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Does a 5-item Frailty Index predict surgical outcomes of endoscopic surgical management for benign prostatic obstruction?
Muhieddine Labban, MD1, Nicola Frego, MD1, Jason Qian, MD1, David-Dan Nguyen, MPH1, Brittany D. Berk, MD1, Stuart R. Lipsirz, ScD1, Naeem Bhojani, MD2, Martin Kathrins, MD1, Quoc-Dien Trinh, MD1.
1Brigham and Women's Hospital, BOSTON, MA, USA, 2University of Montreal, Montreal, QC, Canada.

Background: The 5-item frailty index (5i-FI), an index of reduced physiological reserve, predicts surgical outcomes of urological and non-urological procedures. We sought to assess whether the 5i-FI is a predictor of surgical complications of endoscopic surgery for benign prostatic obstruction (BPO) and examine whether the type of endoscopic surgery predicts complications.
Methods: The National Surgical Quality Improvement Program was queried for patients who underwent transurethral resection of the prostate (TURP), photo-vaporization of the prostate (PVP), and laser enucleation of the prostate (LEP) between 2009-2019. The 5i-FI was calculated by giving a point for each of 1) chronic obstructive pulmonary disease or pneumonia, 2) congestive heart failure, 3) dependent functional status, 4) hypertension, and 5) diabetes. The endpoints were any complication, major complications (Clavien-Dindo 3), length of stay (LOS) ≥2 days, and readmission within 30 days of surgery. A multivariable logistic regression was run to assess the predictors of each outcome adjusting for the surgical approach, 5i-FI, and patient demographics. Then, we conducted a multinomial logistic regression to examine which baseline patient characteristics predicted the surgical approach. Significant predictors were included in the inverse probability treatment weighting (IPTW) propensity score to evaluate the independent effect of the surgical approach on complications.
Results: The cohort included 38,399 (62.6%) TURP, 19,121 (31.2%) PVP and 3,797 (6.2%) LEP. Baseline characteristics and outcomes across BPO treatments are reported in Table 1. We found that 5i-FI ≥2 was associated with 50%, 63%, 31%, and 65% increased risk for any complication, major complication, LOS ≥2, and readmission, respectively (Table 1). In comparison to TURP, PVP and LEP had a safer surgical profile (Table 2). Despite decreased odds of surgical complications with LEP, frail patients were less likely to receive LEP (OR 0.83; 95%CI [0.75-0.92]; p<0.01) (Table 3). We also found that age, race, obesity, 5i-FI, history of bleeding diathesis (including anticoagulation within 30 days of surgery), among others, predicted the type of BPO surgery received (Table 3). After IPTW adjustment, LEP had the lowest weighted risk for any complication (6.29; 95%CI 5.48-7.20), major complication (2.30; 95%CI 1.83-2.89), and readmission (3.80; 95%CI 3.18-4.53) (Table 4). PVP had the lowest risk of LOS ≥ 2 (5.98; 95%CI 5.63-6.34).
Conclusion: The 5i-FI is an independent predictor of surgical complications after endoscopic BPO surgery, and LEP had the lowest risk of complications after weighting for baseline patient characteristics. Thus, preoperative frailty assessment could improve risk stratification prior to BPO surgery.

Table 1: Comparison of baseline characteristics and surgical outcomes across BPO treatment modalities (TURP, PVP, LEP)
VariablesTreatmentp-values
TURP (38,399)PVP (19,121)LEP (3,797)
Baseline Characteristics
5i-FI score
Score 012,894 (33.8%)6,330 (33.1%)1,454 (38.3%)< 0.001
Score 116,708 (43.5%)8,492 (44.4%)1,628 (42.9%)
Score  28,707 (22.7%)4,299 (22.5%)715 (18.8%)
Age
< 604,081 (10.6%)1,981 (10.4%)445 (11.7%)< 0.001
60 6912,558 (32.7%)6,073 (31.8%)1,432 (37.1%)
70 7914,361 (37.4%)7,160 (37.4%)1,403 (36.9%)
 807,398 (19.3%)3,907 (20.4%)517 (13.6%)
Race
White22,608 (58.9%)13,011 (68.1%)3,008 (79.2%)< 0.001
Black2,309 (6%)943 (4.9%)185 (4.9%)
Hispanic2,354 (6.1%)811 (4.2%)125 (3.3%)
Other11,128 (29%)4,356 (22.8%)479 (12.6%)
ASA classification
1-218,158 (47.4%)9,004 (47.2%)2,037 (53.7%)< 0.001
 320,132 (52.6%)10,088 (52.8%)1,759 (46.3%)
Obesity
No26,097 (68%)12,931 (67.6%)2,462 (64.8%)< 0.001
Yes12,302 (32%)6,190 (32.4%)1,335 (35,2%)
Bleeding Diathesis
No37,335 (97.2%)18,301 (95.7%)3,684 (97%)< 0.001
Yes1,064 (2.8%)820 (4.3%)114 (3%)
Surgical Outcomes
Total operative time
< 60 min24,392 (63.5%)12,470 (65.2%)965 (25.4%)< 0.001
60 120min12,198 (31.8%)5,868 (30.7%)1,749 (46.1%)
> 120 min1,809 (4.7%)783 (4.1%)1,083 (28.5%)
Length of Stay
0 day7,478 (19.5%)13,274 (69.4%)1,105 (29.1%)< 0.001
1 day20,938 (54.3%)4,642 (24.3%)2,116 (55.7%)
> 2 days9,983 (26%)1,205 (6.3%)576 (15.2%)
Clavien-Dindo
Grade 1-22,060 (5.4%)956 (5%)153 (4%)< 0.001
Grade 3639 (1.7%)205 (1.1%)53 (1.4%)
Grade 4519 (1.3%)317 (1.7%)34 (0.9%)
Grade 5104 (0.3%)45 (0.2%)4 (0.1%)
Readmission1,877 (4.9%)906 (4.7%)148 (3.9%)0.023

Table 2: Predictors of complications (any complication, major complication, extended LOS, and readmission) adjusting for baseline characteristics, frailty index, and endoscopic surgical modality (TURP, PVP, and LEP)
PredictorsOutcomes
Any ComplicationMajor ComplicationLOS ≥ 2 daysReadmission
OR (95%CI)p-valueOR (95%CI)p-valueOR (95%CI)p-valueOR (95%CI)p-value
Treatment
TURPRef-Ref-Ref-Ref-
PVP0.92 (0.86-0.98)0.010.90 (0.81-0.99)0.050.18 (0.17-0.19)< 0.010.98 (0.91-1.07)0.69
LEP0.66 (0.57-0.75)< 0.010.65 (0.52-0.82)< 0.010.50 (0.45-0.55)< 0.010.81 (0.68-0.97)0.02
FI Score
0Ref-Ref-Ref-Ref-
11.15 (1.07-1.24)< 0.011.16 (1.03-1.31)0.021.03 (0.97-1.08)0.381.20 (1.09-1.33)< 0.01
≥21.50 (1.37-1.63)< 0.011.63 (1.42-1.85)<0.011.31 (1.23-1.39)< 0.011.65 (1.48-1.85)< 0.01
Race
WhiteRef-Ref-Ref-Ref-
Black1.15 (1.02-1.30)0.031.16 (0.96-1.40)0.131.14 (1.04-1.25)< 0.011.16 (0.99-1.36)0.07
Hispanic1.05 (0.93-1.20)0.430.87 (0.70-1.09)0.241.01 (0.92-1.12)0.810.97 (0.81-1.17)0.78
Others1.14 (1.06-1.22)< 0.011.13 (1.01-1.25)0.032.48 (2.36-2.60)< 0.011.27 (1.16-1.38)< 0.01
Age
< 60Ref-Ref-Ref-Ref-
60-690.98 (0.88-1.10)0.760.96 (0.80-1.15)0.661.14 (1.05-1.24)< 0.010.83 (0.72-0.97)0.02
70-791.10 (0.98-1.22)0.111.17 (0.98-1.41)0.081.39 (1.28-1.51)< 0.011.02 (0.88-1.17)0.84
≥801.50 (1.33-1.69)< 0.011.47 (1.21-1.78)<0.011.92 (1.76-2.10)< 0.011.40 (1.20-1.63)< 0.01
Obesity
NoRef-Ref-Ref-Ref-
Yes0.98 (0.92-1.05)0.610.98 (0.89-1.09)0.730.91 (0.86-0.95)< 0.010.93 (0.86-1.02)0.11
ASA Score
ASA ≤ 2Ref-Ref-Ref-Ref-
ASA ≥ 31.28 (1.20-1.37)< 0.011.41 (1.27-1.57)< 0.011.25 (1.19-1.31)< 0.011.70 (1.55-1.86)< 0.01
Operative time
< 60 minutesRef-Ref-Ref-Ref-
60-120 minutes1.22 (1.15-1.30)< 0.011.10 (0.99-1.22)0.071.43 (1.36-1.50)< 0.011.01 (0.93-1.10)0.73
> 120 minutes1.73 (1.54-1.94)< 0.011.74 (1.46-2.08)< 0.012.35 (2.15-2.56)< 0.011.23 (1.04-1.44)0.01
Bleeding Diathesis
NoRef-Ref-Ref-Ref-
Yes1.87 (1.65-2.11)< 0.011.94 (1.61-2.32)< 0.011.59 (1.42-1.78)< 0.011.98 (1.70-2.30)< 0.01
Year of operation1.02 (1.01-1.03)< 0.011.04 (1.02-1.06)< 0.010.92 (0.90-0.92)< 0.011.07 (1.06-1.09)< 0.01

Table 3: Multinomial logistic regression to assess the predictors of receipt of different BPO surgery modalities (TURP vs. PVP vs. LEP) in function of baseline patient characteristics
Baseline CharacteristicsBPO Treatment Modalities
TURPPVPLEP
RRR (95%CI)p-valueRRR (95%CI)p-value
Frailty Index
1Reference1.02 (0.98-1.07)0.290.92 (0.85-0.99)0.04
≥2Reference1.00 (0.95-1.06)0.860.83 (0.75-0.92)< 0.01
Race/Ethnicity
BlackReference0.73 (0.67-0.79)< 0.010.59 (0.50-0.69)< 0.01
HispanicReference0.60 (0.56-0.66)< 0.010.38 (0.32-0.46)< 0.01
OthersReference0.70 (0.68-0.73)<0.010.31 (0.28-0.34)< 0.01
Age
60-69Reference0.98 (0.92-1.05)0.601.07 (0.96-1.20)0.22
70-79Reference1.01 (0.95-1.08)0.690.96 (0.86-1.08)0.51
≥80Reference1.06 (0.99-1.34)0.120.74 (0.65-0.86)< 0.01
Obesity
YesReference1.02 (0.98-1.06)0.291.12 (1.04-1.39)< 0.01
ASA Score
ASA ≥ 3Reference0.96 (0.92-0.99)0.030.78 (0.72-0.84)< 0.01
Bleeding Diathesis
YesReference1.51 (1.37-1.66)< 0.011.12 (1.04-1.21)< 0.01
Year of surgery
Reference0.94 (0.94-0.95)< 0.011.10 (1.09-1.12)< 0.01

Table 4: Unadjusted and weighted proportions for any complications, major complications, extended LOS, and readmission with endoscopic BPO surgeries (TURP, PVP, and LEP)
Surgical OutcomesTURPPVPLEP
UnadjustedWeightedUnadjustedWeightedUnadjustedWeighted
Any complications8.65 (8.37-8.94)8.63 (8.34-8.91)8.0 (7.59-8.36)8.0 (7.58-8.40)6.28 (5.52-7.14)6.29 (5.48-7.20)
Major complications3.28 (3.11-3.47)3.28 (3.11-3.47)2.97 (2.73-3.22)2.93 (2.69-3.20)2.45 (1.98-3.02)2.30 (1.83-2.89)
LOS ≥ 226.0 (25.6-26.4)25.6 (25.2-26.0)6.30 (5.97-6.66)5.98 (5.63-6.34)12.9 (11.8-14..0)12.4 (11.3-13.7)
Readmission4.89 (4.68-5.11)4.83 (4.62-5.04)4.74 (4.44-5.05)4.52 (4.22-4.84)3.86 (3.27-4.56)3.80 (3.18-4.53)


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