We Know About Rehab, But What About Prehab?

Many of us are familiar with the concept of rehabilitation following surgery. It often involves some combination of exercise and other therapies to help restore a patient’s ability to function following a surgery or an accident.

Bladder removal surgery can require months of rehabilitation

For bladder cancer patients, bladder removal (known as a radical cystectomy) can require many weeks and months of rehabilitation. Recovery includes adapting to a new way to urinate (the urinary diversion) after the bladder has been removed.

Since it is a highly complex surgery, it does tend to have a high rate of complications. A patient is likely to have the best outcomes if he or she goes into the surgery in the best possible condition.

Enter prehabilitation

In recent years, the concept of “prehabilitation” has become more widely employed for cancer patients prior to surgery. Prehabilitation, similar to rehabilitation, is the work a patient can do prior to surgery to best position him or herself for a positive surgical outcome and smoother recovery. There is a lot of common sense in this approach.

Prehabilitation continues to be studied

The studies specific to prehabilitation in the context of radical cystectomy (versus a range of surgeries for different cancers) tend to be small. But still, I think they can teach us something.

A 2019 study published by the European Association of Urology found that the “data suggested that multimodal prehabilitation resulted in faster functional recovery after radical cystectomy.”¹

A 2016 study from Denmark found that exercise-based prehabilitation was feasible for and helpful to a significant number of the patients.²

Prehabilitation before urologic surgeries

A detailed 2018 article on preparing patients for urologic surgeries (published by the American Urologic Association) states the following with regard to prehabilitation:

“Although prehabilitation is not yet a common component of the urologic patient's pre-operative pathway, there is mounting evidence that strength and endurance conditioning prior to major surgery can reduce post-operative complications, shorten length of hospital stay, and result in durable improvements in physical capacity. Further work is necessary to establish soundly the functional and quality of life benefit of prehabilitation in urological patients.”³

The article notes the value of aerobic reserve and strength for patients as they recover from major urologic surgery. The extent to which prehabilitation improves actual outcomes, reduces the length of hospital stays or the rates of readmission due to complications are still being studied.

What exactly is prehabilitation?

Prehabilitation may include exercise therapy, nutrition guidance, psychological counseling, improving chronic conditions like diabetes or anemia, eliminating bad habits like smoking. It can also include training (before the surgery) about how to deal with a stoma.

The prehabilitation depends on the person

The exercise therapy could be as simple as the patient walking more on his or her own to build aerobic capacity. Or it could include supervise strength training ahead of surgery. Much depends on the urgency and severity of the patient’s cancer as well as his or her fitness and health levels prior to the cancer. A 56-year-old with a history of running and working out would have a very different prehabilitation that an 82-year-old lifelong smoker.

Setting yourself up for the best possible outcome

In a nutshell, I view prehabilitation as stacking the odds in your favor. Surgery can be exhausting. I think it is tough to conceive of just how challenging any surgery can feel until you are the patient experiencing it. Patients want to feel back to normal or feel like themselves again as soon as possible after surgery. I tend to think of prehabilitation as addressing in any way possible those things that can be addressed. Improving on the good and reducing the bad. Whether we have cancer or not, we could likely all use some prehabilitation.

Regardless of the proven or yet-to-be-proven benefits, it seems hard to go wrong with the broad concept of prehabilitation, especially under a doctor’s supervision. I suppose there is the risk of injury in exercising, but that’s where professional guidance helps.

Even if prehabilitation doesn’t speed a recovery, having better aerobic capacity and muscle strength is a good thing.