Effect of early pelvic floor muscle exercises (Kegel’s) after Robotic Prostatectomy in Prostate cancer patients

Post-prostatectomy Urinary incontinence (PPUI) due to open or robotic surgery has a negative impact on patients’ psycho-social well-being and leads to altered quality of life (Kielb and Dunn in J Urol 166:958–61, 2001). Sphincteric incompetence overall remains the primary cause of PPUI, and it is believed that direct damage and manipulation intraoperatively could be the probable causes [1] (Bayoud et al. in Int J Urol 22:283–7-10, 2015). Pelvic floor muscle (PFM) rehabilitation appears to be beneficial in hastening the return of continence (Kampen and Poppel in Lancet 355:98–102, 2000). Hence, there is a need to re-educate or strengthen the pelvic floor muscles. To study the return of continence, and time duration required for the pelvic floor muscles to regain strength and endurance, thereby, leading to urinary continence and its effect on the quality of life of patients who have undergone robotic prostatectomy. Pelvic floor muscle grading, a 24 h pad test, and an International Prostate symptom scoring (IPSS) were the outcome measures used to assess the effect on incontinence status post-operatively. 69 patients were screened between a duration of 3 years, i.e., 2017–2020. Four patients remained incontinent 3 months post-surgery. On the contrary, 65 patients regained continence. There is a definitive effect of early Kegel’s exercise, the patient gains good pelvic floor muscle strength, portraying a reduction in dribbling or leakage of urine. Also, there is an improvement in the quality of life after Robotic Prostatectomy in Prostate cancer patients after 6 weeks of surgery. 94.20% of the patients have shown a have gained continence by 3 months post-robotic prostatectomy following a regular exercise regime of Kegel’s exercise.


Introduction
Urinary incontinence is said to possess a negative impact on the patient's psycho-social well-being and thus leading to an altered quality of life. Patients with prostate cancer who undergo robotic prostatectomy are said to encounter urinary incontinence immediately post-surgery. It is noted that, even after the removal of the catheter on day 10, urinary incontinence persists. The prevalence of urinary incontinence after Robotic prostatectomy: 1-87% [2,3]. Sphincteric incompetence overall remains the primary cause of Post-prostatectomy Incontinence (PPI), believed due to direct damage and manipulation intraoperatively [4]. Pelvic floor muscle (PFM) rehabilitation appears to be beneficial in hastening the return of continence [5]. EUA guidelines define continence following radical prostatectomy as either total control with no leakage or pad usage, no pad use but the loss of a few drops of urine, or use of up to one "safety" pad per day. Therefore, there is a need to re-educate or strengthen the pelvic floor muscles and identify the duration at which the patient gains urinary continence, which could be achieved by Kegel's exercises. Thus, there is a need to study the effect of Kegel's exercises on this population. Aim and objective 1. To study the effect of Kegel's exercise after prostatectomy in patients with prostate cancer. 2. To study the duration required for the pelvic floor muscles to gain strength and endurance, thereby leading to urinary continence.

Methodology
In this study, 69 patients who underwent robotic prostatectomy were included. These patients were assessed on day 3 of the surgery, catheter removal day, at 3 weeks, and at 6 weeks. Patients who had metastasis were excluded from the study.

ACI protocol for post-prostatectomy patients
According to the protocol followed at Asian Cancer Hospital: Patients were mobilized out of bed with an abdominal binder and ambulated on immediate postoperative day 1 [1]. Later, Kegel's exercise was taught on day 3 which comprised contraction of the PFM in which a patient was advised to draw in the perineal muscles (in case of fast-twitch contract & relax) which was taught on day 3 (with a catheter in situ). A rest pause of approximately 5 s was maintained between two consecutive repetitions. On day 10 (after catheter removal), the patient was advised to draw in the perineal muscles (in case of slow-twitch contract & hold for 10 s, and progress to 20 s on attaining comfort for performing contractions, for which patients were asked to perform the contraction in case they had an episode of the urgency of urination and could not urinate due to social reasons) and also perform four exercises namely: a posterior pelvic tilt, a pelvic bridge, static adductors, and pelvic rotation. The patient was advised to perform the exercises five times a day, with ten repetitions with a rest pause of 5 s between each repetition of the exercise was suggested. In the 3rd week, progressions of exercise were carried on in the form of a hold which progressed from 10-20 s to 30 s hold time (slowtwitch fibers' recruitment). During this tenure, a few patients had issues comprehending commands or understanding the technique of the PFM contraction. The relatives and patients were therefore instructed to place their hand over the lower abdomen of the patient to attain feedback on the contraction. The patients were thereby expected to continue with the exercises for 6 weeks and note down the reduction in the level of incontinence over this period. Compliance with Kegel exercises was not a major issue, since the feedback of the same was taken via telephonic conversations with the patient themselves. The patients and relatives were found to cooperate and comply with the prescribed protocol.

Docking of the robot-robotic prostatectomy
Exercise regime for Kegel's exercise

Outcome measures
Pelvic floor muscle grading, a 24 h pad test, and an International Prostate symptom scoring were incorporated to assess the reduction in incontinence at 3 weeks and 6 weeks post-operatively.

Pelvic floor muscle grading
Laycock developed the Modified Oxford Grading System to evaluate the strength of pelvic floor muscles. This is a method used to manually check pelvic floor muscle strength. It is a six-point scale: 0 = no contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 = good (with lift), and 5 = strong. This testing is done in the semi-fowlers position.

h pad test (in gms)
The patients were instructed to wear a pad for 24 h. Later, this pad was weighed and the weight was noted in terms of grams.

International Prostate Symptom Score (I-PSS)
The International Prostate Symptom Score (I-PSS) is based on 7 questions concerning urinary incontinence and 1 question concerning quality of life. The urinary symptoms scoring is from 0 to 5 and can range from 0 to 35 (asymptomatic to symptomatic), whereas the quality of life scoring is from 0 to 6. Questions under urinary symptoms:

Results and analysis
A total 69 patients were screened between the duration of 1 year, i.e., 2017-2018, and it was observed that 4 patients had incontinence 3 months post-surgery. On the contrary, 65 patients gained continence.
Total no. of patients (n = 69) Patients studied = 69 Incontinence at 3 months = 4 Continence at 3 months = 65 In Fig. 1, it was evident that total 69 patients were included in the study, out of which 65 gained continence and 4 patients remained incontinent after the duration of the 6 weeks protocol period.
In Fig. 2, it is evident that the patients showcased a pelvic floor muscle grading of 2, 3, 4 at the point of catheter removal, 3 weeks and 6 weeks follow-up post-robotic prostatectomy, respectively. Therefore, it was seen that at 6 weeks, the patient has a significant improvement in pelvic floor muscle strength.
In Fig. 3, it states that the loss of urine due to incontinence using 24 h pad test (in gms) was 72 gms, 34 gms, and 12 gms at the time of catheter removal, 3 weeks, and 6 weeks follow-up post-robotic prostatectomy, respectively. This means that there was a reduction in the dribbling of urine which was achieved at 6 weeks and came down from 72 to 12 gms.
In Fig. 4, it is seen that the symptom scoring and quality using an International Prostatectomy Symptom Score (IPSS) was found to be 27, 12, and 6 at the time of catheter removal, 3 weeks, and 6 weeks, respectively. Therefore, it was seen, there was an improvement in the quality of life and a reduction in the symptoms related to urinary incontinence.

Discussion
It has been observed that there is a definite degree of improvement in 92.20% (n = 65) of the patients who gained continence for a duration of 3 months. Only 5.79% (n = 4) of the patients had incontinence. The probable reason was the damage to the sphincters and the disruption of the detrusor muscles. Robotic prostatectomy is a safe, minimally invasive technically feasible procedure with comparable functional and oncological outcomes. The study by Kulkarni JN and Tillu N showed superior perioperative and continence outcomes in RALP [6]. Another a few studies by Kulkarni et al. [7][8][9] also have similar conclusions which depict that prostatectomy itself leads to incontinence and affects the Quality of life and there is a constant need to re-educate the Pelvic floor muscle to regain continence. The study will be discussed under three domains: 1. Pelvic floor muscle strength 2. 24 h pad test 3. Improvement of symptoms and quality of life.

Pelvic floor muscle strength
It has been noted that there was an improvement from grade 2 (weak contractions) to grade 3 (moderate contractions) at week 3 and finally up to grade 4 (good contractions) at week 6. This effective improvement in pelvic floor muscle strength is on account of the regularity of the patient performing exercises, and the re-education of the pelvic floor muscles due to the contractions at the early phase which prevent the muscles from fatiguing and disuse atrophy [10], [11].

h Pad test
The reduction in weight of the pad from 72 gms on the day of catheter removal to 34 gms at week 3 and in turn to 12 gms at week 6 was seen as there was an improvement in the pelvic floor muscle strength, and thereby, the ability to control the urine and avoid it from dribbling lead to this reduction in weight. The other probable cause of this weight of pad reduction was due to the sphincter control due to increased strength of the pelvic floor muscles.

Improvement of symptoms and quality of life
It was observed that there had been a marked improvement in the symptoms from severe on the day of catheter removal to moderate to week 3, and thereby, mild symptoms at week 6. This change from severe to mild discomfort in the symptoms was due to the improvement in the symptoms such as incomplete emptying, reduction in the frequency of urination, the reduction in gaping between washroom visits, the reduction in urgency to visit the washroom, improvement in the stream of urine passage, fewer efforts in straining while micturition, and reduction in nocturia, i.e., visits to the washroom at night. Also, there is improvement in the quality of life [6] which proves to have positive feedback and there is lesser psycho-social stress in the patient's life. This lesser stress re-enforces the patient to perform exercises on daily basis.

Conclusion
This study states that there is a definitive effect of early pelvic floor muscle exercises (Kegel's exercises) post-Robotic Prostatectomy in Prostate cancer patients after a span of 6 weeks [12], [13]. The patient regained good pelvic floor muscle strength, a reduction in dribbling, or leakage of urine, and there is an improvement in the quality of life post 6 weeks of robotic prostatectomy. It is also evident that 94.20% of the patients have shown a full recovery or have gained continence by 3 months post-robotic prostatectomy following a regular exercise regime of pelvic floor muscle (Kegel's exercises).