1. Introduction

Prehabilitation (PREHAB) is defined as the process of improving the functional capacity of an individual before a surgical procedure in order to reduce potential complications and enhance surgical success ^[1]. Different forms of prehab can be distinguished: from complex training containing diverse sensorimotor and strengthening exercises ^[2] to preoperative pain neuroscience education ^[3]. Pelvic floor surgery remains challenging. The success rate of various procedures ranges from 40 to 100%. Many factors contribute to obtaining an optimal surgical result. Adequate individualized qualification, preoperative preparation, surgical skills and course of postoperative healing are crucial. Each of these factors could be modified and improved; however, it seems that the proper preoperative preparation of the patient constitutes one of the key points of surgical success. Most of the pathologies of the pelvic floor ensue, in general, from the weakness of the pelvic floor muscles (PFM) resulting from previous deliveries, surgery or aging. PFM training is recommended as the initial therapy for stress, urge or mixed incontinence in women of any age ^[4]. It seems rational that improving the function of the PFM should positively influence other nonconservative treatments, including the outcomes of surgical procedures. In the literature, there is a paucity of trials contributing to preoperative PFM training in women. The benefits of six-month pelvic floor muscle training in improving symptoms and anatomical relationships at short-term follow-up were confirmed in the Cochrane review on the conservative treatment and prevention of pelvic organ prolapse in women. The authors highlighted the lack of medium- and long-term observations as well as the need for trials combining PFM training and surgery ^[5]. Surgery remains the golden standard for the management of severe pelvic organ prolapse in women who failed conservative therapy, although the combination of conservative and surgical treatment could be effective for enhancing surgical results.

2. Discussion

2.1. Perioperative Physiotherapy in Female Pelvic Floor Surgery

2.1.1. Perioperative Intervention in Pelvic Organ Prolapse and/or Stress Urinary Incontinence Surgery

Jarvis et al. ^[6] analyzed the synergistic potential of preoperative physiotherapy and surgery in women with pelvic organ prolapse and stress urinary incontinence. This randomized controlled trial included 60 women, of whom 30 underwent preoperative physiotherapy and 30 were treated only surgically. Women in the study group received an individually selected set of four pelvic floor muscle exercises, which they were to perform daily. Particular attention was paid to the correct execution of the Knack maneuver, which consists of the rapid maximal contraction of the pelvic floor muscles in order to protect the pelvic floor against a sudden increase in intra-abdominal pressure ^[7]. Additionally, the participants of the treated group were taught the correct defecation and voiding techniques to reduce the need to tighten the abdominal muscles. There were no significant differences between the groups in the reduction of stress urine leakage in the paper towel test. However, the groups differed in their results for urinary symptom-specific health and the quality of life questionnaire, the mean maximum squeeze and the mean difference in daily frequency, favoring the pelvic floor PREHAB group.

2.1.2. Perioperative Intervention in Pelvic Organ Prolapse

The influence of preoperative muscle performance on surgical outcomes and the effect of preoperative PFM training is still controversial, and clinical trials remain inconclusive ^[8]. The systematic review from the year 2016 also does not give any clear recommendations. Primary outcomes were defined as prolapse symptoms and prolapse-specific quality of life. Secondary outcomes included pelvic floor muscle function, the degree of prolapse, urinary and bowel functions, the activity scale, PFM training adherence and adverse effects. An analysis of five randomized controlled trials (RCTs) including 591 patients showed no improvement in primary and secondary outcomes in women undergoing surgery for genital prolapse combined with PFM training compared to surgery-only groups. Although the authors did not find evidence to support adding preoperative PFM training to surgery, they indicated the need for further research to evaluate the potential benefits from preoperative PFM training and to establish an optimal PFM training regimen using sufficiently long-term follow-ups ^[9].

2.1.3. Perioperative Intervention in Mixed Urinary Incontinence

The recently published “The Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence” (ESTEEM) study comparing the effect of behavioral training and PFM training associated with surgery vs. surgery alone among women with mixed urinary incontinence revealed only a small statistically significant difference in urinary incontinence symptoms at the 12-month follow-up. This difference did not reach the threshold for clinical importance. The study comprised 416 women with bothersome mixed urinary incontinence who were randomized to sling-only surgery or sling combined with pelvic floor muscle training. The primary outcomes were established as a change in symptoms at one year, based on the long form of the Urogenital Distress Inventory (UDI). The secondary outcomes were determined as a change in UDI-stress and UDI-irritative subscale scores between the groups at 12 months. Although the difference between the groups did not reach the clinical importance attributed to primary and secondary outcomes (adjusted mean change of −128 points vs. −114 points; the model-estimated between-group difference of −13.4 points; 95 confidence interval (CI): −25.9 to −1.0; p = 0.04), a statistically significant difference was found in exploratory outcomes including the three-day bladder diary and the incontinence-specific quality of life. Bladder diary results favored the combined group, and this group demonstrated a significantly greater improvement in Incontinence Impact Questionnaire scores. At 12 months, the likelihood of additional treatment for lower urinary tract symptoms in the combined group was significantly lower than in the sling-only group (8.5% vs. 15.7%, odds ratio (OR): 0.47; 95% CI: 0.26–0.85, p = 0.008) ^[10].

2.2. Prehab in Male Pelvic Floor Surgery

The PREHAB concept has been studied much more extensively in males. Several trials were conducted on men who underwent prostatectomy and received PFM training before surgery. Ocampo-Truijllo et al. ^[11] investigated the effectiveness of preoperative PFM training on histomorphometry, muscle function, urinary incontinence and health-related quality of life in men who were scheduled for radical prostatectomy. The study involved 16 men who were randomized into two groups. The experimental arm subjects received a supervised PFM four-week training regimen, three times a day and one month before surgery. During the surgical procedure, samples of the external urethral sphincter were collected for histomorphometric analysis. The study revealed that preoperative pelvic floor muscle training induces histological changes in the muscles of the pelvis. The cross-sectional area of the muscle fibers was increased in subjects who underwent pelvic floor muscle training (PFMT) (1.313 ± 1.075 μm² vs. 1.056 ± 844 μm², p = 0.03). Moreover, this group presented a significantly higher-pressure contraction of the levator ani. (F = 9.188; p = 0.010). After removing the catheter from the bladder, 62% of the participants in the experimental group showed no incontinence and 75% of the subjects in this group did not require any pads compared to 37% and 25% in the control group, respectively. However, the difference did not reach statistical significance. Furthermore, no significant differences were found between the two groups in any of the health-related quality of life domains studied. Nevertheless, the trial revealed a positive impact of PFM training on the PFM function.

In another study by Manley et al. ^[12], pelvic floor strength was investigated prior to and post robot-assisted laparoscopic radical prostatectomy. The exercise used included coordination, reflex action, strength and endurance training. Pelvic floor muscle strength four weeks after catheter removal was associated with continence. The only significant predictor of incontinence was advanced age. The lack of a control group, subjective assessment of pelvic muscle strength and some loss to follow-up limited the evaluation of the outcomes. However, the authors positively assessed preoperative pelvic floor muscle training as improving surgical outcomes for men undergoing robot-assisted laparoscopic radical prostatectomy. This conclusion was confirmed in a meta-analysis including eleven trials with a total number of 739 patients who underwent prostatectomy. The subjects who were allocated to the PFM training groups received before-surgery training sessions that ranged in various studies from 20 min to 1 h in length and from once to twice weekly. The analysis showed a significantly lower rate of postoperative incontinence at three months in the PFMT group compared with the control group (p = 0.005). However, no improvement in the long-term continence rate was demonstrated. No significant differences were revealed between the groups at six months in postoperative incontinence (p = 0.12) ^[13].

Another systematic review concerning PFM training preprostatectomy based on nine RCTs revealed a significant improvement in postsurgical urinary incontinence, reduction in erectile dysfunction and postmicturition dribble, regardless of the PFM training regimen ^[14]. Similar observations were made by Tienforti et al. who, in a prospective randomized study based on 34 participants undergoing open radical prostatectomy, showed a beneficial effect of a postoperative monthly supervised pelvic exercise program, preceded by a preoperative educational session and PFM training with biofeedback, on postoperative urinary incontinence. In the six-month follow-up, men in the intervention group reported faster recovery of voiding control after surgery, lower number of incontinence episodes and pads per week compared to the control group, which received only oral and written instructions on postoperative pelvic floor exercises performed at home ^[15]. These outcomes were not confirmed by the study reporting the effects of preoperative PFM training with biofeedback on stress urinary incontinence and quality of life in men undergoing laparoscopic radical prostatectomy. The analysis was based on 248 men randomly allotted into one of two groups (PFM training with biofeedback and surgery or surgery alone). The study did not show a beneficial effect of preoperative PFMT on postoperative stress urinary incontinence and quality of life ^[16]. This observation was confirmed by an RCT conducted on 180 men undergoing radical prostatectomy. The median urinary continence recovery time was similar in the preoperative pelvic floor exercise group and in the group with only postoperative PFMT: 30 and 31 days, respectively (p = 0.878) ^[17]. Similar results were revealed in a meta-analysis of five RCTs concerning urinary incontinence after radical prostatectomy in men with preoperative PFM training. The survey showed no improvement in postoperative urinary incontinence in men with preoperative pelvic floor muscle training in any follow-up period ranging from one month to one year ^[18]. Other authors found no impact of preoperative rectal electrical stimulation of pelvic floor muscles on urinary continence in patients undergoing radical prostatectomy ^[19].