Grand Journal of Urology
E-ISSN : 2757-7163

Effect of Preoperative Kegel Exercises on Continence Rates After Open Radical Prostatectomy
Cigdem Cinar1, Ali Ayranci2
1Department of Physical Medicine and Rehabilitation, Biruni University Medical Faculty, Istanbul, Türkiye
2Department of Urology, Haseki Numune Training and Research Hospital, Istanbul, Türkiye
DOI : 10.5505/GJU.2023.27147
Pages : 097-101

Abstract

Objective: To reveal the effect of preoperative Kegel exercises on early period continence rates after open radical prostatectomy.

Materials and Methods: Data of patients with open radical prostatectomy between January 2019 and July 2022, in a tertiary academic health center were retrospectively reviewed. Patient" characteristics, perioperative parameters and postoperative follow-up results were recorded. Patients were divided into two groups as those who did Kegel exercises in the preoperative period and those who did not, and groups were compared.

Results: There were 38 patients in the Kegel exercise group and 40 patients in the other group. Postoperative 1st month and postoperative 3rd month incontinence rates were similar between the groups (p=0.406, and p=0.387). At 6th months postoperatively, the rate of incontinence in the Kegel group was 7.9%, while it was 25.0% in the other group (p=0.043). Similarly, the rate of incontinence at 1st year postoperatively was significantly lower in the Kegel group (5.3% vs 20.0%, p=0.001). At 6 months postoperatively, the QoL score in the Kegel positive group was 86, while it was 65 in the other group (p=0.001). In the postoperative 1st year controls, the quality of life (QoL) score was statistically significantly higher in patients with preoperative Kegel exercise (p=0.001).

Conclusion: Our study demonstrated that preoperative Kegel exercises had a significant positive effect on continence rate after radical prostatectomy in the postoperative 6th month and in the first year follow-up, and preparative Kegel exercises were significantly associated with higher quality of life scores at 6th months and 1st year follow-up.

Introduction

Prostate cancer is the most diagnosed cancer in men, and surgery has a pivotal role in the treatment of prostate cancer. Although radical prostatectomy surgery has satisfactory oncological results, the possibility of encountering problems such as urethral stricture, erectile dysfunction and urinary incontinence in the postoperative period causes patients to be suspicious of the surgery [1]. Since the definition of urinary incontinence after radical prostatectomy is not the same in different clinics, the rates of urinary incontinence after radical prostatectomy have been found in a wide range in studies [2]. Even, Peyromaure et al. found that postoperative urinary incontinence rates could reach 30% [3]. Previous studies have shown that urinary incontinence after radical prostatectomy may cause more hospital admissions, more drug use, increased costs in the healthcare system, and social isolation of patients in the postoperative period [4].

Kegel exercises are defined to strengthen the muscles of pelvic floor, involving rapid and sustained voluntary contractions of the pelvic floor muscles to improve sexual function and urinary incontinence [5]. Studies examining the effect of Kegel exercises on urinary incontinence after radical prostatectomy have obtained conflicting results. Lilli and colleagues analyzed 90 patients" data who underwent radical prostatectomy, and authors concluded that pelvis floor muscles exercises did not significantly improve urinary incontinence recovery following radical prostatectomy [6]. In contrast, Ribeiro et al. found that Kegel exercises associated with significant improvements in urinary incontinence severity after radical prostatectomy [7].

Although previous studies have examined the effect of postoperative pelvic floor exercises on post-radical incontinence, the number of studies examining the effect of preoperative Kegel exercises on continence after radical prostatectomy is limited. In this study, we aimed to reveal the effect of preoperative Kegel exercises on early period continence rates after open radical prostatectomy.

Materials and Methods

In this study, data of patients with open radical prostatectomy between January 2019 and July 2022, in a tertiary academic health center were retrospectively reviewed. Patients from this group with at least 1 year follow-up were included in the study. Before the study was planned, permission was obtained from the Haseki Training and Research Hospital local ethics committee with registration number 2023-12. All patients included in the study were informed in detail about prostate cancer and all treatments to be applied in prostate cancer. In addition, possible complications that may occur after prostate cancer surgery and the follow-up process were explained in detail to all patients. Informed consent for radical prostatectomy was signed by each patient 24 hours before surgery.

Patient" characteristics such as age, body mass index (BMI), smoking status, comorbidities, Prostate Specific Antigen (PSA) level, and tumor-related parameters were noted. In addition, perioperative parameters and postoperative follow-up results were recorded for each patient. Patients who underwent salvage radical prostatectomy surgery, patients who received prior pelvic radiotherapy, and patients with previous nerve or muscle disease affecting the pelvic floor muscles (Parkinson's disease, stroke, multiple sclerosis, spinal disorders etc.) were excluded from the study. Other exclusion criteria were undergoing laparoscopic or robotic radical prostatectomy, had transurethral resection of the prostate (TURP) before radical prostatectomy, and failed to complete the one-year follow-up period.

Preoperative Kegel Exercises, Radical Prostatectomy Procedure, and Follow up Procedure
Kegel exercises were started after the patient was diagnosed with prostate cancer pathologically and the patient chose prostate cancer surgery among the treatment options. The time from the diagnosis of prostate cancer to the operation of all patients was between 1-2 months. Kegel exercises were explained to all patients in detail by a professional health worker without any time limit. In addition, to avoid possible misunderstandings, all patients were provided with written and visual resources describing how to do Kegel exercises. All patients were taught to tighten their pelvic floor muscles and keep them tight until they counted one to five, and when patients relax their pelvic floor muscles, they have finished one Kegel exercise. Patients were advised to do 15- 20 Kegel exercises three to four times each day. In radical prostatectomy, the classical method described by Walsh et al. was used as a standard technique [8]. All operations were performed by the same team experienced in open radical prostatectomy. In the post-operative period, Kegel exercises were recommended to the patients for one year, the same as in the preoperative period.

In order to demonstrate the effect of Kegel exercise performed in the preoperative period on continence after radical prostatectomy, the patients were divided into two groups as those who did Kegel exercises in the preoperative period and those who did not. Patients who did and did not perform Kegel exercises in the preoperative period were compared in terms of preoperative demographic characteristics, operative parameters, postoperative patients" life quality and postoperative continence status.

Statistical Analysis
Statistical analysis was done with "Statistical Package for the Social Sciences" (SPSS) 27 program. The normality assessment of data distribution was analyzed with the Shapiro-Wilk test and Q-Q plots. Independent Samples t-test was used for continuous variables. Quantitative data were presented as mean ± standard deviation. Chi-square test was used to compare qualitative data. The data were analyzed at 95% confidence level and the values with p<0.05 were noted statistically significant.

Results

Demographic data of patients are compared between groups in Table 1. There were 38 patients in the Kegel exercise group and 40 patients in the other group. While the mean age was 63.5 years in the Kegel group, it was 61.8 in the other group (p=0.196). There was no difference between the groups in terms of BMI, PSA, and prostate volume (p=0.144, p=0.557, and p=0.147; respectively). Comorbidities and smoking rates were similar between the groups. Radical prostatectomy pathologies were compared according to International Society of Urological Pathology (ISUP) degrees, and no significant difference was observed between the groups (p=0.876).

Table 1. Comparison of preoperative demographic data and postoperative pathology results between groups

Comparison of patients" incontinence status between groups is given in Table 2. Postoperative 1st month and postoperative 3rd month incontinence rates were similar between the groups (p=0.406, and p=0.387; respectively). At 6th months postoperatively, the rate of incontinence in the Kegel group was 7.9%, while it was 25.0% in the other group (p=0.043). Similarly, the rate of incontinence at 1st year postoperatively was significantly lower in the Kegel group (5.3% vs 20.0%, p=0.001).

Table 2. Comparison between incontinence groups at different postoperative periods

The patients" life quality at the postoperative 1st month and 3rd month were statistically similar between the groups. At 6 months postoperatively, the QoL score in the Kegel positive group was 86, while it was 65 in the other group (p=0.001). In the postoperative 1st year controls, the quality of life (QoL) score was statistically significantly higher in patients with preoperative Kegel exercise (p=0.001) (Figure 1).

Figure 1. Comparison of quality of life between groups at different postoperative periods

Discussion

Prostate cancer is a common disease all over the world and radical prostatectomy is an effective and safe treatment method in prostate cancer [9]. However, urinary incontinence occurring after radical prostatectomy adversely affects the general health of the patient and studies to prevent this situation continue [10]. On the other hand, there is strong evidence that Kegel exercises are effective in preventing incontinence by strengthening the pelvic floor muscles, and many centers recommend that patients do Kegel exercises after radical prostate surgery [4,11]. In this study, we aimed to investigate the effect of preoperative Kegel exercises on continence after radical prostatectomy, and our findings revealed that preoperative Kegel exercises had a significant positive effect on continence after radical prostatectomy in the postoperative 6th month and in the first year follow-up. In addition, preparative Kegel exercises were significantly associated with higher quality of life scores at 6th months and 1st year follow-up.

Urinary incontinence is not life-threating but disturbing complication of radical prostatectomy. Hodges and colleagues performed literature analyses to define relation between pelvic muscle training and post-prostatectomy continence, and authors stated the importance of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy [12]. In different study, Overgard et al. recommended that patients with radical prostatectomy perform pelvic floor exercises under the guidance of a specialist physiotherapist, and those who accepted this offer had a significantly lower rate of incontinence at firstyear follow-up than those who did not. However, Overgard et al found that pelvic floor work did not affect continence rates at 3rd, 6th, and 9th month follow-ups [13]. In their meta-analysis, Levy et al. determined that pelvic endurance was important in early incontinence after radical prostatectomy and stated that pelvic floor exercises increased pelvic endurance and significantly decreased continence at the 3rd month postoperatively [14]. In present study, we found that preoperative Kegel exercises had a significant positive effect on continence after radical prostatectomy in the postoperative 6th month and in the first year follow-up. Because of these results, we recommend that all patients undergoing radical prostatectomy perform Kegel exercises before surgery.

Previous reports demonstrated relation between urinary incontinence and embarrassment, social isolation and deterioration of quality of life. Bernardes and colleagues investigated the life quality of patients undergoing radical prostatectomy, and authors determined that urinary incontinence is one of the most important factors that impair the quality of life after surgery [15]. In another study, Nyarangi-Dix recommended to perform bladder neck preservation during radical prostatectomy to achieve higher urinary incontinence rate and higher patient satisfaction [16]. In this study, we found higher patients" life quality with radical prostatectomy at the 6th month and 1st year follow-up, we think that this result is associated with a significant decrease in incontinence rates in the same period.

Present study included small patient number, which accepted as study limitation. Moreover, this study only focused on short term results of preoperative Kegel exercises on post radical prostatectomy continence, and we believe that effect of Kegel exercises on long-term incontinence after radical prostatectomy may be the subject of a different study. Finally, we accepted on the basis of patient statements whether the patients did the Kegel exercises or did them correctly. In addition, the fact that the study was single-centered and the peroperative data were not taken into account can be shown as other limitations.

Conclusion

Our study demonstrated that preoperative Kegel exercises had a significant positive effect on continence rate after radical prostatectomy in the postoperative 6th month and in the first year follow-up, and preparative Kegel exercises were significantly associated with higher quality of life scores at 6th months and 1st year follow-up. Kegel exercises should be offered to patients who will be scheduled for radical prostatectomy operation, starting before the procedure.

Ethics Committee Approval: This study was approved by the local institutional review board (University of Health Sciences, Haseki Training and Research Hospital, approval date and number: 05.06.2023-12).

Informed Consent: An informed consent was obtained from all the patients.

Publication: The results of the study were not published in full or in part in form of abstracts.

Peer-review: Externally peer-reviewed.

Authorship Contributions: Any contribution was not made by any individual not listed as an author. Concept – C.C., A.A.; Design – C.C., A.A.; Supervision – C.C., A.A.; Resources – C.C., A.A.; Materials – C.C., A.A.; Data Collection and/or Processing – C.C., A.A.; Analysis and/or Interpretation – C.C., A.A.; Literature Search – C.C., A.A.; Writing Manuscript – Â.U., S.G.U.; Critical Review – C.C., A.A.

Conflict of Interest: The authors declare that they have no conflicts of interest.

Financial Disclosure: The authors declare that this study received no financial support.

Reference

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Keywords : Kegel exercise, incontinence, prostate cancer, radical prostatectomy

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