Dr. Black presented an overview of prehabilitation which begins with the preoperative risk assessment and then defining 2 broad categories including modifiable and fixed risk factors. Modifiable risk factors can be further broken down into lifestyle (nutrition, activity, smoking, alcohol) and acquired (anemia, diabetes, frailty, COPD). Fixed factors include age, sex, and genetics. Radical cystectomy is a morbid procedure with a non-negligible risk of mortality. Interestingly, Dr. Black presented the risk of transfusion for complex surgeries including ruptured abdominal aortic aneurysm and radical cystectomy which remains the most common procedure carrying up to 44% risk of transfusion. Addressing the preoperative assessment and management of anemia in these patients, the Vancouver General Hospital has developed a perioperative blood management program which aims to reduce pre-operative anemia and initiate automatic referral of patients with Hb<135 g/L. As part of this automatic referral are timely visits within 3 weeks prior to surgery as well as additional testing and treatment including iron infusion. Preliminary data comparing pre vs. post-implementation of this automated referral program at 1 year showed decreased anemia at surgery (41% v. 27%, p<0.001) and increased referral to perioperative blood management program (41% vs. 79%, p<0.001). Increasing pre-operative activity is another salient feature of prehabilitation. Increased use of technological devices such as SenseWear® allows providers to monitor patients' total energy expenditure, total number of steps, sleep duration and lying down: a few examples of some parameters to provide objective evidence and intervention prior to surgery. Such devices allow patients a faster recovery as well as continued monitoring and targeted intervention if needed following surgery.
In conclusion, prehabilitation is safe for this population. We can improve fitness in cystectomy patients with a 4 week prehab intervention. Finally, prehab data has shown that the patient experience is durable with continued improvements over baseline quality of life measures. At our institution, we incorporate a prehab multidisciplinary program including nutrition counseling and referral, smoking cessation, activity enduring at least 30 minutes for 3-5 times per week pending preoperative frailty score, anemia screening with referral and glucose screening and referral if needed. Critical incorporation of the patient and family members including information handout and support are salient features of a prehab program and surgical journey of the patient.
Presented by: Peter Black, MD, Senior Research Scientist, Vancouver Prostate Centre, Professor, Department of Urologic Sciences, University of British Columbia
Written by: Stephen B. Williams, MD, Associate Professor, Division of Urology, The University of Texas Medical Branch, Galveston, Texas at the 7th ERAS World Congress, Liverpool, UK, 1-3 May 2019.