score matching was performed (ratio 1:2 ratio). Perioperative outcomes were analyzed and compared. Multivariate analyses were modeled to assess for association between NEEW pathway and postoperative outcomes.

RESULTS

One hundred and niney-two were included in the study: 64 patients (33%) in the pathway group vs 128 patients (67%) in the prepathway group. Pathway group had shorter median inpatient stay (5 vs 6 days, P <.01), faster bowel recovery (3 vs 4 days, P <.01), and better pain scores, and demonstrated fewer 30-day high grade complications (5% vs 16%, P = .02). On multivariate analysis, the NEEW pathway was associated with shorter hospital stay (1.75 days shorter), faster bowel recovery (1 day faster), longer functional mobility time (4 minutes longer) and less pain scores (average 1 point less).

CONCLUSION

Standardized perioperative pathway with weekly multidisciplinary team meeting was associated with improved short-term perioperative outcomes after robot-assisted radical cystectomy.

The CanMoRe trial - evaluating the effects of an exercise intervention after robotic-assisted radical cystectomy for urinary bladder cancer: the study protocol of a randomised controlled trial

Background

Patients who have undergone radical cystectomy for urinary bladder cancer are not sufficiently physically active and therefore may suffer complications leading to readmissions. A physical rehabilitation programme early postoperatively might prevent or at least alleviate these potential complications and improve physical function. The main aim of the CanMoRe trial is to evaluate the impact of a standardised and individually adapted exercise intervention in primary health care to improve physical function (primary outcome) and habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications in patients undergoing robotic-assisted radical cystectomy for urinary bladder cancer.

Methods

In total, 120 patients will be included and assigned to either intervention or control arm of the study. All patients will receive preoperative information on the importance of early mobilisation and during the hospital stay they will follow a standard protocol for enhanced mobilisation. The intervention group will be given a referral to a physiotherapist in primary health care close to their home. Within the third week after discharge, the intervention group will begin 12 weeks of biweekly exercise. The exercise programme includes aerobic and strengthening exercises. The control group will receive oral and written information about a home-based exercise programme.

Physical function will serve as the primary outcome and will be measured using the Six-minute walk test. Secondary outcomes are gait speed, handgrip strength, leg strength, habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications. The measurements will be conducted at discharge (i.e. baseline), post-intervention and 1 year after surgery. To evaluate the effects of the intervention mixed or linear regression models according to the intention to treat procedure will be used.

Discussion

This proposed randomised controlled trial has the potential to provide new knowledge within rehabilitation after radical cystectomy for urinary bladder cancer. The programme should be easy to apply to other patient groups undergoing abdominal surgery for cancer and has the potential to change the health care chain for these patients.

Trial registration

ClinicalTrials.gov. Clinical trial registration number NCT03998579. First posted June 26, 2019.

Enhanced recovery after surgery (ERAS) protocols in patients undergoing radical cystectomy with ileal urinary diversions: A randomized controlled trial

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols were introduced in clinical practice to reduce complication rates and hospital stay. We performed a randomized controlled single center study to evaluate perioperative benefits of an adapted ERAS protocol in patients with bladder cancer who underwent radical cystectomy (RC) and ileal urinary diversions (IUD).

MATERIALS AND METHODS

Forty five from 90 consecutive randomized patients were enrolled in an adapted ERAS protocol. Length of stay, diet issues, return of bowel function, readmission rates and complications were examined.

RESULTS

Among patients following ERAS protocol, we found a significant reduction in time to first flatus (1 vs 5 days, P < .001), time to first stool (2 vs 5 days, P < .001), time to normal diet (5 vs 6 days, P < .001) and length of stay (16 vs 18 days, P < .001). Also, postoperative ileus at less than 4 days was lower than in non-ERAS patients (15.6% vs 24.4%), but with a marginal trend toward significance (P = .05). Readmission rate was lower in the ERAS group, but the difference did not reach statistical significance. We also found a lower readmission and complication rate in patients with ERAS protocol (6.6% vs 11.1%, P = .23 and 46.6% vs 57.5%, P = .29, respectively).

CONCLUSIONS

Implementation of ERAS protocol for patients undergoing RC in our center was associated with a significant reduction in the time to the first flatus, time to the first stool, time to a normal diet, length of hospital stay.

Quality Indicators for Bladder Cancer Services: A Collaborative Review

CONTEXT

There is a lack of accepted consensus on what should constitute appropriate quality-of-care indicators for bladder cancer.

OBJECTIVE

To evaluate the optimal management of bladder cancer and propose quality indicators (QIs).

EVIDENCE ACQUISITION

A systematic review was performed to identify literature on current optimal management and potential quality indicators for both non-muscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer. A panel of experts was convened to select a recommended list of QIs.

EVIDENCE SYNTHESIS

For NMIBC, preoperative QIs include tobacco cessation counselling and appropriate imaging before initial transurethral resection of bladder tumour (TURBT). Intraoperative QIs include administration of antibiotics, proper safe conduct of TURBT using a checklist, and performing restaging TURBT with biopsy of the prostatic urethra in appropriate cases. Postoperative QIs include appropriate receipt of perioperative adjuvant therapy, risk-stratified surveillance, and appropriate decision to change therapy when indicated (eg, bacillus Calmette-Guerin [BCG] unresponsive). For MIBC, preoperative QIs include multidisciplinary care, selection for candidates for continent urinary diversion, receipt of neoadjuvant cisplatin-based chemotherapy, time to commencing radical treatment, consideration of trimodal therapy as a bladder-sparing alternative in select patients, preoperative counselling with stoma marking, surgical volume of radical cystectomy, and enhanced recovery after surgery protocols. Intraoperative QIs include adequacy of lymphadenectomy, blood loss, and operative time. Postoperative QIs include prospective standardised monitoring of morbidity and mortality, negative surgical margins for pT2 disease, appropriate surveillance after primary treatment, and adjuvant cisplatin-based chemotherapy in appropriate cases. Participation in clinical trials was highlighted as an important component indicating high quality of care.

CONCLUSIONS

We propose a set of QIs for both NMIBC and MIBC based on established clinical guidelines and the available literature. Although there is currently a lack of level 1 evidence for the benefit of implementing these QIs, we believe that the measurement of these QIs could aid in the improvement and benchmarking of optimal care for bladder cancer.

PATIENT SUMMARY

After a systematic review of existing guidelines and literature, a panel of experts has recommended a set of quality indicators that can help providers and patients measure and strive towards optimal outcomes for bladder cancer care.

Long-term outcomes of major abdominal surgery and postoperative delirium after multimodal prehabilitation of older patients

PURPOSE

The long-term outcomes of surgery followed by delirium after multimodal prehabilitation program are largely unknown. We conducted this study to assess the effects of prehabilitation on 1-year mortality and of postoperative delirium on 1-year mortality and functional outcomes.

METHODS

The subjects of this study were patients aged ≥ 70 years who underwent elective surgery for abdominal aortic aneurysm (AAA) or colorectal cancer (CRC) between January 2013, and June 2018. A prehabilitation program was implemented in November 2015, which aimed to optimize physical health, nutritional status, factors of frailty and preoperative anemia prior to surgery. The outcomes were assessed as mortality after 6 and 12 months, compared between the two treatment groups; and mortality and functional outcomes, compared between patients with and those without delirium.

RESULTS

There were 627 patients (controls N = 360, prehabilitation N = 267) included in this study. Prehabilitation did not reduce mortality after 1 year (HR 1.31 [95% CI 0.75-2.30]; p = 0.34). Delirium was significantly associated with 1-year mortality (HR 4.36 [95% CI 2.45-7.75]; p < 0.001) and with worse functional outcomes after 6 and 12 months (KATZ ADL p = 0.013 and p = 0.004; TUG test p = 0.041 and p = 0.011, respectively).

CONCLUSIONS

The prehabilitation program did not reduce 1-year mortality. Delirium and the burden of comorbidity are both independently associated with an increased risk of 1-year mortality and delirium is associated with worse functional outcomes.

TRIAL REGISTRATION

Dutch Trial Registration, NTR5932. https://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5932 .