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) | ||||
| Variables | Treatment | p-values | ||
| TURP (38,399) | PVP (19,121) | LEP (3,797) | ||
| Baseline Characteristics | ||||
| 5i-FI score | ||||
| Score 0 | 12,894 (33.8%) | 6,330 (33.1%) | 1,454 (38.3%) | < 0.001 |
| Score 1 | 16,708 (43.5%) | 8,492 (44.4%) | 1,628 (42.9%) | |
| Score 2 | 8,707 (22.7%) | 4,299 (22.5%) | 715 (18.8%) | |
| Age | ||||
| < 60 | 4,081 (10.6%) | 1,981 (10.4%) | 445 (11.7%) | < 0.001 |
| 60 – 69 | 12,558 (32.7%) | 6,073 (31.8%) | 1,432 (37.1%) | |
| 70 – 79 | 14,361 (37.4%) | 7,160 (37.4%) | 1,403 (36.9%) | |
| 80 | 7,398 (19.3%) | 3,907 (20.4%) | 517 (13.6%) | |
| Race | ||||
| White | 22,608 (58.9%) | 13,011 (68.1%) | 3,008 (79.2%) | < 0.001 |
| Black | 2,309 (6%) | 943 (4.9%) | 185 (4.9%) | |
| Hispanic | 2,354 (6.1%) | 811 (4.2%) | 125 (3.3%) | |
| Other | 11,128 (29%) | 4,356 (22.8%) | 479 (12.6%) | |
| ASA classification | ||||
| 1-2 | 18,158 (47.4%) | 9,004 (47.2%) | 2,037 (53.7%) | < 0.001 |
| 3 | 20,132 (52.6%) | 10,088 (52.8%) | 1,759 (46.3%) | |
| Obesity | ||||
| No | 26,097 (68%) | 12,931 (67.6%) | 2,462 (64.8%) | < 0.001 |
| Yes | 12,302 (32%) | 6,190 (32.4%) | 1,335 (35,2%) | |
| Bleeding Diathesis | ||||
| No | 37,335 (97.2%) | 18,301 (95.7%) | 3,684 (97%) | < 0.001 |
| Yes | 1,064 (2.8%) | 820 (4.3%) | 114 (3%) | |
| Surgical Outcomes | ||||
| Total operative time | ||||
| < 60 min | 24,392 (63.5%) | 12,470 (65.2%) | 965 (25.4%) | < 0.001 |
| 60 – 120min | 12,198 (31.8%) | 5,868 (30.7%) | 1,749 (46.1%) | |
| > 120 min | 1,809 (4.7%) | 783 (4.1%) | 1,083 (28.5%) | |
| Length of Stay | ||||
| 0 day | 7,478 (19.5%) | 13,274 (69.4%) | 1,105 (29.1%) | < 0.001 |
| 1 day | 20,938 (54.3%) | 4,642 (24.3%) | 2,116 (55.7%) | |
| > 2 days | 9,983 (26%) | 1,205 (6.3%) | 576 (15.2%) | |
| Clavien-Dindo | ||||
| Grade 1-2 | 2,060 (5.4%) | 956 (5%) | 153 (4%) | < 0.001 |
| Grade 3 | 639 (1.7%) | 205 (1.1%) | 53 (1.4%) | |
| Grade 4 | 519 (1.3%) | 317 (1.7%) | 34 (0.9%) | |
| Grade 5 | 104 (0.3%) | 45 (0.2%) | 4 (0.1%) | |
| Readmission | 1,877 (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) | ||||||||
| Predictors | Outcomes | |||||||
| Any Complication | Major Complication | LOS ≥ 2 days | Readmission | |||||
| OR (95%CI) | p-value | OR (95%CI) | p-value | OR (95%CI) | p-value | OR (95%CI) | p-value | |
| Treatment | ||||||||
| TURP | Ref | - | Ref | - | Ref | - | Ref | - |
| PVP | 0.92 (0.86-0.98) | 0.01 | 0.90 (0.81-0.99) | 0.05 | 0.18 (0.17-0.19) | < 0.01 | 0.98 (0.91-1.07) | 0.69 |
| LEP | 0.66 (0.57-0.75) | < 0.01 | 0.65 (0.52-0.82) | < 0.01 | 0.50 (0.45-0.55) | < 0.01 | 0.81 (0.68-0.97) | 0.02 |
| FI Score | ||||||||
| 0 | Ref | - | Ref | - | Ref | - | Ref | - |
| 1 | 1.15 (1.07-1.24) | < 0.01 | 1.16 (1.03-1.31) | 0.02 | 1.03 (0.97-1.08) | 0.38 | 1.20 (1.09-1.33) | < 0.01 |
| ≥2 | 1.50 (1.37-1.63) | < 0.01 | 1.63 (1.42-1.85) | <0.01 | 1.31 (1.23-1.39) | < 0.01 | 1.65 (1.48-1.85) | < 0.01 |
| Race | ||||||||
| White | Ref | - | Ref | - | Ref | - | Ref | - |
| Black | 1.15 (1.02-1.30) | 0.03 | 1.16 (0.96-1.40) | 0.13 | 1.14 (1.04-1.25) | < 0.01 | 1.16 (0.99-1.36) | 0.07 |
| Hispanic | 1.05 (0.93-1.20) | 0.43 | 0.87 (0.70-1.09) | 0.24 | 1.01 (0.92-1.12) | 0.81 | 0.97 (0.81-1.17) | 0.78 |
| Others | 1.14 (1.06-1.22) | < 0.01 | 1.13 (1.01-1.25) | 0.03 | 2.48 (2.36-2.60) | < 0.01 | 1.27 (1.16-1.38) | < 0.01 |
| Age | ||||||||
| < 60 | Ref | - | Ref | - | Ref | - | Ref | - |
| 60-69 | 0.98 (0.88-1.10) | 0.76 | 0.96 (0.80-1.15) | 0.66 | 1.14 (1.05-1.24) | < 0.01 | 0.83 (0.72-0.97) | 0.02 |
| 70-79 | 1.10 (0.98-1.22) | 0.11 | 1.17 (0.98-1.41) | 0.08 | 1.39 (1.28-1.51) | < 0.01 | 1.02 (0.88-1.17) | 0.84 |
| ≥80 | 1.50 (1.33-1.69) | < 0.01 | 1.47 (1.21-1.78) | <0.01 | 1.92 (1.76-2.10) | < 0.01 | 1.40 (1.20-1.63) | < 0.01 |
| Obesity | ||||||||
| No | Ref | - | Ref | - | Ref | - | Ref | - |
| Yes | 0.98 (0.92-1.05) | 0.61 | 0.98 (0.89-1.09) | 0.73 | 0.91 (0.86-0.95) | < 0.01 | 0.93 (0.86-1.02) | 0.11 |
| ASA Score | ||||||||
| ASA ≤ 2 | Ref | - | Ref | - | Ref | - | Ref | - |
| ASA ≥ 3 | 1.28 (1.20-1.37) | < 0.01 | 1.41 (1.27-1.57) | < 0.01 | 1.25 (1.19-1.31) | < 0.01 | 1.70 (1.55-1.86) | < 0.01 |
| Operative time | ||||||||
| < 60 minutes | Ref | - | Ref | - | Ref | - | Ref | - |
| 60-120 minutes | 1.22 (1.15-1.30) | < 0.01 | 1.10 (0.99-1.22) | 0.07 | 1.43 (1.36-1.50) | < 0.01 | 1.01 (0.93-1.10) | 0.73 |
| > 120 minutes | 1.73 (1.54-1.94) | < 0.01 | 1.74 (1.46-2.08) | < 0.01 | 2.35 (2.15-2.56) | < 0.01 | 1.23 (1.04-1.44) | 0.01 |
| Bleeding Diathesis | ||||||||
| No | Ref | - | Ref | - | Ref | - | Ref | - |
| Yes | 1.87 (1.65-2.11) | < 0.01 | 1.94 (1.61-2.32) | < 0.01 | 1.59 (1.42-1.78) | < 0.01 | 1.98 (1.70-2.30) | < 0.01 |
| Year of operation | 1.02 (1.01-1.03) | < 0.01 | 1.04 (1.02-1.06) | < 0.01 | 0.92 (0.90-0.92) | < 0.01 | 1.07 (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 Characteristics | BPO Treatment Modalities | ||||
| TURP | PVP | LEP | |||
| RRR (95%CI) | p-value | RRR (95%CI) | p-value | ||
| Frailty Index | |||||
| 1 | Reference | 1.02 (0.98-1.07) | 0.29 | 0.92 (0.85-0.99) | 0.04 |
| ≥2 | Reference | 1.00 (0.95-1.06) | 0.86 | 0.83 (0.75-0.92) | < 0.01 |
| Race/Ethnicity | |||||
| Black | Reference | 0.73 (0.67-0.79) | < 0.01 | 0.59 (0.50-0.69) | < 0.01 |
| Hispanic | Reference | 0.60 (0.56-0.66) | < 0.01 | 0.38 (0.32-0.46) | < 0.01 |
| Others | Reference | 0.70 (0.68-0.73) | <0.01 | 0.31 (0.28-0.34) | < 0.01 |
| Age | |||||
| 60-69 | Reference | 0.98 (0.92-1.05) | 0.60 | 1.07 (0.96-1.20) | 0.22 |
| 70-79 | Reference | 1.01 (0.95-1.08) | 0.69 | 0.96 (0.86-1.08) | 0.51 |
| ≥80 | Reference | 1.06 (0.99-1.34) | 0.12 | 0.74 (0.65-0.86) | < 0.01 |
| Obesity | |||||
| Yes | Reference | 1.02 (0.98-1.06) | 0.29 | 1.12 (1.04-1.39) | < 0.01 |
| ASA Score | |||||
| ASA ≥ 3 | Reference | 0.96 (0.92-0.99) | 0.03 | 0.78 (0.72-0.84) | < 0.01 |
| Bleeding Diathesis | |||||
| Yes | Reference | 1.51 (1.37-1.66) | < 0.01 | 1.12 (1.04-1.21) | < 0.01 |
| Year of surgery | |||||
| Reference | 0.94 (0.94-0.95) | < 0.01 | 1.10 (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 Outcomes | TURP | PVP | LEP | |||
| Unadjusted | Weighted | Unadjusted | Weighted | Unadjusted | Weighted | |
| Any complications | 8.65 (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 complications | 3.28 (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 ≥ 2 | 26.0 (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) |
| Readmission | 4.89 (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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