5-item Frailty Index Predicts Complications of Endoscopic Treatment for Benign Prostatic Obstruction

Urologist pointing to anatomical model of male reproductive system

The frailty index can identify patients with a reduced physiologic reserve who may be less able to recover from major stressors, including surgery. In urology, the 5-item Frailty Index (5i-FI) has accurately predicted morbidity and mortality after radical prostatectomy, cystectomy, and partial nephrectomy.

Researchers at Brigham and Women’s Hospital now report that the 5i-FI is also useful for predicting surgical complications after endoscopic treatment for benign prostatic obstruction (BPO). Muhieddine Labban, MD, research fellow at the Division of Urological Surgery, Nicola Frego, MD, formerly a research fellow there, Quoc-Dien Trinh, MD, MBA, director of Ambulatory Clinical Operations for the Division of Urology and section chief at Brigham and Women’s Faulkner Hospital, and colleagues published their findings in the World Journal of Urology.


The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) prospectively collects risk-adjusted and validated 30-day outcomes data from hospitals both within and outside the U.S. From its registry, the researchers identified 61,317 patients who underwent the three most common procedures for treating BPO:

  • Transurethral resection of the prostate (TURP)—38,399 patients
  • Photoselective vaporization of the prostate (PVP)—19,121
  • Laser enucleation of the prostate (LEP)—3,797

The 5i-FI was calculated for each patient. One point each is assigned for:

  • Congestive heart failure
  • Presence of insulin-dependent or noninsulin-dependent diabetes mellitus
  • History of chronic obstructive pulmonary disease or pneumonia within 30 days before surgery
  • Totally or partially dependent functional health status at the time of surgery
  • Presence of hypertension requiring medication

Patients were categorized as having zero, one, two, or more risk factors.

Predictors of Complications

In multivariable analyses, patients with a 5i-FI score ≥2 had higher odds of the following, independent of the endoscopic procedure performed (P<0.01 for all):

  • Any complication—OR, 1.50
  • A major complication—OR, 1.63
  • Length of stay ≥2 days—OR, 1.31
  • Unplanned readmission—OR, 1.65

Weighted Rates of Complications by Modality

The researchers then used inverse probability of treatment weighting propensity score analysis to simulate the effects of randomly allocating patients to one of the three endoscopic treatments. This process balanced the groups on frailty index, age, race, obesity, American Society of Anesthesiology score, bleeding diathesis, and year of surgery.

By modality, the weighted rates of complications were:

  • TURP—8.63%
  • PVP—8.0%
  • LEP—6.29%

Compared with TURP, LEP was associated with significantly less risk of readmission, and both PVP and LEP were associated with significantly shorter hospital stays. Yet, patients with 5i-FI score ≥2 and older men were less likely to receive LEP than TURP.

These findings suggest preoperative assessment with the 5i-FI is likely to improve the stratification of surgical risk and could guide more individualized decision-making about the choice of endoscopic procedure for BPO.

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