Discussion
cancer, prostate cancer, urinary incontinence, fatigue
CANCER, PROSTATE CANCER, URINARY INCONTINENCE, POSTOPERATIVE COMPLICATIONS
In this study, we compared prehabilitation and rehabilitation supervised exercise in the setting of prostatectomy. There were three main findings. First, 6 weeks of supervised exercise before prostatectomy enhanced muscle strength, physical function at pre-surgery and at 6 weeks post-surgery despite reductions in lean mass so that even though these patients were in the postsurgical recovery period, their physical performance was comparable to or better than prior to surgery when compared to rehabilitation. In addition, improvements in strength and function were accompanied by reduced fatigue prior to surgery. Second, for those initiating exercise post-surgery, supervised exercise helped recoup losses and enhance muscle strength and physical function. Third, both groups experienced comparable resolution in urinary incontinence with similar hospital LOS.We demonstrated that commencing exercise 6 weeks before surgery substantially improved muscle strength and physical function, which may act to buffer the effects of surgery. As a result of the patient’s improved reserve capacity, declines that do occur in strength and function do not typically result in the patient falling below their pre-exercise levels. In addition, we observed a reduction in fatigue levels in those who exercised before surgery. These findings support previous research in the prehabilitation setting (Singh et al. The rehabilitation programme also showed important benefits for patients who are unable to engage in exercise before surgery due to numerous medical appointments and commitments or the short time between diagnosis and prostatectomy (e.g., the urgency of the prostate cancer condition and surgeon availability). Exercise that commenced after this initial period, with rehabilitative intent, is also beneficial to recoup losses and enhance muscle strength and physical function while maintaining or improving QoL. These findings are clinically important as increasing physical reserve capacity is associated with reduced risk of postoperative complications and all-cause mortality in cancer patients (Ezzatvar et al. Although improvements in both muscle strength and physical function resulted from the training program in both groups, there was an absence of improvement in whole body LM. Consequently, improvements in strength and function are likely attributable to neural adaptations to exercise (Carli and Zavorsky The evidence regarding prehabilitative exercise for reducing post-operative urinary incontinence is conflicting in patients with prostate cancer (Xiangyun et al. The strengths of this study include a comprehensive clinic-based exercise programme with supervision, a high attendance rate, a battery of physical function and muscle strength assessments, and use of DXA for body composition. Nevertheless, there are limitations worthy of comment. Most participants underwent a less invasive surgical technique, which may have limited our ability to observe the effects of exercise on urinary incontinence and hospital LOS. Additionally, the study participants may not represent all prostate cancer patients undergoing surgery, as they agreed to participate in an exercise intervention during a challenging period. Lastly, the study did not have a long-term follow-up to assess the persistence of exercise over time, such as 6 months or longer. Nevertheless, we found that a relatively brief programme of supervised resistance and aerobic exercise undertaken either before or after prostatectomy can be safely undertaken and results in improvements in muscle strength and physical function. The time period between diagnosis and surgery, despite being a relatively short time frame, provides a window of opportunity to introduce targeted exercise programmes.In conclusion, exercise before prostatectomy enhances muscle strength and physical function, and reduces fatigue in patients with prostate cancer. If exercise before surgery is not possible, starting supervised exercise after prostatectomy may recoup losses and enhance muscle strength, physical function and potentially body composition while maintaining QoL. It may well be that exercising both before and after surgery may provide the most significant physical enhancement. Clinicians should encourage patients to engage in exercise either before or as soon as possible after the acute post-operative phase to assist with their recovery.