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Frailty as a Continuous Predictor of Postoperative Outcomes Following Midurethral Sling Surgery
Rachel C. Bernardo, BS1, Meredith C. Wasserman, MD2.
1The George Washington University School of Medicine and Health Sciences, Washington, DC, USA, 2Division of Urology, Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA.

BACKGROUND: Frailty is increasingly recognized as a predictor of poor postoperative outcomes, but its role in midurethral sling surgery for stress urinary incontinence remains unclear. Prior studies have used binary definitions of frailty, which may miss dose-dependent associations.
METHODS: We conducted a retrospective cohort study of 15,384 patients who underwent midurethral sling surgery from 2019-2023 using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Frailty was measured using the 5-factor Modified Frailty Index (mFI-5) and analyzed as a continuous variable. Outcomes included prolonged length of stay (>0 days), 30-day readmission, urinary tract infection (UTI), unplanned reoperation, and prolonged operative time (top quartile). Multivariable logistic regression was used to evaluate associations between mFI-5 score and each outcome, adjusting for age, body mass index (BMI), and race/ethnicity.
RESULTS: The cohort had a mean age of 55.4 years (SD 12.9) and mean BMI of 30.5 kg/mē (SD 7.2). Frailty was uncommon; 2.1% of patients had an mFI-5 score ≥2. Higher mFI-5 scores were independently associated with prolonged length of stay (OR 1.34, 95% CI: 1.33-1.35), 30-day readmission (OR 1.61, 95% CI: 1.58-1.63), unplanned reoperation (OR 1.57, 95% CI: 1.54-1.60), and prolonged operative time (OR 1.09, 95% CI: 1.08-1.10), all p<0.001. There was no association with UTI.
CONCLUSIONS: Frailty, when measured as a continuous variable, was independently associated with multiple adverse outcomes following midurethral sling surgery. Even in a low-frailty population, increasing frailty conferred measurable risk. Incorporating frailty into preoperative assessment may improve individualized risk prediction, guide perioperative planning, and help identify patients who may benefit from additional prehabilitation or postoperative support.
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