For radical cystectomy patients, the postoperative period can be a time of difficult convalescence due to the psychological and physical impact of the procedure.^1-3 Within this context, the preoperative setting serves as an opportune time to administer interventions for these patients that are designed to reduce postoperative complications, improve cardiopulmonary reserve, promote psychological well-being, and adopt healthy lifestyle habits. One study demonstrated the challenges of implementing these types of interventions after a radical cystectomy. In that randomized trial, a 12-week strength training and walking program was employed for radical cystectomy patients in the postoperative period; however, approximately 28% of patients dropped out prior to randomization, often citing postoperative physical exhaustion as a reason for leaving the study, and the study was largely underpowered as a result.⁴ Prehabilitation prior to radical cystectomy serves as an important mode for rendering interventions designed to mitigate the physiologic impact of surgery. Aerobic exercise, dietary modifications, and psychosocial support are often components that are either combined or employed alone in a prehabilitation program for radical cystectomy patients.^5-8

The physiologic benefits of prehabilitation for radical cystectomy patients are well documented with studies showing increased cardiovascular fitness after a 2- to 4-week regimen of moderate to vigorous exercise.^5,6 One study showed an improvement in leg muscle power prior to surgery among patients engaging in a 2-week strength and endurance program prior to cystectomy (2.35 W/kg vs 2.01 W/kg, P < .006).⁶ Similarly, a feasibility trial demonstrated that patients who completed a median of 8 preoperative supervised vigorous intensity aerobic interval exercise sessions before radical cystectomy exhibited improvements in key cardiovascular adaptations such as peak oxygen pulse (12.74 mL/beat vs 10.83 mL/beat, P = .001) and power output (148 W vs 129 W, P < .001) in the preoperative period compared to usual care.⁵ In addition, a multimodal prehabilitation regimen comprised of aerobic and resistance exercise, diet therapy, and relaxation-based techniques showed that cystectomy patients in the prehabilitation group experienced preservation of their functional capacity as measured by the 6-minute walk test postoperatively compared to usual care. In the prehabilitation group, the distance walked at 4 weeks postcystectomy declined by 15 m from baseline compared to a 97.9 m decline in the usual care group (P = .014).⁸

Psychosocial support has been used as a prehabilitative intervention to ameliorate the psychological stress that patients can experience while preparing for a radical cystectomy; however, there is a relative dearth of evidence in this realm.⁷ One study showed that the anxiety and mental stress that patients feel after a radical cystectomy was improved by preoperative psychoeducation compared to usual care. In that study, patients were randomized to usual care or a single preoperative session of counseling and education regarding the postoperative course after a radical cystectomy in which the patient was encouraged to discuss their fears and concerns surrounding the effect of the surgery on their body, social, and marital life.⁹ Patients in the intervention group experienced a 12-point decrease in mean anxiety scores as measured by the validated State Trait Anxiety Inventory on postoperative day 3 compared to the usual care group.⁹

Despite the reported immediate physiologic benefits of prehabilitation for radical cystectomy patients, there are still few studies that have examined or shown the impact of these measures on long-term operative outcomes such as length of stay and complication rates, often due to small sample sizes.^5,8 Moreover, research regarding the effect of prehabilitative interventions on patient-reported metrics such as health-related quality of life and psychological reserve are limited.¹⁰ Future study within this realm is needed to provide clinicians with evidence-based recommendations regarding perioperative exercise, nutrition, and psychological support for radical cystectomy patients that are based on clinically meaningful end points.

Support: Christine Ibilibor is an iTHRIV Scholar at the University of Virginia. The iTHRIV Scholars Program is supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Numbers UL1TR00315 and KL2TR00316. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health or the author’s institutions.