SUO 2017: Prehabilitation for Cystectomy Patients - The Impact of Bladder Boot Camp

Washington, DC ( Radical cystectomy (RC), surgical removal of the bladder, is among the most complicated and morbid cancer surgeries. RC is associated with 30-40% major complication rate, up to 7% 90-day mortality rate. In addition to the inherent technical challenges, the patients requiring a radical cystectomy tend to be of advance age, malnourished, and frail adding to the morbidity of the procedure. Prehabilitation is the process by which the patient’s fitness is improved prior to a medical intervention, by a variety of strengthening and cardiovascular exercises. Most of the research performed in this field has been in the orthopedic setting in which elderly and/or frail patients are subjected to a conditional regimen prior to hip or knee arthroplasty. Multiple studied in this space has shown a decrease in the hospital length of stay, complication and re-admission rates.

Dr. Jeffery Montgomery, from the University of Michigan, presets preliminary data on a prospective trial assessing the application of prehabilitation program in bladder cancer patients requiring a radical cystectomy. The inclusion criteria for the trial was any patient ≥ 60 years old, with no hard exclusion criteria. The primary end points of the trial were safety, patient adherence, changes in the patient’s baseline exercise tolerance, patient reported QoL outcomes, hospital length of stay, complication and re-admission rates. All patient included in the trial underwent a 1:1 exercise training program with a certified personal trainer 3 days/week for 4 weeks.

53 patients were recruited for the trial with a mean age of 71.3 years. Most of the cohort presented with locally advanced muscle invasive bladder cancer with 21% of the patients presenting with node positive disease at the time of resection. Importantly, patients who underwent neoadjuvant chemotherapy were included in the trial and represented approximately 50% of the cohort. The intervention improved the baseline exercise outcomes (15 feet walk test, 6-minute walk distance, and submax exercise test) of all patients, with a patient session attendance rate of 77% and no associated adverse side effects. A wearable device, SenseWear, was used to track the activity of patients throughout the prerehab program, during the immediate post-operative period and 90 days post-op. Activity was increased by the prerehab program and not surprising it saw a sharp decrease immediately after surgery. Of most interest was the prolonged effect in conditioning associated with RC procedure, with none of the patients reaching their pre-surgical activity by the 90-day end point. The prehab regimen saw improvements in all QoL outcomes domains, with patients reporting improved in overall physical and mental health. The mean hospital length of stay was 6.9 days, with a complication and re-admission rate of 38% and 23%, respectively. Unfortunately, the trial did not have a control group so meaningful complication and readmission rate comparisons could not be made.

In summary, a prehabilitation program can improve fitness measures in patients with bladder cancer planned to undergo a radical cystectomy. The program has a good safety profile with no reported adverse event. The impact a prerehabilitation program on complication and re-admission rates remains to be defined.

 Presented by: Jeffrey S. Montgomery MD, MHSA, Associated Professor of Urology at University of Michigan, Ann Arbor, MI

Written by: Andres F. Correa, Society of Urologic Oncology Fellow, Fox Chase Cancer Center-Temple Health, Philadelphia, PA  at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC