Evidence-based perioperative nutritional management for patients undergoing prostate cancer surgery: a systematic review

Introduction

Prostate cancer (PCa) is one of the most common malignancies in the male genitourinary system. For localized disease, radical prostatectomy—particularly minimally invasive approaches such as robot-assisted radical prostatectomy (RARP) —is a primary curative treatment, offering advantages like reduced blood loss and faster recovery (1-3). However, the perioperative period imposes significant physiological stress. Intraoperative pneumoperitoneum can impair visceral perfusion, increase oxidative stress, and compromise gastrointestinal barrier function, thereby elevating nutritional risk (3). Research shows (4) that diet and lifestyle are related to the progression and mortality of PCa, such as maintaining a reasonable body mass index (BMI), engaging in effective exercise, and quitting smoking.

Nutritional status is a well-established determinant of surgical outcomes. Malnutrition is common in PCa patients, especially among the elderly who constitute the primary risk group, and is a high-risk factor for postoperative complications, prolonged hospital stays, and poorer long-term prognosis (5-9). Consequently, proactive perioperative nutritional management is essential to mitigate these risks, support recovery, and enhance quality of life.

Several professional organizations have issued guidelines and consensus statements on nutritional support for cancer or surgical patients (10-13). However, recommendations specifically tailored to the unique perioperative journey of prostatectomy patients are dispersed across these documents, sometimes lack consistency, and have not been systematically evaluated and integrated. This fragmentation creates a challenge for clinicians seeking to implement cohesive, evidence-based nutritional care pathways.

Therefore, this systematic review aims to bridge this gap by rigorously searching, evaluating, and synthesizing the highest quality available evidence. The objective is to provide a clear, consolidated set of evidence-based recommendations to inform standardized perioperative nutritional management protocols for patients undergoing PCa surgery. We present this article in accordance with the PRISMA reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0070/rc).

Methods

Establishing the evidence-based question

The evidence-based question was established based on the PIPOST model (14).

• Evidence application target population (P): patients undergoing surgical treatment for PCa, their families, and caregivers.
• Intervention (I): perioperative nutritional management measures for PCa patients.
• Implementers (P): relevant medical staff, nutritionists, anesthesiologists.
• Outcome indicators (O): biochemical indicators, anthropometric measurements, etc.
• Setting for evidence application (S): urology outpatient clinics, wards, home.
• Evidence type (T): guidelines, systematic reviews, evidence summaries, expert consensus, randomized controlled trials (RCTs), clinical decisions.

This study has been registered with the Fudan University Center for Evidence-Based Nursing (ES20244411).

Search strategy

Utilizing the ‘6S’ evidence resource pyramid model (15) for literature retrieval involves accessing a wide range of evidence-based resources, we conducted a comprehensive search across five electronic databases (PubMed, Embase, CINAHL, Cochrane Library, China CNKI) without time restrictions. The search was limited to studies published in Chinese and English. The search strategy involves using Chinese keywords such as ‘prostate cancer/prostate tumor/prostate malignant tumor’ and ‘nutrition/nutritional management/nutritional support/diet/dietary intervention/nutritional preparations’, as well as English keywords like ‘prostate cancer/prostate neoplasm’ and ‘Nutrition/Nutritional management/Nutritional support/Nutritional intervention/Dietary intervention’. The database search is set to be completed by March 2026. We manually screened the reference lists of all included articles to identify additional eligible studies that were not captured in the initial search. The complete search string can be found at Appendix 1.

Literature inclusion and exclusion criteria

Inclusion criteria

• Study population: PCa patients.
• Study content: perioperative nutritional management measures for PCa patients undergoing surgery, including nutritional assessment, nutritional support, health education, etc.
• Literature type: clinical decisions, guidelines, expert consensus documents, evidence summaries, meta-analyses, systematic reviews, RCTs.
• Language: Chinese or English.

Exclusion criteria

• Literature type: research proposals, abstracts, case reports, literature reviews, conference proceedings.
• Duplicate publications or translated versions.
• Literature with incomplete data or where the full text is unavailable.
• Literature for which a newer updated version exists.
• Literature rated as low-quality during appraisal.

Evidence quality assessment

Two reviewers (T.C., M.L.) independently conducted the literature quality assessment using the following standards. In case of disagreement or uncertainty about inclusion, the department’s evidence-based research team discussed and made a decision.

Guidelines: Appraisal of Guidelines for Research & Evaluation II (AGREE II) (16). This instrument includes 6 domains with 23 items and 2 overall assessment items, each scored from 1 to 7. The standardized percentage score for each domain is calculated as: (Obtained Score − Minimum Possible Score)/(Maximum Possible Score − Minimum Possible Score) × 100%. A higher score indicates better quality in that domain. Based on AGREE II final domain scores, guidelines are rated “A” (all domains ≥60%), “B” (≥3 domains ≥30%), or “C” (≥3 domains <30%; generally not recommended).

This study employed quality assessment tools provided by the JBI Evidence-Based Medicine Centre in Australia, including systematic reviews, RCTs, evidence reviews, and expert consensus (17,18). Among these, the tools for RCTs, evidence reviews, and expert consensus comprised 6 assessment items, whereas the tool for systematic reviews included 11 assessment items. each judged as “yes”, “no”, “unclear”, or “not applicable”.

All literature quality assessments were performed independently by two reviewers (T.C., M.L.). Inter-rater reliability was assessed by calculating the intraclass correlation coefficient (ICC) using a two-way random-effects model (consistency definition). An ICC value >0.75 was considered indicative of excellent agreement, ensuring high consistency in the appraisal process.

Evidence extraction, synthesis, and grading

Two reviewers (T.C., M.L.) independently extracted and synthesized data from the included literature, focusing on the author, publication year, source, type, topic, evidence level, etc. Disagreements during the extraction and synthesis processes were resolved through discussion with a third researcher.

Evidence extraction, synthesis, and grading

Two reviewers (T.C., M.L.) independently extracted data from the included literature using a standardized form. Extracted information included: author, publication year, source, literature type, main topic/focus, specific recommendations or findings, and the associated evidence level or grading. Any disagreements during extraction were resolved through discussion or, if necessary, consultation with a third senior researcher.

Evidence synthesis followed four pre-defined principles:

• Identical content: for evidence on the same topic with identical content, the most comprehensive, accurate, and clearly expressed statement was selected.
• Complementary content: for evidence on the same topic with complementary aspects, the information was integrated into a single, logically coherent statement.
• Conflicting content: priority was given to evidence with higher levels (e.g., systematic reviews over expert consensus), higher methodological quality, and the most recent publications from authoritative sources.
• Independent content: for topics with scant guideline or consensus coverage, evidence from systematic reviews and primary studies was incorporated while preserving the original context as much as possible.

Evidence grading: for systematic reviews and primary studies that did not provide their own grading, the JBI Evidence Pre-appraisal System (2014 version) was applied, ranking evidence from Level 1 (highest, e.g., RCTs) to Level 5 (lowest, e.g., expert opinion) (19). The original evidence grading systems were retained for guidelines and evidence summaries.

Results

Literature search results

A preliminary search yielded 1,047 articles. After removing duplicates, 640 remained. Screening titles and abstracts led to 211 potentially eligible articles. Full texts were retrieved, and after a detailed review, 14 articles were finally included: 4 guidelines (10-13), 5 expert consensus documents (20-24), 3 systematic review (25-27), 1 evidence summary (28), and 1 RCT (29). The literature screening flow chart is presented in Figure 1.

Figure 1 Literature screening for PCa nutritional management studies. PCa, prostate cancer; RCT, randomized controlled trial.

General characteristics of the included literature are shown in Table 1.

Quality evaluation results of included literature

For all the literature evaluations in this study, ICC was calculated using a two-way random-effects model (consistency definition), with values >0.75 indicating excellent agreement, which shows the high consistency and good reliability between the two evaluators.

Quality evaluation results of the guidelines

The guidelines consisted of a total of 4 guidelines, which were endorsed by reputable organizations, including the Extracorporeal and Enteral Nutrition Branch of the Chinese Medical Association, the Cancer Nutrition Professional Committee of the Chinese Anti-Cancer Association, and the European Society for Extracorporeal and Enteral Nutrition. The methodological quality evaluation results of these guidelines are presented in Table 2.

Expert consensus, evidence summary, and RCT quality assessment results

Five expert consensus documents (20-24) (2 from Embase, 2 from PubMed, 1 from CNKI), 1 evidence summary (28) (CNKI), and 1 RCT (29) (CNKI) were included. The RCT, expert consensus, and evidence review were included in the study, as all evaluated items demonstrated high quality, with conclusions summarized in Table 3.

Systematic review quality assessment result

Three systematic reviews were included (25-27) (PubMed). With all assessment items rated as “yes”, indicating a complete study design and high overall quality, the study was thus included. The results are presented in Table 4.

Evidence synthesis and description

Evidence from the 14 included articles was screened and synthesized, resulting in 30 best evidence statements. These were categorized into six aspects: preoperative nutritional assessment and screening, optimal timing of nutritional supplementation, personalized nutrition formulation, selection of enteral nutrition preparations, follow-up nutrition management strategies, and health education (Table 5).

The synthesized evidence comprises 30 recommendations across six domains. A critical analysis of the evidence levels reveals that the majority of recommendations are graded as Level 3 (evidence from well-designed non-randomized trials) or Level 5 (evidence from expert opinion and basic research). Only a small proportion are supported by Level 1 evidence (from RCTs). This distribution highlights that while a strong expert consensus and considerable mid-level evidence exist to guide practice, there is a definitive need for more high-quality, RCTs to strengthen the evidence base, particularly for interventions related to personalized formulation and specific perioperative management strategies.

Discussion

Nutritional risk screening and nutritional assessment

Guidelines indicate (13,20) that preoperative assessment of nutritional status, timely screening for nutritional risk, and comprehensive evaluation of factors such as BMI, Glycemic Index (GI) function, dietary intake, chewing/swallowing function, metabolic rate, nutritional needs, economic status, and social support are crucial for formulating effective oral nutritional supplements (ONS) treatment plans. Correcting preoperative hypoalbuminemia and anemia can effectively improve the prognosis. PCa patients themselves, due to the disease and age factors, are prone to nutritional risk, which can lead to surgical complications (8). Nurses should conduct nutritional risk screening upon the patient’s admission. Evidence statements 1–4 summarize the main methods and importance of nutritional screening.

If severe malnutrition is present, a professional dietitian should provide nutritional support therapy, generally starting 7–10 days preoperatively, or longer for severe cases, to improve the nutritional status and reduce postoperative complications (20). A randomized controlled study by Wang et al. (26) on preoperative nutritional assessment in PCa surgical patients indicated that malnourished patients had significantly higher rates and greater severity of postoperative complications, longer hospital stays, and longer tube indwelling times compared to the normal nutrition group.

Therefore, providing reasonable and scientific nutritional support to ensure adequate nutrition is an urgent task for medical staff.

Optimal timing of nutritional supplementation and choice of nutritional preparations

Malnutrition is a common complication among cancer patients, often associated with tumor-induced anorexia and hypermetabolism, which can potentially lead to severe outcomes such as cachexia, an increased incidence of postoperative complications, prolonged hospital stays, and a reduced quality of life (30). Therefore, upon a patient’s admission, the admitting nurse and physician should initiate an assessment of the patient’s nutritional status. Nutritional Risk Screening 2002 (NRS 2002) is the preferred method for nutritional screening in cancer patients. When a nutritional risk is identified, a comprehensive and proactive nutritional treatment plan should be formulated immediately (10,13). However, a critical gap persists between guideline recommendations and consistent clinical implementation. Evidence suggests that healthcare professionals, including nurses who are often the first-line assessors, may lack sufficient, specialized knowledge in oncology nutrition to execute dynamic and comprehensive nutritional management plans (31). Therefore, the translation of these evidence-based screening and assessment protocols into routine practice necessitates parallel efforts in interdisciplinary education and training for relevant medical staff.

A systematic review of RCTs on abdominal surgery by Noba and Wakefield (32) indicated that oral carbohydrate intake 2 hours preoperatively can reduce insulin resistance and improve postoperative discomfort, without increasing the risk of aspiration. American and European anesthesia societies also recommend a low-fat, low-protein diet up to 6 hours preoperatively, clear fluids up to 2 hours preoperatively, or oral carbohydrates 2–3 hours preoperatively to alleviate preoperative anxiety and hunger, reduce postoperative protein loss, and maintain normal muscle strength.

Within 24 hours after PCa surgery, once the patient wakes up from anesthesia and has no nausea, vomiting, abdominal distension, or dysphagia, oral intake can be started as soon as possible (29). Within 48 hours postoperatively, if the patient has no malnutrition or malnutrition risk, enteral tube feeding is not recommended. If enteral feeding intolerance occurs, parenteral nutrition can be chosen (13).

Parenteral nutrition includes “all-in-one” solutions prepared in the hospital according to a physician’s prescription and industrially produced “multi-chamber bags”. Personalized nutritional treatment plans can be formulated (10). “Multi-chamber bags” can be used immediately upon opening, avoiding contamination and errors during preparation, and allow for the convenient addition of specific nutrients as needed. However, the frequency of adding medications should be controlled, and strict aseptic principles should be followed. When adding medication to a “multi-chamber bag”, first mix the glucose/amino acid chamber, then the lipid chamber, and invert to mix thoroughly. If adding other nutrients, this should be done under medical guidance, paying attention to drug compatibility.

Unopened “multi-chamber bags” should be stored sealed at room temperature, not frozen. After mixing (without added drugs), they can be stored for 24 h; after adding drugs, they should be used immediately or stored at 2–8 ℃ for no more than 24 h. In cases where a patient has severe electrolyte disorders and strict intake control is necessary, a specialized nutritional plan can be devised by a physician, utilizing the ‘all-in-one’ formula developed within the hospital (33).

Perioperative patient nutrition management strategies and health education

Bowel management: due to the close anatomical proximity of the prostate and rectum, traditional preoperative mechanical bowel preparation and nasogastric tube placement are still routinely used in clinical practice. However, Sugihara et al. (34) suggested that mechanical bowel preparation offers no benefit for laparoscopic surgery, increases patient discomfort, and shows no statistically significant advantage in preventing rectal injury or anastomotic leakage in radical prostatectomy.

Fluid management: fluid overload or hypovolemia can lead to inadequate perfusion of visceral organs. The renin-angiotensin system constricts mesenteric arterioles to maintain systemic arterial pressure and perfusion of non-mesenteric organs, potentially causing ileus. Chewing gum and drugs like Alvimopan can reduce postoperative ileus and promote bowel recovery. However, for high-risk patients, goal-directed fluid therapy should be retained. Due to individual patient variability, fluid management lacks specific targets: experienced anesthesiologists will implement personalized goal-directed fluid therapy based on the patient to ensure adequate tissue perfusion (5,35).

Nutrition management: during nutrition therapy, regardless of the chosen regimen, follow the principle of gradually and slowly increasing intake. Appropriately add various micronutrients and dynamically monitor the patient’s electrolyte changes.

Diet management: it is recommended that PCa patients drink water immediately upon waking up postoperatively if no nausea or vomiting occurs. Start the oral diet and add ONS on the second postoperative day. A study on perioperative ONS by Luo and Li (36) showed that patients who were given 50 mL of warm water orally immediately upon regaining consciousness after anesthesia and initiated ONS as soon as no adverse symptoms occurred (until the normal diet was resumed) had statistically significant differences in postoperative ambulation time and catheter removal time.

Health education: the European Society for Clinical Nutrition the European Society for Clinical Nutrition and Metabolism (ESPEN), the American Society for Parenteral and Enteral Nutrition (ASPEN), and the Chinese Society for Parenteral and Enteral Nutrition (CSPEN) all recommend that nutrition therapy should cover the patient’s entire hospitalization period, including home nutrition therapy after discharge. Specialist follow-up nurses should offer routine nutritional health education to PCa patients and their families, guiding them to quit smoking and drinking, adhere to a low-fat, low-calcium diet, limit red meat intake, increase plant-based protein intake. They should also promptly provide nutritional information and develop personalized nutrition plans to cultivate good dietary and lifestyle habits (37).

While the evidence regarding the optimal timing for intervention is relatively robust, the what—specifically, the optimal macronutrient and micronutrient composition for PCa patients—remains less defined. The recommendation for personalized formulation based on patient preferences and comorbidities (Evidence content 15-16) is a principle that acknowledges biological and psychosocial complexity yet requires more operational guidance. Future research must move beyond generic recommendations to define “personalization” more precisely. It could potentially integrate pharmaconutrition (e.g., immunonutrition formulas) and tailor regimens according to individual metabolic profiles and treatment phases.

Matsushita et al.’s (37) research showed that obesity is closely related to the incidence and mortality of PCa. Obese PCa patients have poorer surgical prognoses. Therefore, a reasonable diet and exercise to maintain a normal BMI range have a positive impact on the prognosis of PCa patients. Nurses, as the first observers of patients and executors of medical orders, play a crucial role in patient recovery. A study on the importance of nurses in patient rehabilitation (14) indicated that it is paramount for nurses to possess the latest technical skills. Therefore, in the nutritional management of PCa surgical patients, nurses should enhance themselves, strengthen learning, acquire more nutritional knowledge, and provide higher-quality care (38).

Stage-specific nutritional challenges: the unmet need in advanced and androgen deprivation therapy (ADT)-managed patients

A significant limitation of the current evidence base, as identified in this synthesis, is its insufficient differentiation between the nutritional needs of patients at different disease stages. The review predominantly addresses the perioperative context for localized disease. Yet, a substantial proportion of PCa patients, especially those with advanced disease, undergo ADT, which introduces a distinct set of metabolic challenges. ADT is strongly associated with adverse body composition changes, including increased fat mass, loss of lean muscle mass (sarcopenia), and the development of metabolic syndrome (21,39,40). These changes not only impair quality of life but may also negatively influence treatment tolerance and cancer-related outcomes. The current evidence summary lacks targeted strategies to counteract ADT-induced sarcopenia and metabolic dysregulation. In contrast, patients in the early postoperative phase encounter challenges associated with surgical stress and recovery. In this stage, the objective is to prevent acute catabolism and promote wound healing. The lumping together of these distinct pathophysiological states under a general “PCa nutrition” category represents a significant knowledge gap.

Future research directions

This study focuses on perioperative nutritional management for patients undergoing radical prostatectomy. However, it should be noted that there may be significant differences in nutritional metabolism characteristics and intervention needs between different stages of PCa (e.g., early localized carcinoma vs. advanced metastatic carcinoma).

For early-stage PCa patients, nutritional support emphasizes stress regulation during the perioperative period and maintenance of long-term metabolic balance (such as ADT-related body composition management) (20,40).

In late-stage patients, however, factors like tumor-induced high catabolism, bone metastasis (hypercalcemia, osteoarticular pain), and ADT-related side effects (muscle wasting, metabolic syndrome) (16,21,36) require tailored approaches. The treatment must simultaneously combat cachexia and alleviate toxicity, yet current evidence lacks sufficient differentiation between these aspects.

Future research should prioritize the following:

• Stage-specific pathophysiological mechanisms: elucidate the biological differences in malnutrition between the early postoperative recovery and advanced systemic therapy phases.
• Precision nutrition assessment tools: validate or develop screening criteria for ADT side effects (e.g., body composition changes) in late-stage patients.
• Stage-guided intervention strategies: design personalized nutritional regimens for advanced patients [e.g., high-protein resistance training combined with ω-3 fatty acid supplementation (25)].
• Synergy between nutrition and therapy: explore how nutritional interventions can enhance novel endocrine therapies.

The study demonstrates the optimization of therapeutic tolerance and the enhancement of the quality of life. These findings provide evidence-based foundations for staging-specific precision nutrition management, ultimately improving patients’ overall quality of life throughout treatment.

Among the 14 studies included in this review, 10 (71%) were authored by Chinese scholars, resulting in significant regional bias in the evidence system. Cultural differences (such as dietary preferences between Asian and Western populations) may affect the applicability of the findings. Future research should validate the results across different cohorts. However, cultural differences are not sources of evidence bias; they act as regulators for precision nutrition. Integrating the Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria (Evidence 3) with the cultural dietary adaptation framework could facilitate the transformation of “Chinese evidence” into a “global protocol”.

Limitations

Although this study comprehensively summarizes the evidence of nutritional management in patients undergoing PCa surgery, regional, racial, and cultural differences may affect the research results. Additionally, this study only searched English and Chinese databases and did not include literature published in other languages. In future research, these pieces of evidence should be continuously updated, and appropriate evidence should be selected based on its feasibility, suitability, effectiveness, and clinical practice to facilitate its implementation.

Conclusions

As the first evidence synthesis focusing exclusively on prostatectomy nutrition, this study systematically searched domestic and international evidence resources and synthesized 30 best evidence statements regarding perioperative nutritional assessment, prevention, and management for patients undergoing radical prostatectomy. These statements cover six aspects: preoperative nutritional assessment and screening, the optimal timing of nutritional supplementation, personalized nutrition formulation, the selection of enteral nutrition preparations, nutrition management strategies, and health education, providing an evidence-based foundation for medical personnel.

It is recommended that during clinical evidence translation, each piece of evidence should be comprehensively considered based on the patient’s actual situation and clinical context to scientifically prevent and manage nutritional risks in PCa surgical patients. Although the literature discussed in this study mainly reflects the consensus views among Chinese nutrition experts in cancer care and the overall quality is somewhat limited, it is also essential to combine this evidence with practical experience to develop personalized nutritional support plans for patients, ultimately enhancing their survival quality and optimizing nursing services.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0070/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0070/prf

Funding: This work was supported by the Humanities and Social Sciences Fund of Army Medical University (No. 2024XRW12), Discipline Talent Construction Project of the Second Affiliated Hospital of Army Medical University, Chongqing Science and Health Joint Fund for Top Young and Middle-aged Talent (No. 2023GDRc007), and Chongqing Natural Science Foundation (No. CSTB2022NSCQ-MSX1002).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0070/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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