More than 45% of individuals ages 65 years or older who are seeking care for urological conditions are either prefrail or frail, meaning that they have a clinical phenotype that predisposes them to physiologic disability.¹ This astoundingly high number is worrisome because frailty is known to be associated with poor outcomes such as increased risk of hospitalizations, falls, adverse treatment outcomes and even death. Specific to urological surgery, frailty has been shown to be associated with poor surgical outcomes including increased rates of postoperative complications, postoperative functional decline and discharge to skilled or assisted living facilities.

The majority of the urological literature on frailty demonstrates the unsurprising finding that frail older adults undergoing urological surgery have higher rates of postoperative complications compared to nonfrail older adults. This has been demonstrated repeatedly and for various different types of urological procedures such as radical prostatectomy, nephrectomy, cystectomy, retropubic sling placement, transurethral resection of the prostate (TURP), hydrocelectomy and orchiectomy among many others.^2,3 Interestingly, one study evaluating 95,108 patients undergoing 21 different types of urological procedures of varying complexity using data from the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) Program found not only that rates of major and minor complications increased with increasing frailty, but also that this trend was consistent regardless of the complexity of the surgery being performed.⁴ Furthermore, even a seemingly small procedure such as a midurethral sling or a hydrocele repair may have high rates of complications among frail individuals, raising the point that no procedures are small procedures in this vulnerable population.

While postoperative complications are important, there are many other surgical outcomes that are arguably just as important or even more meaningful to many older adults. These include postoperative functional decline. One study looked at patients ages 75 years and older undergoing curative surgery for urologic malignancy and using the Clinical Frailty Scale (CFS) to measure preoperative frailty. The study evaluated 82 individuals and found that those with CFS scores ≥5 demonstrated 8.5-times and 21.4-times higher risks for a decline in their activities of daily living (ADLs) within 30 and 90 days postoperatively, respectively.⁵ Another study that focused on frail nursing home residents undergoing seemingly minor urological procedures (cystoscopy, bladder biopsy, transurethral resection of bladder tumor, prostate biopsy, TURP, prostate biopsy, removal of ureteral obstruction and suprapubic tube placement) demonstrated functional decline that persisted up to 1 year after surgery and never recovered to the collective preoperative functional baseline.⁶ These findings are alarming and highlight the important and lasting functional impairment that can result from even seemingly minor urological surgery. Certainly, many older adults may choose to forgo (especially elective) urological surgery if they knew that they may not be able to maintain their preoperative functional baseline long after surgery.

Another important surgical outcome for older adults is discharge to a skilled or assisted living facility, which represents a loss of independence to many older adults. One study looking at commonly performed urological surgery using the ACS-NSQIP database evaluated 20,794 patients ages 65 years and older undergoing 19 different urological procedures and found that 25% of patients undergoing surgery were defined as frail and 9.8% were discharged to a skilled or assisted living facility. This finding was consistent across a variety of types of urological procedures ranging from TURP to cystectomy and partial nephrectomy.⁷

In summary, frailty has been demonstrated to be associated with increased rates of postoperative complications, sustained functional decline and discharge to skilled or assisted living facilities in older adults undergoing a variety of common urological procedures. Of note, these findings are surprisingly consistent across procedures of varying complexity, underscoring the real-world risks of performing any type of surgery in frail older adults. An understanding of frailty and its associated potential outcomes are important both for surgical decision making/counseling and potential opportunities for prehabilitation and preoperative optimization among frail older adults who decide to proceed with surgery. Ultimately, this knowledge is essential to ensure that frail older adults have the knowledge to make surgical decisions that are aligned with their priorities and goals of care.