Low testosterone (T) has been associated with anemia,¹ decreased muscle mass,^2,3 frailty,^4-6 risk of cardiovascular disease,^7,8 and overall lower health-related quality of life. Given the high prevalence of low T in the general population and increasing prevalence with age,⁹ a large proportion of men undergoing transurethral procedures for benign prostatic hyperplasia (BPH) are likely to have low T. Furthermore, in light of the many potential consequences of low circulating androgens, we hypothesized that low T may adversely impact perioperative outcomes for patients undergoing surgical procedures in a variety of ways. We sought to characterize the prevalence of low T and the association between low T, frailty, and perioperative outcomes in patients undergoing transurethral resection of the prostate (TURP) and laser photovaporization of the prostate (PVP).

We performed a retrospective evaluation of men across our integrated health care system who underwent TURP or PVP and had a recorded T level within 1 year prior to their procedure date. We determined the prevalence of low T using the cutoff of 300 ng/dL according to the AUA Guideline on Testosterone Deficiency.¹⁰ We then compared the clinical characteristics, lab values, and Hospital Frailty Risk Scores of patients with and without low T. Descriptive statistics were performed using t-test and chi-squared test, where applicable. Univariate and multivariate regression were performed to determine the association between low T, frailty, and specific perioperative outcomes.

Among 181 patients who underwent either TURP or PVP, 89 (49%) had low T (see Table). Mean preoperative T was 176.0 (±100.9) vs 471.7 (±162.4) ng/dL in the low vs normal T group (P < .001). Patients with low T were older (68.7±9.2 vs 64.8±11.7 years old, P = .014) and had longer postoperative stays (4.1±10.3 vs 1.4±0.9 days, P = .03), and lower postoperative hemoglobin (12.5±2.0 vs 13.8±1.7, P < .001) and hematocrit (37.3±6.0 vs 41.0±4.7, P < .001) values. Patients with low T also had higher rates of readmission within 180 days (28% vs 13%, P = .020). T was not independently associated with frailty (P = .6). On multivariable analysis, both Hospital Frailty Risk Score and low preoperative T were independently associated with 180-day readmission on multivariable analysis (OR 1.04, 95% CI 1.00-1.07, P = .05 and OR 1.00, 95% CI 0.99-1.0, P = .002, respectively).

We found that almost half of men undergoing transurethral prostate surgery had low T. The relationship between low T and BPH is complex.¹¹ T is trophic for prostatic tissue, and it is widely recognized that antiandrogenic therapies such as GnRH agonists and 5-a reductase inhibitors can lead to decreased prostate volume.^12,13 Yet, low T does not preclude the development of lower urinary tract symptoms due to BPH, as evidenced by the high number of men undergoing transurethral procedures with low T. Furthermore, the effect of low T on prostatic angiogenesis and fibrosis is not fully characterized, and this may have implications for intraoperative bleeding and operative approaches in men with low T.

While low T was not independently associated with frailty, both low T and frailty were independently associated with higher risk of 180-day readmission. These data provide a signal that low T may be an independent risk factor for adverse perioperative outcomes after transurethral surgery, indicating a potential for T assessment and possibly treatment preoperatively. Future prospective studies are needed to better characterize the role of low T in perioperative outcomes and to determine the potential role for T replacement therapy in optimizing both perioperative and patient-reported outcomes, particularly given the complex relationship between T and prostatic growth.