Prehabilitation before surgery: what actually works? A systematic review and critical synthesis of multimodal strategies

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Introduction: Prehabilitation is a comprehensive, multilayered approach implemented before surgery to enhance patient’s functional and mental resilience. Although increasingly used across surgical specialties, its effects vary depending on patient population, intervention components, and selected outcomes. The aim of this review was to synthesize contemporary evidence to determine what appears to work, for whom, and under what clinical conditions. Methods: This systematic review followed PRISMA guidelines and was registered in PROSPERO. PubMed, Embase, and Web of Science databases were searched from January 2000 until March 2026. Eligible studies included adult surgical populations receiving exercise‑based, nutritional, psychological, educational, or multimodal prehabilitation. Randomized and nonrandomized studies were considered. Risk of bias was assessed using RoB-2 and Risk Of Bias In Non‑Randomized Studies – of Interventions tools. Results: A total of 123 studies were included. Prehabilitation was most frequently investigated in oncology, orthopedics, cardiology, urology, and gynecology. Exercise was the core component across nearly all programs (88%–100%), whereas nutritional and psychological support were mainly integrated in multimodal oncological (38%) and gynecological (75%) programs. The most consistent benefits were observed for functional capacity, physical performance, cardiopulmonary fitness, selected patient‑reported outcomes, and procedure‑specific end points, such as continence recovery in urology. Effects on postoperative complications, length of hospital stay, readmission, and long‑term recovery were heterogeneous. High adherence reported in several studies suggests that prehabilitation may strengthen patient engagement and perceived control before surgery. Conclusions: Prehabilitation should be viewed as a phenotype- and procedure‑specific strategy rather than a universal intervention. Current evidence supports its feasibility and potential value, particularly when targeted, supervised, and multimodal, but standardized protocols remain essential.