Optimizing a frail elderly patient for radical cystectomy with a prehabilitation program

Abstract

The purpose of this case report is to discuss the positive impact of a multimodal prehabilitation program on postoperative recovery of a frail patient undergoing radical cystectomy. An 85-year-old man with significant history for poorly controlled type II diabetes, anemia, chronic renal failure, and glaucoma was found to have muscle invasive urothelial carcinoma of the bladder with hydronephrosis. He was scheduled for elective radical cystoprostatectomy and ileal conduit diversion. He was enrolled in a multimodal prehabilitation program in view of his frailty (Fried score = 5), 15% body weight loss, weak grip strength, severe depression and moderate anxiety, poor nutritional status (patient-generated subjective global assessment [PG-SGA] = B), low functional walking capacity (6-minute walking test [6MWT] = 210 metres, predicted 621 metres). The 4-week program included moderate aerobic and resistant exercises, nutritional counselling with whey protein supplementation (20 g/day), and relaxation exercises. Surgery and the postoperative period were uneventful, although he required treatment of his hyperglycemia and hypomagnesemia. He left the hospital on postoperative day 7 and returned home where he continued the multimodal program for 8 weeks. Measurements of 6MWT, Health-Related Quality of Life (SF-36), physical activity, Hospital Anxiety and Depression Scale (HADS), were conducted at baseline, before surgery and at 4 and 8 weeks after surgery. These tests revealed a progressive remarkable improvement before surgery that continued after surgery.