Preoperative exercise-based prehabilitation for reducing postoperative pulmonary complications after lung cancer surgery: a systematic review and meta-analysis

Background Postoperative pulmonary complications (PPCs) are common and clinically important adverse outcomes after lung cancer surgery. Preoperative exercise-based prehabilitation may enhance functional reserve before surgery, but its effects on PPCs and related perioperative outcomes remain uncertain. Methods This systematic review and meta-analysis followed the PRISMA 2020 guidelines and was registered with PROSPERO (CRD420251273259). PubMed, Web of Science, Embase, the Cochrane Library, CINAHL, CNKI, Wanfang Data, and the VIP Database were searched from inception to 25 December 2025. Randomized controlled trials evaluating preoperative exercise-based prehabilitation in adults undergoing lung cancer surgery were included. Risk of bias was assessed using the Cochrane RoB 2 tool, and certainty of evidence was assessed using the GRADE approach. Random-effects meta-analyses were performed using RevMan 5.4.1. Results A total of 28 reports comprising 29 randomized controlled trials and 2,900 eligible surgical participants were included. Compared with usual perioperative care, preoperative exercise-based prehabilitation significantly reduced the risk of overall PPCs (RR = 0.42, 95% CI 0.33–0.53; I 2 = 0%), pneumonia or pulmonary infection (RR = 0.52, 95% CI 0.36–0.75; I 2 = 0%), atelectasis (RR = 0.36, 95% CI 0.25–0.51; I 2 = 0%), and respiratory failure (RR = 0.37, 95% CI 0.17–0.78; I 2 = 0%). Prehabilitation also reduced postoperative length of hospital stay (MD = −2.22 days, 95% CI −2.52 to −1.92; I 2 = 52%). Results for preoperative 6-minute walk distance were inconsistent and were summarized narratively because of substantial heterogeneity. Conclusion Preoperative exercise-based prehabilitation may reduce PPCs and shorten postoperative hospital stay after lung cancer surgery, but the certainty of evidence ranged from moderate to very low across outcomes. Evidence for functional improvement remains uncertain. Future multicenter trials should standardize prehabilitation protocols, outcome definitions, safety monitoring, and adherence reporting. Systematic review registration https://www.crd.york.ac.uk/prospero/ , identifier CRD420251273259.