This work aimed to evaluate the safety and efficacy of holmium laser enucleation of the prostate across different degrees of frailty using the 11-item and 5-item modified frailty indices and to compare perioperative and postoperative outcomes across multiple frailty thresholds.
We retrospectively reviewed patients who underwent HoLEP at our institution between July 2017 and August 2025. Frailty was assessed using mFI-11 (cutoffs ≥0.18, ≥0.27, ≥0.36) and mFI-5 (≥0.40). Perioperative variables, functional outcomes, and postoperative complications were compared. Agreement between frailty definitions was assessed using Cohen's kappa. Logistic regression was used to evaluate complication risk.
Among 857 patients, overall frailty burden was low ranging from 16.2% with mFI-11 ≥0.36 to 52.6% with mFI-11 ≥0.18, and 27.5% by mFI-5 ≥0.40. Functional outcomes improved in all groups, though patients defined as frail by mFI-11 ≥0.36 demonstrated less improvement in IPSS at 1 year and lower Qmax at select time points. Major complications were uncommon and did not demonstrate a consistent frailty gradient. Transfusion risk was higher only at mFI-11 ≥0.36. Urinary tract infection showed a dose-response relationship with increasing mFI-11, with approximately a 20% increase in odds per one-point increase.
HoLEP is safe and effective across frailty definitions. Frailty cutoff selection meaningfully influences risk stratification, with mFI-11 ≥0.36 providing the most clinically informative discrimination.
BJUI compass. 2026 Jul 08*** epublish ***
Hasim Bakbak, Gurpremjit Singh, Ahmad Abdelaziz, Adam Williams, Juanita Velasquez Ospina, Jonathan E Katz, Robert Marcovich, Alan Jerome Wein, Hemendra N Shah
Desai Sethi Urology Institute University of Miami Miller School of Medicine Miami Florida USA.