Progression and predictors of physical activitylevels after radical prostatectomyInge Geraerts, Hendrik Van Poppel*, Nele Devoogdt, Annouschka Laenen†,An De Groef and Marijke Van KampenDepartment of Rehabilitation Science, KU Leuven, *Department of Urology, UZ Leuven, and †Interuniversity Centre forBiostatistics and Statistical Bioinformatics, KU Leuven, Leuven, Belgium

Objective• To investigate the progression of all aspects (total,

occupational, sports, household) of physical activity (PA)over time after radical prostatectomy (RP) and to findpredictive factors for a decrease in PA.

Patients and Methods• In all, 240 men planned for open or robot-assisted RP were

analysed.• All patients completed the Flemish Physical Activity

Computerised Questionnaire before RP concerning PA overthe past year and at 6 weeks, 3, 6 and 12 months after RP forthe PA of the past month.

• A linear model for repeated measures was used to evaluatethe progression of continuous variables over time and theeffect of various predictors for the progression of patientsover time. A logistic regression model for repeated measureswas used to evaluate binary measures.

Results• Total, occupational, sports and household PA levels were

significantly decreased at 6 weeks after RP, but recoveredquickly to approximately baseline levels from that time.

• Predictive factors for decreased PA levels at 6 weeks afterRP were a younger age (total PA level), being

unskilled/semi-skilled (occupational PA level) and beingunemployed/retired (household PA level).

• RP type (open vs robot-assisted) did not influence thedifferent PA levels at 6 weeks, 3, 6 or 12 months after RP.

• The severity of first day incontinence and urine lossmeasured at 6 weeks and 3, 6 and 12 months after RPsignificantly affected total and/or household PA level at alltime-points.

Conclusions• This is the first study to investigate the progression of all

aspects of PA (total, occupational, sports and household)after RP and to find predictive factors for a decrease in PA.

• All PA levels were significantly decreased at 6 weeks afterRP and recovered quickly to approximately baseline levelsfrom that time.

• Patients that had robot-assisted RP did not have a fasterrecovery of PA than those that had open RP. Severity of firstday incontinence and urine loss measured at 6 weeks and 3,6 and 12 months after RP were significantly related to totaland/or household PA level at all time-points.

Keywordsphysical activity, open and robot-assisted radicalprostatectomy, occupation, sports, household, predictivefactors

IntroductionFor years localised or locally advanced prostate cancer havebeen indications for a radical prostatectomy (RP) [1–4]. Openradical prostatectomy (ORP) is performed through an openincision, and more recently robot-assisted laparoscopic RP(RALP) has been developed [4–6]. The impact of diagnosisand treatment of several cancers on the physical activity (PA)of the patient has been explored in numerous studies [7–11].PA concerns total PA, time to return to sports, work,household function and leisure time [12]. Most studies haveinvestigated only one aspect of PA during the first year afterRP. Three studies investigated occupational PA, but patients

were not assessed before RP and at fixed intervals after RP upto 12 months [6,13,14]. However, many studies have evaluatedthe progression in health-related quality of life (HRQL)[3,15–21].

Patient- and treatment-related factors can be associated withdecreased PA after surgery. Younger age, higher educationallevel, low physical workload, nerve-sparing status, highmonthly salary and having a partner have been identified asfactors with a favourable impact on postoperative PA, HRQLand return to work [6,13,22,23]. Only one study hasinvestigated the impact of RALP on the physical componentscores (SF-12) of the patient [5]. They showed that the scores

© 2013 The AuthorsBJU International © 2013 BJU International | doi:10.1111/bju.12465 BJU Int 2014; 114: 185–192Published by John Wiley & Sons Ltd. www.bjui.org wileyonlinelibrary.com

Urological Oncology

in the RALP group were significantly higher than those in theORP cohort [5]. Furthermore, Hohwü et al. [6] reported thatpatients that had a RALP returned to work significantly fasterthan those that had an ORP.

Finally urinary incontinence remains a bothersomeconsequence of RP with an important impact on PA andHRQL [1,24–26].

The aims of the present study were to determine the amountand duration of the decrease in the different PA levels after RPand to find predictive factors for a decrease in PA after RP.

Patients and MethodsThis study is a longitudinal cohort study and received ethicalapproval from the commission medical ethics of theUniversity Hospitals Leuven responsible for human/animalexperimentation (ML5471).

In all, 278 consecutive patients that were planned for ORP orRALP for localised or locally advanced prostate cancer in theUniversity Hospitals Leuven, between September 2009 andJuly 2011 were eligible. In all, 240 men were included andsigned informed consent. Men with cognitive problems,non-Dutch speaking patients, patients with neurologicaldisease (e.g. Parkinson’s disease) or patients, who refused toparticipate, were excluded.

Patients were asked to participate when RP was planned. Thesurgical approach was based on the decision of the surgeon. Ingeneral, low-risk patients more often had RALP, while allhigh-risk patients (≥ cT3, PSA level ≥20 ng/mL and Gleasonscore ≥8) underwent ORP because an extended lymph nodedissection was needed. Three surgeons each specialised inORP and/or RALP completed all the operations. The firstsurgeon had performed >3000 ORPs, the second hadperformed ≈700 ORPs and 50 RALPs, and the third hadperformed ≈150 RALPs at the start of the study. After RP, allpatients had a urinary catheter in situ for ≈12 days. In all, 173(72%) patients were willing to register urine loss per 24 h dailyuntil total continence was achieved. Further continence data ofthis group were published previously [27].

All patients were asked to complete the Flemish PhysicalActivity Computerized Questionnaire (FPACQ) before RPconcerning their physical activities over the past year.Subsequently at 6 weeks, 3, 6 and 12 months after RP, patientsreported their PA over the past month. Patients werecontacted by telephone if no response was received. After RPmen were counselled that they should avoid cycling and liftingduring the first 6 weeks after RP.

The FPACQ

The FPACQ is a reliable and valid questionnaire [12]. The firstpart collects patient-related data. The second part concerns

occupational activities: occupational status, working hours perweek, job intensity and transport to the job. The third partcollects information on sporting activities: the three mostfrequently performed sports, frequency and duration of eachsport. The fourth part records household activities (light,moderate and vigorous). Transport during leisure time andsedentary activities were also noted.

The four different PA variables were calculated: total PAlevel and occupational, sports and household PA levels. Allmetabolic equivalent of task (MET) values used forcalculating the PA variables were determined using theAinsworth compendium of activities [28]. Using thedefinition for a MET as the ratio of work metabolic rate toa standard resting metabolic rate of 1.0 kcal/kg/h, one METis considered as the resting metabolic rate during quietsitting. Calculation of each variable is explained with anexample.

The total PA level is the sum of occupational, sports,household PA levels (explained below) and active transport inleisure time (1.0 h/week × 4 MET), eating (8.8 h/week × 1.8MET), sleeping (49 h/week × 0.9 MET) and quiet leisure time(47.7 h/week × 1.5 MET) = 307 MET-h/week.

A patient worked 38 h/week with 20% light, 70% moderateand 10% vigorous activities. The occupational PA level was:(38 h/week × 20% × 2 MET) + (38 h/week × 70% × 3 MET) +(38 h/week × 10% × 4 MET) = 110 MET-h/week. He drove1.3 h/week for work by car. Consequently, the PA levelfor transport for work was: 1.3 h/week × 1.5 MET = 2MET-h/week.

This patient performed two sports. He danced 2 h/week andwalked 0.7 h/week. The sports PA level was: (2 h/week × 5.5MET) + (0.7 h/week × 3.5 MET) = 13 MET-h/week. He alsoperformed 10 h/week light, 4 h/week moderate and 1.5 h/weekvigorous household activities. The household PA level was:(10 h/week × 2.5 MET) + (4 h/week × 3.5 MET) + (1.5 h/week× 4.5 MET) = 46 MET-h/week.

Predictive Factors

Patient- and treatment-related factors were prospectivelycollected. Patient-related factors were age, body mass index(BMI), partner status, educational level, employment status(retired, employed [labourer/self-employed], unemployed)and smoking behaviour. Additionally, incontinence on thefirst day after catheter removal and urine loss at 6 weeks and3, 6 and 12 months after RP (urine loss = mean urine loss of7 days around the time the PA level was measured) wereassessed. These factors were collected with the FPACQ,except for incontinence (criterion >0 g of urine loss per day[24-h pad test]). Treatment-related factors included type ofRP and nerve-sparing status and were obtained from thesurgeon.

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Statistical Analysis

A linear model for repeated measures was used to evaluate theprogression of continuous variables (total, occupational, sportsand household PA levels) over time. The model used anunstructured covariance matrix for measurements over timeand has, compared with the classical repeated measuresANOVA, the advantage that subjects with missingmeasurements were still included in the analysis and that theresults are still valid when drop-out is missing at random [29].The same models were used to analyse the effect of variouspredictors for the progression of patients over time.Differences in progression over time according to patients’characteristics were evaluated by testing time by predictorinteraction effects. A logistic regression model for repeatedmeasures, with unstructured covariance matrix, was used toevaluate longitudinal binary measures, e.g. job status orpracticing sports. The analysis of the occupational PA levelwas restricted to preoperatively employed patients and thesports PA level to patients practicing some sportspreoperatively. Patients, who retired during follow-up, wereonly taken into account at the time points they were stillemployed. Tukey–Kramer or Holm adjustment was used formultiple post hoc comparisons.

Results should be interpreted with care given the multitude ofmodels and P values.

ResultsIn all, 240 patients completed the FPACQ before RP, and 232(97%), 231 (96%), 225 (94%) and 224 (93%) at 6 weeks, 3, 6and 12 months after RP, respectively. Baseline characteristicsfor the whole group are shown in Table 1.

Progression of PA (Table 2)

The total PA level decreased by 10% at 6 weeks after RP (from268.7 to 240.81 MET-h/week). At 3, 6 and 12 months after RP,total PA levels were respectively, 3%, 2% and 2% lower thanbefore RP (Fig. 1).

A similar trend was found for occupational, sports andhousehold PA levels (Fig. 2). For patients employed before RP(89 patients), the average amount of MET-h/week spent onoccupational activities decreased by 56% at 6 weeks after RP.At 3, 6 and 12 months after RP, occupational activities wererespectively decreased by 22%, 9% and 10%. Before RP, 89(85%) of 105 non-retired patients were employed. At 6 weeks,3, 6 and 12 months 42%, 70%, 81% and 80% of patientsemployed before RP had resumed their preoperativeoccupational activities. The sports PA level of sport-activepatients before RP (171 patients) was reduced with 72% at 6weeks after RP. At 3, 6 and 12 months after RP sports PA levelwas still respectively 26%, 21% and 17% lower than before RP.Only 42%, 73%, 73% and 74% of sport-active patients before

RP were practicing some sports between 1 and 12 monthsafter RP. For patients not performing a sport before RP, 20%practiced a sport at 12 months after RP.

The household PA level decreased by 36% in the firstmonth after surgery (P < 0.01). Afterwards, the householdPA level recovered approximately to baseline in all 240patients.

Predictive Factors for Progression of PA Levels(Table 3, Fig. 3)

Younger patients had a greater decrease in total PA level thanolder patients at 6 weeks after RP, because younger patientshad a higher PA level than older patients at all time-points,except at 6 weeks (Fig. 3). Additionally, highly active patientsbefore RP had a larger decrease compared with those with lowPA levels. A greater decrease in occupational activities wasassociated with being unskilled/semi-skilled at 6 weeks afterRP (Table 3, Fig. 3). Before RP, 25% of working patients wereself-employed. At 6 weeks, 3, 6 and 12 months after RP 85%,

Table 1 Baseline characteristics (N = 240) and incontinence data (N =173).

Variable Value

Mean (SD) age, years 61.7 (6.3)N (%):BMI, kg/m2:

≤25 78 (32.5)25.1–30.0 135 (56.3)>30.0 27 (11.2)

Employment status:Retired 135 (56.2)Employed 89 (37.1)Unemployed 16 (6.7)

Smoking status:Non-smoker 204 (85.0)Smoker 36 (15.0)

Partner:No 13 (5.4)Yes 227 (94.6)

Educational level:Semi-/unskilled 110 (46.0)Highly skilled 129 (54.0)

Type of RP:Open 174 (72.5)Robot-assisted 66 (27.5)

Surgical margins status:Negative 175 (73.5)Positive/doubtful 63 (26.5)

Adjuvant radiotherapyNo 208 (86.7)Yes 32 (13.3)Missing 2 (0.9)

Median (range) incontinence day 1 after catheter removal, g 132 (0.0–2648.0)N (%):Incidence of incontinence:

Preoperatively 53 (32.3)At 1 month 85 (49.1)At 3 months 35 (20.3)At 6 months 11 (6.5)At 12 months 6 (3.6)

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100%, 100% and 100% of the self-employed patients wereworking again vs only 38%, 77%, 88% and 92% of theemployees. Seven patients, all employees, retired in the firstpostoperative year. No predictive factor could be found for agreater decrease in sports PA level. The only predictive factorfor a decrease in the household PA level at 6 weeks after RPwas being unemployed or retired (Table 3, Fig. 3).

There was no interaction effect between RP type (ORP/RALP)and time, indicating similar progression over time for bothgroups (Table 4). Furthermore the PA level at almost alltime-points was higher in the RALP group, but the differencewas only significant for total PA (P = 0.02). After correctionfor the significant patient- and treatment-relatedcharacteristics (age, risk group and nerve-sparing) thedifference in total PA between both groups clearly diminished

and statistical significance disappeared (P = 0.37; data notshown). For sports, occupational and household PA levels,differences were not significantly different between ORP andRALP (Fig. 4).

The effect of first day incontinence and urine loss (measuredat 6 weeks and 3, 6, 12 months after RP) on total,occupational, sports and household PA levels was not differentat the various time points (P > 0.05). However, the amount offirst day urine loss had a significant effect on the absolute levelof total and household PA. For every 10 g increase in first dayincontinence a patient was, 0.07 MET-h/week (total, P = 0.01;household, P = 0.03) less physically active. Additionally, forevery 10 g increase in urine loss at 6 weeks, 3, 6 and 12months, a patient was overall 0.2 MET-h/week less physicallyactive for the household PA level (P = 0.01).

Table 2 Progression of PA levels over time.

PA Preoperative 6 Weeks 3 Months 6 Months 12 Months

Total PA:Mean estimate, MET-h/week 268.70 240.81 260.00 263.24 263.5795% CI 264.82–272.58 237.97–243.64 256.18–263.81 259.16–267.31 259.71–267.43P <0.001 <0.001 0.016 0.013

Occupational PA:Mean estimate, MET-h/week 107.07 46.96 83.97 97.60 96.6395% CI 99.92–114.21 35.30–58.63 73.61–94.32 88.11–107.08 87.79–105.47P <0.001 <0.001 0.079 0.016

Sports PA:Mean estimate, MET-h/week 32.93 9.17 24.52 25.89 27.2195% CI 28.91–36.95 6.16–12.19 20.11–28.92 21.29–30.50 22.48–31.94P <0.001 0.001 0.004 0.051

Household PA:Mean estimate, MET-h/week 37.47 23.88 36.87 35.74 35.3095% CI 33.48–41.47 20.46–27.29 32.40–41.34 31.33–40.15 31.30–39.30P <0.001 0.999 0.921 0.790

P value of pairwise differences between preoperative and the particular point in time.

Fig. 1 Progression of the total PA levels of patients with prostate cancer

from before to 12 months after RP.

230Preop 6 weeks 3 months 6 months 12 months

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patients with prostate cancer from before to 12 months after RP.

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Patient’s BMI, nerve-sparing status, having a partner, smokingbehaviour, surgical margins status and adjuvant radiotherapyduring the first year after RP did not predict a differentprogression of PA over time.

Discussion

In the present study the total PA level of patients after RPdecreased by 10% at 6 weeks after RP. Additionally, we found

Table 3 Predictive factors for the progression of PA levels.

Age Educationallevel

Employment status

Employed vsunemployed

Employedvs retired

Total PA:Difference in MET-h/week

estimate at 6 weeks9.99

P 0.037CI 2.49 to 17.49

Occupational PA:Difference in MET-h/week

estimate at 6 weeks–32.06

P 0.048CI –56.89 to –7.23

Household PA:Difference in MET-h/week

estimate at 6 weeks–23.17 –15.29

P 0.020 0.011CI –38.29 to –8.05 –24.62 to –5.97

A positive value for the difference in the MET-h/week estimate at 6 weeks indicates a stronger decrease in the patientsaged <60 years/high education/employed group, a negative value for the difference in the MET-h/week estimate at 6weeks indicates a stronger decrease in the patients aged ≥60 years/low education/unemployed or retired groups.

Fig. 3 Predictive factors for the progression of the (A) total, (B) occupational and (C) household PA levels from before to 12 months after RP.

230 0

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that patients recovered to approximately baseline PA levelsfrom 3 months after RP. Previous studies have only beenconcerned with HRQL and have found that at 3 months afterRP, 60% of patients reached baseline HRQL levels [18,20]. Theoccupational PA levels of the present patients decreased by56%, 22%, 9% and 10%, respectively, at 6 weeks, 3, 6 and 12

months after RP. No other study was found that examinedpostoperative occupational activities as part of PA andexpressed in MET-h/week. Other studies have investigatedreturn to work after RP. A median of 25–49 days of sick leavewas found after ORP [6,14] and 11 days of sick leave afterRALP [6]. Also, 27.9% and 72.4% of the patients after

Table 4 Main effects of urinary incontinence and type of RP.

Type of RP(ORP/RALP)

Urine loss at day 1 after catheter removal(per 10 g increase in urine loss)

Urine loss as continuous longitudinalmeasurement (per 10 g increase in urine loss)

Total PA:Interaction effect, P 0.459 0.921 0.681Main effect –6.31 –0.07 –0.11Main effect, P 0.026 0.010 0.110CI –11.85 to –0.77 –0.13 to 0.02 –0.25 to 0.02

Occupational PA:Interaction effect, P 0.115 0.880 0.697Main effect 1.77 –0.21 –0.70Main effect, P 0.793 0.062 0.079CI 11.63 to 15.18 –0.44 to 0.01 –1.48 to 0.08

Sports PA:Interaction effect, P 1.543 0.786 0.186Main effect –1.74 0.01 0.09Main effect, P 0.525 0.756 0.142CI –7.15 to 3.65 –0.04 to 0.05 –0.03 to 0.22

Household PA:Interaction effect, P 0.971 0.353 0.330Main effect –3.17 –0.07 –0.20Main effect, P 0.332 0.03 0.013CI –9.60 to 3.25 –0.14 to –0.01 –0.36 to –0.04

Fig. 4 Progression of the (A) total, (B) occupational, (C) sports and (D) household PA levels of patients with prostate cancer from before to 12 months

after RP.

230Preop 6 weeks Preop 6 weeks3 months 6 months

Time Time12 months 3 months 6 months 12 months

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P = 0.37 P = 0.55

P = 0.31P = 0.93

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respectively ORP and RALP returned to work 6 weeks afterRP [6]. In the present study both groups had 6 weeks of paidsick leave prescribed.

The sports PA level in the present patients decreased by 72%in the first month after RP. A partial explanation is thatpatients were counselled not to cycle and not to lift in thefirst 6 weeks after RP. The household PA levels were onlysignificantly different from preoperative levels up to 6 weeksafter RP. We could not find any other studies evaluating sportparticipation or household PA levels after RP to compare with.

Previously published studies on PA levels after RP have somelimitations. Most studies investigated only one aspect of PA,e.g. return to work [6,13] or HRQL [15,17,18,20,30]. Thepostoperative follow-up period was variable and often rathershort [5,13,15,26]. Most studies only investigated one surgicalapproach [13,16,26]. One study examined a small sampleconcerning lifetime PA before RP, but compared this withpostoperative HRQL [15].

In the present study, being younger was a predictive factor fora decreased total PA level at 6 weeks after RP. Similar to thepresent study, Sultan et al. [13] found being younger wasassociated with a slower return to work. Bradley et al. [22],on the contrary, concluded that older men were less likelyto be employed 6 months after RP. In the present studypreoperatively more active patients had a larger decrease in PAat all-time points. According to Mina et al. [15] higher levels oftotal PA before RP were associated with a lessened HRQLreduction at 4 weeks after RP.

Furthermore, educational level predicted a decreasedoccupational PA level at 6 weeks after RP in the present study.The importance of type of profession on time to workresumption has been confirmed in other studies [6,13]. Also,we found that being unemployed/retired was a predictivefactor for a decrease in household PA levels at 6 weeks afterRP. No other studies have evaluated household PA levels.According to Sultan et al. [13] married men returned faster tofull-time work than unmarried men. This was not confirmedin the present study.

Additionally RP type did not influence the different PA levelsat 6 weeks, 3, 6 or 12 months after RP. On the contrary, Milleret al. [5] reported a faster return to baseline physicalcomponent scores after RALP.

Two studies found a significant effect of incontinence on PA[16,26]. In the present study, patients with a large amount offirst day incontinence were significantly less physically activefor total and household PA levels than patients with a smalleramount of first day incontinence. Similarly, patients with alarger amount of urine loss (longitudinally measured) at 6weeks, 3, 6 and 12 months were significantly less active inhousehold tasks than patients with a small amount of urineloss.

The present study has several strengths. Patients weremeasured prospectively before RP and at fixed time intervalsafter RP up to 12 months. All aspects of PA were measured:occupational, sports and household PAs, transport duringleisure time and sedentary activities. The return rate of thequestionnaires was very high. Furthermore, this study isunique in finding a determinant of return to PA inincontinence. Finally, patients were operated on by threeexperienced surgeons, who used highly standardisedprocedures. However, due to the fact that only three surgeonsprovided the surgery and a strong relationship existed betweensurgical expertise and surgeon, we were not able to correct forsurgical experience.

The limitations of the present study were that the FPACQ wastested for reliability and validity in healthy adults and notspecifically in patients with prostate cancer. As sick leave andavoidance of PA were prescribed for 6 weeks, earlier return toPA for RALP in this first period may have been masked. Only30% of the cohort underwent RALP. Finally not all, but still72% of patients were willing to record daily urine loss untiltotal continence was achieved.

In conclusion, this is the first study to investigate theprogression of all aspects of PA (total, occupational, sports andhousehold) after RP, to find predictive factors for a decrease inPA and to assess the impact of type of RP and incontinenceon PA. All aspects of PA decreased significantly at 6 weeksafter RP. Predictive factors for decreased PA levels at 6 weeksafter RP were a younger age (total PA level), beingunskilled/semi-skilled (occupational PA level) and beingunemployed/retired (household PA level). The RP type did notinfluence the different PA levels at 6 weeks, 3, 6 or 12 monthsafter RP. The severity of first day incontinence had asignificant effect on total and household PA levels. Urine lossmeasured at 6 weeks and 3, 6 and 12 months after RPsignificantly affected the household PA level.

Conflict of InterestNone declared.

FundingThis study was funded by the Agency for Innovation byScience and Technology (IWT). The IWT had no role in studydesign and realisation, data collection, analysis andinterpretation.

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Correspondence: Inge Geraerts, Department of RehabilitationScience, KU Leuven, Tervuursevest 101, Postoffice box 1501,3000 Leuven, Belgium.

e-mail: inge.geraerts@faber.kuleuven.be

Abbreviations: BMI, body mass index; FPACQ, FlemishPhysical Activity Computerized Questionnaire; HRQL.health-related quality of life; MET, metabolic equivalentof task; PA, physical activity; (O)RP, (open) radicalprostatectomy; RALP, robot-assisted laparoscopic RP.

Geraerts et al.

© 2013 The Authors192 BJU International © 2013 BJU International