Prehabilitation for patients undergoing radical cystectomy: Patient selection and targeted interventions

Radical cystectomy (RC) is associated with high perioperative morbidity, reflecting common preoperative vulnerability from frailty, sarcopenia, malnutrition, systemic inflammation, deconditioning (including during neoadjuvant chemotherapy), and psychological distress. Although prehabilitation is safe and feasible and has demonstrated improvements in functional capacity, quality of life, and select postoperative outcomes, real-world uptake remains low, in part due to uncertainty regarding appropriate patient selection and how to operationalize evidence-based interventions. We aimed to provide a pragmatic framework for identifying candidates for prehabilitation before RC and to summarize evidence-based prehabilitative interventions that can be implemented or referred from routine urologic oncology practice. A non-systematic, expert narrative review of contemporary literature was performed, evaluating prehabilitation in bladder cancer and RC populations, with emphasis on feasible clinic-based tools to identify physiologic and psychological vulnerability and on intervention components with demonstrated benefit. Multiple efficient screening approaches can identify candidates for prehabilitation, including frailty indices (e.g., Clinical Frailty Scale, modified frailty indices, claims- or chart-derived frailty tools), functional assessments (e.g., Short Physical Performance Battery, Timed Up & Go, sit-to-stand tests, grip strength, 6-minute walk test), and markers of nutritional risk and catabolism (e.g., albumin, unintentional weight loss, low body mass index (BMI), computed tomography (CT)-based sarcopenia measures, inflammatory markers). Psychological vulnerability (e.g., anxiety/depression, low mental health scores, limited social support) is also associated with worse postoperative recovery and can be screened using brief questionnaires. Evidence supports multimodal prehabilitation incorporating aerobic and resistance exercise, nutritional optimization (primarily targeted perioperative supplementation), and perioperative education (including stoma counseling), with emerging data for stress-management, smoking cessation, and cognitive prehabilitation. Establishing streamlined referral pathways to physical therapy/rehabilitation, nutrition, psychology/psychiatry, and social work improves feasibility. Prehabilitation prior to RC is an actionable, patient-centered strategy to improve functional reserve and recovery, though evidence to date demonstrates inconsistent effects on harder perioperative endpoints such as complications, length of stay, or readmissions. Routine vulnerability screening and standardized referral pathways can increase prehabilitation utilization and may reduce morbidity in this high-risk surgical population.