Stress urinary incontinence (SUI) is a common complication after treatment for prostate cancer. Subsequent SUI surgery, including artificial urinary sphincter (AUS) and male urethral sling placement, is commonly performed in older men, many of whom are also frail. Frailty, a state of decreased physiologic reserve and function, has been shown to increase the risk of AUS removal and post-operative complications. This study examined the association between frailty and postoperative complications and procedure revisions in men undergoing AUS and male urethral sling placement.
This is a retrospective cohort study of 100% fee-for-service Medicare beneficiaries ages 66 years and older who underwent AUS or male urethral sling placement between 2014-2016. Baseline frailty was quantified for each subject using the Claims-Based Frailty Index (CFI), a validated measure of frailty in Medicare data, and comorbidity was quantified using the Charlson comorbidy index (CCI). Subjects were categorized as not frail (CFI<0.15), pre-frail (0.15≤CFI<0.25), and mildly-to-severely frail (CFI≥0.25). Primary outcomes were 30-day post-operative complications and AUS/male urethral sling removal or revision.
In total, 7252 beneficiaries underwent SUI surgery: 2739 underwent male urethral sling placement and 4514 underwent AUS. Beneficiaries were not frail (N=3936, 54.27%), pre-frail (N=2995, 41.3%) and mildly-to-severely frail (N=321, 4.43%). Increased risk of 30-day post-operative complications was associated with pre-frail and mildly-to-severely frail compared to not frail (RR 1.47, p<0.001 and RR 2.46, p<0.001, respectively), age ≥75 years compared to 65-74 years (global p-value <0.001), and CCI ≥1 compared to 0 (global p-value <0.001). Beneficiaries who were pre-frail (RR 1.17, p=0.03) and mildly-to-severely frail (RR 1.31, p=0.04) or age ≥75 years compared to age 65-74 (global p-value=0.0002) were at significantly higher risk of AUS or sling revision or removal within 1 year, though this was not associated with CCI (global p-value=0.2).
Among beneficiaries undergoing surgery for male SUI, frailty, age, and comorbidity were significantly associated with 30-day surgical complications, but only age and frailty were associated with AUS/male urethral sling revision and removal. These findings suggest that frailty is an important factor in the preoperative assessment of patients undergoing consideration for male SUI surgery and may be a predictor of adverse surgical outcomes.
