Nutritional Prehabilitation: A Pragmatic Guide

Catabolic surgeries in urology, such as radical cystectomy (RC), remain high-risk procedures, with 90-d complication rates nearing 64% and 30-d mortality rates of 1.5–2.7%. Enhanced recovery after surgery (ERAS) protocols have improved outcomes, but further optimization is essential. A structured preoperative evaluation and intervention approach is crucial in the management of patients undergoing RC [1,2]. This approach involves nutrition optimization, exercise prehabilitation, and the engagement of a multidisciplinary team when surgery is anticipated. Here we aim to provide a practical overview of effective interventions for patients undergoing catabolically demanding urologic surgeries.

A team of multidisciplinary specialists can address interventions at the outset of treatment. For instance, referrals to physical therapists or exercise physiologists can help in improving physical function and muscle mass, while geriatricians can provide specialized care for older patients, focusing on frailty and comorbidities. Smoking cessation programs can be crucial in reducing perioperative complications, and psychologists can address the emotional and psychological stress associated with surgery. Dietitians and nutritionists can assist patients in remaining nourished while building strength and stamina around the time of surgery. Social workers can offer support in navigating the health care system and addressing social determinants of health, while occupational therapists can assist in planning for postoperative functional independence. The collaboration of these diverse specialists ensures a holistic approach to perioperative care, thereby improving surgical outcomes and patients’ overall quality of life.

Early nutritional optimization includes proactive management of anemia, diabetes, and food security to mitigate perioperative risks. Patients are screened for malnutrition using a validated tool, such as the Malnutrition Universal Screening Tool or the Nutritional Risk Screening 2002 [2]. A clinician assesses patients at risk of malnutrition using a validated tool such as the Patient-Generated Subjective Global Assessment. An intervention is needed to optimize the nutritional status of malnourished patients. Nutrition optimization strategies often include incorporation of more protein, calories, and nutrients to support the metabolic demand during recovery. Many patients benefit from oral nutrition supplements (ONS), which may boost protein intake or even provide extra nutrients, including specialized immunonutrition (SIM) [3]. Fortified with nutrients like Larginine, omega-3 fatty acids, and dietary nucleotides, SIM has significantly reduced postoperative complications such as paralytic ileus and infection [4]. In a pilot study, SIM decreased postoperative complications and infections in comparison to ONS [5,6]. A phase 3 multicenter trial (NCT03757949) is currently under way to further evaluate these effects.

Exercise prehabilitation is a fundamental component of the preoperative optimization process, particularly for addressing issues such as sarcopenia, frailty, and muscle mass. During the initial consultation before neoadjuvant chemotherapy (NAC), screening for sarcopenia using either gait speed or the SARC-F questionnaire is recommended. Patients with a positive screening result then undergo a comprehensive diagnostic assessment that includes measurements of lean muscle mass via imaging (computed tomography, magnetic resonance imaging, dual-energy X-ray absorptiometry, or ultrasound), evaluation of muscle strength (eg, timed up-and-go test), and assessment of physical performance via walking tests or frailty questionnaires. Patients meeting at least two of the three criteria are referred to an exercise physiologist and a dietitian or nutritionist for specialized interventions, which may include tailored exercise regimens, nutritional counseling, and educational resources.

ERAS pathways play a pivotal role in the perioperative management of patients undergoing RC, with the aim of optimizing surgical outcomes and accelerating recovery. These multidisciplinary protocols integrate evidence-based practices across various domains, including preoperative preparation, anesthesia, and postoperative care, to reduce complications and shorten hospital stays. The early and continual involvement of dietitians or nutritionists in nutritional counseling for patients undergoing RC can offer targeted interventions that address specific postoperative challenges such as impaired bowel function, loss of appetite, and fatigue. These personalized diet plans are crucial in facilitating muscle recovery, enhancing energy levels, and optimizing gastrointestinal function, thereby contributing to better surgical outcomes and quality of life.

Preoperative carbohydrate loading is an important and overlooked ERAS guideline recommendation, as is early postoperative feeding. The American Society of Enhanced Recovery/Perioperative Quality Initiative and the American Society of Anesthesiologists recommend consumption of a preoperative beverage containing ≥50 g of carbohydrates 2–3 h before surgery [7]. The literature also indicates that carbohydrate loading can significantly improve postoperative insulin resistance, reduce the length of hospital stay, and enhance patient comfort [8,9]. Early postoperative feeding in patients undergoing intestinal surgery is increasingly recognized for its role in enhancing recovery and reducing complications and the length of stay.

Smelser et al [10] recently reported their experience in implementing a prehabilitation program using a multidisciplinary approach. The program commences with an initial evaluation that includes a thorough review of laboratory tests by the surgical and specialized anesthesia teams. On the basis of these assessments, appropriate supplements (including SIM) or infusion therapies are prescribed. Concurrently, a review of medications and comorbidities is conducted to fine-tune the preoperative plan. Physical therapy assessments guide the development of individualized exercise plans, which may include home-based regimens. The multidisciplinary team summarizes these findings for the surgeon. The program is designed to meet individual patient needs and is subject to ongoing evaluation. This structured approach aims to enhance both outcomes and resource utilization effectively.

RC, which has high complication and mortality rates, urgently requires a coordinated multidisciplinary approach for prehabilitation. Our responsibility beyond the operating room includes preparing patients for their physiological and psychological challenges. Evidence-based interventions, such as nutritional optimization and exercise prehabilitation, have proven efficacy in enhancing surgical outcomes. However, these interventions are most effective when integrated within a comprehensive care plan that involves multidisciplinary specialists. Our unique position as a lynchpin in this multidisciplinary team is to ensure that each patient is prepared to face the challenges ahead. We owe it to our patients to not only assess their nutritional status but also provide actionable strategies for improvement, both preoperatively and postoperatively. It is now time to adopt a structured, evidence-based approach to prehabilitation that will improve surgical outcomes and enhance the quality of life for our patients.