Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy

Abstract

Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.

Fig. 1. A timeline of surgery for prostate cancer.

The surgical technique for performing radical prostatectomy has evolved over time, from total prostatectomy in the late nineteenth century to the robot-assisted procedure in the 2000s. The development of exercise-based interventions and pelvic floor muscle exercise programmes to manage postprostatectomy incontinence has been more recent, with the development of preoperative models of care and the application of transperineal ultrasonography for pelvic floor muscle training programmes^–. AUA, American Urological Association; PFME, pelvic floor muscle exercise; RP, radical prostatectomy; SUFU, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction; TPUS, transperineal ultrasonography.

Fig. 2. A sagittal view of the anatomy of the male lower urinary tract system.

The action of the puborectalis, striated urethral sphincter and bulbocavernosus muscles during voluntary pelvic floor muscle contraction is indicated by the arrows. Reprinted with permission from ref., Elsevier.

Fig. 3. Imaging measurement of membranous urethral length.

These images show a T2-weighted mid-sagittal magnetic resonance image (part a) and a 2D transperineal ultrasound image of the male lower urinary tract system (part b). The apex of the prostate, the penile bulb and the membranous urethra are identified. The length of the membranous urethra is measured from the apex of the prostate to the point of entry at the penile bulb. MUL, membranous urethral length. Adapted with permission from ref., Taylor & Francis.

Fig. 4. Components of a progressive pelvic floor exercise training programme.

The stepwise approach of a muscle training programme before radical prostatectomy.

Fig. 5. Transperineal ultrasonography of the striated urethral sphincter.

Mid-sagittal 2D cineloop transperineal imaging is used to capture images of the membranous urethra during voluntary pelvic floor muscle contractions. The pubic symphysis is used as a stable bony reference landmark for the position of an x–y axis system to interpret the activity of the striated urethral sphincter as visualized by the displacement of the mid-membranous urethra. a | The membranous urethra at rest. b | The membranous urethra contracted. The same approach is used for the assessment of the displacement of the anorectal junction (puborectalis muscle) and the penile bulb (bulbocavernosus).