Training of the pelvic floor muscles (PFMs) as part of a multimodal prehabilitation program that includes cardiovascular and hip strengthening and patient education can yield patient benefits after urologic surgery. A personalized, multifaceted, holistic care plan that includes PFM training should be developed by an interdisciplinary team. Further research is needed to identify the impact of PFM prehabilitation on various urologic and surgical outcomes.
This recent article by Johnson et al [1] reports on the role of pelvic floor prehabilitation before pelvic surgery. Centemero et al showed already 14 years ago that preoperative PFMT was advantageous for early recovery of continence after RP [2], however data on this topic is often conflicting. It is of notice that the effectiveness of pelvic floor muscle training (PFMT) depends in general on the experience of the physiotherapist, on the protocol used and its timing, and on patients features. This can explain the different results by patient.. According to the article written by Johnson and Kaiser in European Urology Focus “Overall, prehabilitation programmes that incorporate PFM training, cardiovascular and hip strengthening, and patient education provide benefits when a personalised and multifaceted plan of care is developed by an interdisciplinary team”. Although I completely agree with this conclusion, I believe that there are two factors that should be further emphasised especially when it comes to preoperative rehabilitation in patients scheduled for radical prostatectomy (RP).
Patient selection: The preventative function of PFMT may improve the sphincteric mechanism through enhancing rhabdosphincter function and the supportive system through its effect on the levator ani muscle [2]. Patients with a levator ani thickness (LAT) ≥ 10 mm (assessed via mpMRI) have been shown to have significantly higher rates of early and overall continence recovery (CR) compared to patients with a LAT < 10 mm (53.4% vs 38.5%; p=0.04 and 88.1% vs 75.8% p=0.03) [3]. Such evidence confirms the hypothesis that striated muscle function is pivotal to compensate the muscle loss of surgery [4] and it is reasonable to expect that levator ani bulk, and thus thickness, is likely to be associated to a more effective activation during efforts.
In this context, preoperative PFMT could further enhance the support and contraction aspect and be essential in some patient groups. This could help clinicians in the preoperative assessment of patients undergoing RP and can pave the way for the creation of predictive tools in order to choose the best candidate for preoperative PFMT according to clinical characteristics, but also on anatomical patients’ features.
Experience of the physiotherapist and physiotherapy protocol: Recent data on a large series of patients undergoing post operative PFMT by different physiotherapists (own data not published) showed that patients with an experienced PFMT therapist (with ³10-year experience) had higher continence rates compared to the counterpart (75% vs. 56%, p=0.04). At MVA, being treated with a largely experienced PFMT therapist was a predictor for better continence rates (HR 1.34, CI 1.09-1.94, p =0.04). However, not all patients may have access to an experienced physiotherapist, and this can represent a limit especially in some places, and in addition the different PFMT regimen may affect the outcome.
The improvement in the selection of patients who can benefit from pre-operative PFMT and a better standardisation of physical therapy protocols together with physical therapists who have adequate experience could improve the prediction of CR recovery and its timing and should be the focus of future research in order to identify cases that would mostly benefit from specific, standardised preoperative exercises.
References:
[1] Johnson EV, Kaiser K. Clinical Consultation Guide: Pelvic Floor Prehabilitation. Eur Urol Focus. 2024 Jan;10(1):13-15. doi: 10.1016/j.euf.2023.10.007.
[2] Centemero A, Rigatti L, Giraudo D, Lazzeri M, Lughezzani G, Zugna D, et al. Preoperative pelvic floor muscle exercise for early continence after radical prostatectomy: a randomised controlled study. Eur Urol. 2010 Jun;57(6):1039-43. doi: 10.1016/j.eururo.2010.02.028
[3] Tutolo M, Rosiello G, Stabile G, Tasso G, Oreggia D, de Wever L, et al. The key role of levator ani thickness for early urinary continence recovery in patients undergoing robot‐assisted radical prostatectomy: A multi‐institutional study. Neurourol Urodyn 2022;41:1563–72. https://doi.org/10.1002/nau.25001.
[4] Hodges PW, Stafford RE, Hall L, Neumann P, Morrison S, Frawley H, et al. Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy. Urol Oncol 2020;38:354–71. https://doi.org/10.1016/J.UROLONC.2019.12.007.