Trends in rates and outcomes of benign prostatic hyperplasia surgeries: a retrospective cohort study using the ACS-NSQIP database (2008–2021)

Abstract

Background

Advancements in surgical techniques have led to a shift in the types of procedures performed for BPH. This study aims to analyze trends in rates and outcomes of surgical procedures for BPH between 2008 and 2021.

Methods

Using the ACS-NSQIP database, patients who underwent BPH surgery between 2008 and 2021 were identified. Trends, baseline characteristics and perioperative outcomes were collected for transurethral resection of prostate (TURP), photo-vaporization of prostate (PVP), Laser enucleation of the prostate (LEP) and simple prostatectomy.

Results

A total of 99,291 BPH procedures were recorded, increasing from 850 in 2008 to 11,005 in 2021. TURP was the most performed procedure with rates rising from 56.1% in 2008 to 65.2% in 2021. PVP was the second most performed procedure, with rates decreasing from 41.6% in 2008 to 22.5% in 2021. LEP procedures were not recorded prior to 2011 after which the number increased from 82 (2.6%) procedures in 2011 to 971 (8.8%) in 2021. Simple prostatectomy had a relatively stable rate over the course of 14 years (1.8%-3.4%). Over time, a reduction in hospital stay (1.3 to 1.1 days, p < 0.001), and an increase in operative time were observed (55 min ± 31.81 to 66 min ± 46.6, p < 0.001).

Conclusions

There has been a noticeable shift in the surgical management of BPH between 2008 and 2021, with a clear trend favoring novel techniques. Utilizing these approaches has led to improvements in perioperative outcomes. Further research is necessary to evaluate long-term outcomes and cost-effectiveness of novel techniques.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12894-026-02255-6.

Background

Benign prostatic hyperplasia (BPH) is a common condition among men with increasing prevalence after the age of 50, reaching up to 80% at the age of 80 [1]. While often asymptomatic, bladder outlet obstruction (BOO) may necessitate treatment, including medical or surgical options. Surgical treatment of BPH is indicated when patients suffer from refractory symptoms despite optimal medical therapy [2], or when they develop complications associated with BPH such as recurrent infections, urinary retention, etc [3].

Transurethral resection of the prostate (TURP) is the gold standard surgical treatment for BOO due to prostate glands < 80 g [4]. Open simple prostatectomy (OSP), or Robot-assisted simple prostatectomy (RSP) are utilized for prostate glands larger than 100 g in size [3]. However, the high rate of complications with these procedures—including bleeding and prolonged operative time in OSP and RSP, and TUR syndrome in TURP [4] — has led to the evolution of surgical techniques, notably laser-based procedures.

Photo-vaporization of the prostate (PVP) and Laser enucleation of the prostate (LEP) are relatively new modalities that have gained popularity and are being widely adopted due to their demonstrated safety and efficacy [5, 6]. PVP, using the Greenlight laser, benefits high-risk patients by eliminating the need to stop anticoagulants [7], while LEP, especially Holmium Laser Enucleation (HoLEP), effectively treats larger prostates with minimal invasiveness, positioning it as a new gold standard [8].

The main objective of our paper is to examine the trends in the different types of procedures performed for BPH between the years 2008 and 2021. We also aim at comparing general perioperative outcomes and complications associated with these different modalities and their trends between 2016 and 2021.

Methods

Patient population

The ACS-NSQIP database is a comprehensive, multicenter, and prospectively collected registry that captures detailed perioperative and 30-day postoperative outcomes from a diverse range of surgical procedures across participating institutions.

Patients undergoing BPH procedures between 2008–2021 were identified and grouped according to the surgery type. The annual trend analysis for pre-operative characteristics and perioperative outcomes and complications were reported for patients who underwent BPH procedures between 2016 and 2021, since data from previous years were described in a paper by Anderson et al. [9]. The following Current Procedural Terminology (CPT) codes were used to identify the patients: TURP (CPT 52601), PVP (CPT 52648), LEP (CPT 52649) and simple prostatectomy (CPT 55821 – suprapubic, CPT 55831 – retropubic). For simple prostatectomy, there was no CPT code to specify the robotic approach (a laparoscopic simple prostatectomy code was introduced in Jan 2023), hence we could not distinguish between open and robotic approaches. Patients who are coded to have prostate cancer through International Classification of Diseases (ICD) codes (ICD10: C61, ICD9:185) were excluded from the study. No formal sample size calculation was performed, as this was a retrospective study using the ACS-NSQIP database. All patients meeting the predefined inclusion criteria during the study period were included. This study was designed and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines to ensure transparency and completeness in reporting observational research.”

Ethics approval and consent to participate

The de-identified database (ACS-NSQIP) does not constitute human subject research. Individual informed consent was not required for this study as the data were de-identified and are publicly available to participating institutions under data use agreements. Moreover, no institutional review board approval was required or attained from the participating centers as this study was exempt from IRB review by the American University of Beirut Medical Center IRB review committee. This study adheres to the principles outlined in the Declaration of Helsinki where applicable.

Clinical variables

The primary variables of interest included patient demographics, baseline characteristics: age, race, Body Mass Index (BMI), smoking, diabetes, preoperative serum creatinine and hematocrit. Other variables included: American Society of Anesthesiology (ASA) class, type of anesthesia, admission status and bleeding disorders. Additionally, the temporal variable year of surgery, was considered to evaluate trends over time. All variables were obtained from the ACS-NSQIP database, which utilizes standardized definitions and trained clinical reviewers for data collection. This ensures consistency and comparability of variable measurement across institutions and surgical groups.

Outcomes of interest

Perioperative outcomes were compared based on the Clavien-Dindo classification with complications of interest adapted to the ACS-NSQIP. These complications included: Pneumonia, urinary tract infection, deep vein thrombosis, progressive renal insufficiency, bleeding requiring transfusion (Grade I and II) - Unplanned Reoperation. (Grade III)- Sepsis, pulmonary embolism, myocardial infarction, acute renal failure necessitating dialysis, stroke (Grade IV)- Mortality (Grade V). Other outcomes of interest included length of hospital stay and total operation time.

Statistical analysis

Descriptive statistics were used to summarize patient characteristics and outcomes. Categorical variables were presented as frequency (percentages), while continuous variables were presented as mean (standard deviation). Chi-square, Fisher’s exact and ANOVA tests were used to compare categorical and continuous variables between the different procedures. Statistical significance was set as p < 0.05. No formal multivariable adjustment for confounding was performed. Instead, baseline characteristics were compared across groups to assess potential differences. Missing data were handled using complete case analysis, whereby observations with missing values for specific variables were excluded from the respective analyses. No imputation or sensitivity analyses were performed. The proportion of missing data for individual variables was not explicitly quantified. All analysis was performed using IBM SPSS Statistic Version 29. Several potential sources of bias were considered in this study. Selection bias was minimized by including all eligible patients from the ACS-NSQIP database based on predefined procedural (CPT) codes. Information bias was reduced through the use of standardized data collection methods within ACS-NSQIP, which relies on trained clinical reviewers and uniform variable definitions across participating institutions. Confounding was addressed by comparing baseline characteristics across procedure groups and performing appropriate statistical analyses to evaluate differences between groups. Despite these measures, residual confounding inherent to retrospective observational studies may persist.

Results

A total of 99,291 BPH procedures were recorded in the ACS-NSQIP database between 2008 and 2021, increasing from 850 in 2008 to 11,005 in 2021. Overall, TURP was the most commonly performed procedure, accounting for 62,988 cases (63.4%), followed by PVP with 27,283 cases (27.5%), LEP with 5,958 cases (6.0%), and simple prostatectomy with 3,062 cases (3.1%).

Over time, TURP remained the dominant modality, increasing from 477 procedures (56%) in 2008 to 7,180 (65.2%) in 2021. In contrast, PVP showed a decline in relative contribution, decreasing from 41.6% in 2008 to 22.5% in 2021. LEP procedures were not recorded prior to 2011; following their introduction, they increased from 82 cases (2.6%) in 2011 to 971 (8.8%) in 2021. Simple prostatectomy was the least frequently performed procedure, with 19 cases (2.2%) in 2008 and a gradual increase to 379 cases (3.4%) in 2021 (Table 1S, Fig. 1).

Fig. 1.

Benign Prostatic Hypertrophy operation yearly trends between the years 2008 and 2021; (TURP: Transurethral resection of prostate, PVP: photovaporization of the prostate, LEP: Laser enucleation of the prostate; OSP: simple prostatectomy

The average age of the participants between 2016 and 2021 was 71 years (± 9) in all BPH procedures. Most participants were of White ethnicity (63.1%). Locoregional anesthesia was utilized in 12.8–20.2% and in 3.5–15% of TURP and PVP respectively. General anesthesia was utilized in more than 90% of LEP procedures and almost exclusively in Simple Prostatectomy throughout all years (Table 2 S). PVP had the highest prevalence of bleeding disorders in all years ranging from 3.6 to 4.7% (Table 2 S). Operative time was highly variable in all years (p < 0.001) and exhibited a significant overall increase starting with 55 min (± 31.81) in 2008 to 66 min (± 46.6) in 2021 (Table 2 S, Fig. 2C). LEP and Simple Prostatectomy followed the same overall increase in operative time while TURP and PVP remained relatively constant in duration over the years. The longest operation was Simple Prostatectomy with an increasing range of 101 to 158 min through the years of the study followed by LEP with 88 to 111 min (Table 1). Moreover, length of stay was variable among all groups in all studied years (p < 0.001). Simple Prostatectomy was the longest with 3 to 4 days. Nevertheless, an overall downtrend was noted between 2011 and 2021 as the average hospital stay for all procedures had decreased from 1.3 to 1.1 days (p < 0.001) (Fig. 2B).

Fig. 2.

Yearly complication trends using Clavien-Dindo classification (A), length of hospital stay (B) and operation time (C) trends between 2008 and 2021

Table 1.

Yearly outcome trends divided by procedure type between the years 2016 and 2021

	TURP	PVP	LEP	Simple prostatectomy	p-value
2016
Pneumonia	19 (0.3%)	11 (0.4%)	3 (0.6%)	4 (1.4%)	0.02
Urinary Tract Infection	327 (4.8%)	145 (5.1%)	19 (3.5%)	16 (5.5%)	0.4
DVT	14 (0.2%)	5 (0.2%)	3 (0.6%)	2 (0.7%)	0.1
Progressive Renal Insufficiency	10 (0.1%)	7 (0.2%)	2 (0.4%)	0 (0.0%)	0.3
Bleeding Transfusions	95 (1.4%)	10 (0.3%)	8 (1.5%)	42 (14.4%)	< 0.001
Length of hospital stay	1.5 (3)	0.5 (1.8)	1.2 (1.9)	3.5 (2.9)	< 0.001
Operation time	56.28 (36.3)	56.22 (34.53)	95.7 (56.24)	130.01 (63.69)	< 0.001
2017
Pneumonia	19 (0.3%)	14 (0.5%)	0 (0.0%)	2 (0.6%)	0.1
Urinary Tract Infection	372 (5.1%)	176 (5.8%)	21 (3.6%)	17 (5.1%)	0.1
DVT	21 (0.3%)	2 (0.1%)	1 (0.2%)	6 (1.8%)	< 0.001
Progressive Renal Insufficiency	21 (0.3%)	5 (0.2%)	0 (0.0%)	4 (1.2%)	0.02
Bleeding Transfusions	112 (1.5%)	7 (0.2%)	3 (0.5%)	52 (15.5%)	< 0.001
Length of hospital stay	1.5 (3)	0.5 (1.8)	0.9 (0.9)	3.5 (2.3)	< 0.001
Operation time	56.88 (36.68)	54.39 (33.39)	102.7 (49.86)	137.11 (64.19)	< 0.001
2018
Pneumonia	30 (0.4%)	9 (0.4%)	3 (0.4%)	1 (0.3%)	0.9
Urinary Tract Infection	361 (5.1%)	150 (6.0%)	21 (3.1%)	20 (6.2%)	0.02
DVT	16 (0.2%)	1 (0.0%)	0 (0.0%)	5 (1.5%)	< 0.001
Progressive Renal Insufficiency	12 (0.2%)	5 (0.2%)	0 (0.0%)	3 (0.9%)	0.048
Bleeding Transfusions	91 (1.3%)	8 (0.3%)	6 (0.9%)	35 (10.8%)	< 0.001
Length of hospital stay	1.3 (1.8)	0.6 (2.2)	0.9 (1)	3.2 (2.5)	< 0.001
Operation time	58.36 (36.59)	55.77 (34.99)	101.15 (61.65)	136.39 (67.05)	< 0.001
2019
Pneumonia	24 (0.3%)	10 (0.4%)	0 (0.0%)	2 (0.5%)	0.2
Urinary Tract Infection	453 (5.9%)	174 (6.1%)	30 (3.3%)	22 (5.7%)	0.01
DVT	19 (0.2%)	3 (0.1%)	3 (0.3%)	4 (1.0%)	0.015
Progressive Renal Insufficiency	14 (0.2%)	5 (0.2%)	0 (0.0%)	2 (0.5%)	0.2
Bleeding Transfusions	100 (1.3%)	11 (0.4%)	10 (1.1%)	41 (10.6%)	< 0.001
Length of hospital stay	1.3 (1.8)	0.5 (1.3)	0.9 (1.1)	3.1 (2.4)	< 0.001
Operation time	57.28 (36.72)	55.63 (33.07)	101.24 (55.93)	145.01 (74.05)	< 0.001
2020
Pneumonia	23 (0.4%)	3 (0.1%)	1 (0.1%)	1 (0.3%)	0.3
Urinary Tract Infection	335 (5.6%)	100 (4.7%)	23 (3.0%)	31 (10.3%)	< 0.001
DVT	18 (0.3%)	2 (0.1%)	2 (0.3%)	2 (0.7%)	0.13
Progressive Renal Insufficiency	8 (0.1%)	5 (0.2%)	0 (0.0%)	1 (0.3%)	0.28
Bleeding Transfusions	98 (1.6%)	12 (0.6%)	8 (1.0%)	30 (10.0%)	< 0.001
Length of hospital stay	1.2 (1.6)	0.5 (1.7)	0.9 (1.5)	2.8 (2.1)	< 0.001
Operation time	58.84 (35.2)	54.15 (33.16)	99.81 (49.51)	155.81 (68.48)	< 0.001
2021
Pneumonia	41 (0.6%)	8 (0.3%)	2 (0.2%)	2 (0.5%)	0.25
Urinary Tract Infection	448 (6.2%)	125 (5.1%)	36 (3.7%)	27 (7.1%)	0.003
DVT	19 (0.3%)	5 (0.2%)	3 (0.3%)	4 (1.1%)	0.06
Bleeding Transfusions	84 (1.2%)	8 (0.3%)	13 (1.3%)	35 (9.2%)	< 0.001
Length of hospital stay	1.2 (1.8)	0.4 (1.5)	0.9 (1.2)	2.5 (2.3)	< 0.001
Operation time	58.82 (35.07)	55.77 (38.55)	110.94 (63.92)	157.76 (65.92)	< 0.001

When considering complications using the Clavien-Dindo classification, we find that minor (Grade I and II) complications had significantly increased over the years (p < 0.001). In 2008, the rate of these complications was 4.6% with 2011 bearing the highest rate of Grade I and II complications of 9.3%. In the following years, the rate of complications maintained a range of 6.7 to 8.3%. On the contrary, Grade III (p = 0.52) and IV (p = 0.33) complications did not vary over the years. Nevertheless, perioperative mortality (Grade V) was significant in the years of study with a range of 0.2–0.6% (p = 0.01) (Table 3 S).

When considering complications by procedure type, we find that simple Prostatectomy had the highest rate of transfusions in all years. Moreover, it had displayed a steady decline from 15.5% in 2017 to 9.2% in 2021. PVP had the lowest rate of transfusions (0.2–0.6%) followed by LEP (0.5–1.5%) and TURP (1.2–1.6%). Urinary tract infection rates were different in all years except in 2016 and 2017. Simple Prostatectomy had the highest rate of infections (5.1–10.3%), while LEP had the lowest (3.0-3.7%). Pneumonia was comparable between groups except in 2016 (p = 0.02), where it showed a higher rate in Simple Prostatectomy (1.4%). Simple Prostatectomy had demonstrated the highest rate of DVT among procedures ranging from 0.7 to 1.8% (Table 1).

Discussion

Trends in operation rates

The trends in operation rates for various benign prostatic hyperplasia (BPH) surgeries from 2008 to 2021 demonstrate significant shifts in surgical practices and preferences. The annual number of recorded procedures increased steadily from 850 in 2008 to 11,005 in 2021. This rise in surgical cases indicates an increase in the number of participating institutions in the ACS-NSQIP database over the years but can also reflect a growing demand for BPH treatments, potentially driven by an aging population, increased population volume, increased awareness, and advancements in surgical techniques [10, 11].

Transurethral resection of the prostate (TURP) was the most performed procedure in our cohort, with a significant increase from 2008 till 2021, totaling 62,988 (63.4%) procedures over the 14-year span. The dominance of TURP can be attributed to multiple factors including its established efficacy, its widespread acceptance and familiarity among urologists and patients, in addition to reluctance of some urologists to adopt novel techniques. While novel techniques such as HoLEP and PVP have shown improved outcomes with shorter hospital stay, fewer complications and improved short term efficacy (only with HoLEP), TURP remains a cornerstone in BPH treatment [12].

PVP was the second most performed procedure, totaling 27,283 (27.5%) over the study period. However, its contribution decreased from 2008 till 2021. The initial popularity of PVP likely stemmed from its minimally invasive nature and shorter recovery times [13]. The subsequent decline in its relative contribution might be due to the emergence of newer techniques especially LEP, which began to be included in the ACS-NSQIP database in 2011. LEP procedures’ rise in rates reflects growing acceptance and better long-term outcomes. In fact, multiple studies have reported improved overall outcomes with LEP vs. PVP including length of hospital stay, postoperative complications and immediate functional outcomes [12, 14] which could be the reason why we observed the downward trend in PVP paralleled with an upward trend in LEP.

Simple prostatectomy, although less common, showed a consistent rise between 2008 and 2021, accounting for 3.1% of all procedures. This trend may seem counterintuitive given the increasing adoption of minimally invasive endoscopic approaches such as LEP. Several factors may explain this observation. First, simple prostatectomy (particularly RSP) remains the procedure of choice for very large prostates (> 150 g), which are not always optimally managed by endoscopic techniques [15, 16]. Second, the growing availability of robotic platforms has likely contributed to the adoption of RSP, which reduces intraoperative morbidity and transfusion rates compared to OSP [17]. Third, the rise in simple prostatectomy may partly reflect improvements in coding practices within NSQIP over time. Earlier under-reporting or misclassification of these cases could have contributed to their apparent increase in later years once coding practices were standardized. Importantly, while both LEP and simple prostatectomy increased in frequency, the rise in LEP was much more pronounced, suggesting that the broader trend in practice continues to favor minimally invasive endoscopic approaches, while simple prostatectomy remains a niche but necessary procedure for select patients.

In summary, and in line with other utilization studies and national claims data, our analysis confirms that TURP remains the most commonly performed procedure, while PVP use has declined [18, 19]. LEP demonstrated a clear upward trend, often steeper than other modalities, consistent with its growing adoption for larger prostates [18, 19]. More recently, RSP has also shown increased utilization, particularly in the management of very large glands [15]. Together, these patterns support the validity of our findings within NSQIP and reflect broader national trends.

Trends in complications

Analyzing the trends in complications across different types of BPH surgeries provides crucial insights into their safety profiles. Minor complications (Clavien-Dindo Grade I and II) showed a significant increase, from 4.6% in 2008 to a peak of 9.3% in 2011, before stabilizing between 6.7% and 8.3%. Given the descriptive nature of this analysis, these findings should not be interpreted as causal associations. We hypothesize that the initial rise may coincide with the learning curve associated with newer techniques like PVP and LEP, where early adoption phases often parallel higher complication rates [20, 21]. Over time, as surgical proficiency improves, these rates stabilize. Moreover, this rise in PVP and LEP procedure rates can be seen paralleling the increase in operative time and the decrease in length of hospital stay similar to the associations established in other cohorts [22]. Alternatively, it is important to consider that the observed increase in minor (Grade I–II) complications over time may reflect potential surveillance bias. Over the study period, ACS-NSQIP has expanded its variable definitions and improved reporting sensitivity, which may have led to increased detection and documentation of minor complications. Therefore, the observed increase in minor complications should be interpreted cautiously and may not represent a true rise in complication rates.

Major complications (Grade III and IV), however, did not show significant variation over the years. However, when inspecting perioperative mortality (Grade V) rates closely, we notice that rates were significant despite low numbers, ranging from 0.2% to 0.6%. This indicates that while BPH surgeries are generally considered safe, there remains an inherent risk of mortality, albeit minimal. This risk is most linked to post-anesthesia complications, with cardiac etiologies being the most likely [23].

The rates of specific complications such as bleeding, infections, and other postoperative complications varied among the different surgical types. Simple prostatectomy consistently had the highest rates of transfusions and infections, highlighting its more invasive nature compared to TURP, PVP, and LEP [24]. For instance, the transfusion rate for simple prostatectomy, although declining from 15.5% in 2017 to 9.2% in 2021, remained higher than for other procedures. This highlights the inherent invasiveness of this procedure and the need for proper preoperative assessment and preparation of patients. Moreover, the decline in transfusion rates may be related to improved surgical techniques and the adoption of the robotic approach for simple prostatectomy which we could not capture through the NSQIP database [24]. In comparison, PVP had the lowest rates of transfusions (0.2–0.6%), which is reasonable as PVP is most commonly used in patients with bleeding diathesis due to its inherent protection against perioperative bleeding [25].

Limitations of the study

This study has several limitations inherent to its retrospective observational design and use of a large administrative database. First, selection bias may be present, as the ACS-NSQIP database includes only participating institutions and may not fully represent all practice settings. Additionally, patient inclusion was based on procedural coding, which may be subject to misclassification.

Second, information bias is possible due to reliance on recorded variables within the database. Although ACS-NSQIP utilizes standardized definitions and trained clinical reviewers to ensure data quality, variability in data entry and coding across institutions may still occur.

Third, confounding remains a concern, as this study did not employ multivariable adjustment. Differences in baseline patient characteristics across procedure groups may influence outcomes, and unmeasured confounders such as prostate size, surgeon experience, and institutional practices were not available in the dataset.

Fourth, limitations in data availability restrict the scope of analysis. The database lacks information on certain relevant clinical variables, including detailed functional outcomes, long-term follow-up, and minimally invasive outpatient procedures such as Urolift, Rezum, and Aquablation. Additionally, missing data were handled using complete case analysis, which may introduce bias if missingness is not random.

Regarding precision, although the large sample size enhances the robustness of descriptive estimates, the absence of adjusted analyses and confidence intervals limits the ability to quantify statistical uncertainty or infer causality.

Finally, these findings should be interpreted with caution in terms of generalizability. While ACS-NSQIP captures data from a wide range of institutions, the results may not fully reflect global practice patterns or outpatient-based procedures not included in the database. Despite these limitations, the large sample size and standardized data collection provide valuable insights into contemporary trends in BPH surgical management.

Conclusions

The observed trends in operation rates and complications for BPH surgeries over the study period reflect a dynamic interplay between technological advancements, surgical expertise, and patient-centered care. The increasing adoption of minimally invasive procedures like PVP and LEP, despite the dominance of TURP highlights an evolving landscape in BPH surgical treatment. Continued innovation and training in novel surgical techniques is necessary to provide better outcomes and reduce complication rates.

Abbreviations

BPH

Benign prostatic hyperplasia

BOO

Bladder outlet obstruction

TURP

Transurethral resection of the prostate

PVP

Photovaporization of the prostate

LEP

Laser enucleation of the prostate

HoLEP

Holmium laser enucleation of the prostate

OSP

Open simple prostatectomy

RSP

Robot-assisted simple prostatectomy

ACS-NSQIP

American College of Surgeons National Surgical Quality Improvement Program

CPT

Current Procedural Terminology

ICD

International Classification of Diseases

ASA

American Society of Anesthesiologists

BMI

Body mass index

DVT

Deep vein thrombosis

Authors' contributions

JN: Conceptualization, methodology, formal analysis, data curation, investigation, writing (original draft), writing (review and editing); MTH: Methodology, data curation, validation, formal analysis, investigation, writing (original draft), writing (review and editing); BAJ: Conceptualization, methodology, formal analysis, investigation, writing (original draft), writing (review and editing); MZ: Data curation, investigation, writing (original draft), writing (review and editing); RN: Conceptualization, methodology, supervision, formal analysis, investigation, writing (original draft), writing (review and editing). All authors meet the ICMJE criteria for authorship, including substantial contributions to the work, drafting or critical revision of the manuscript, final approval of the version to be published, and agreement to be accountable for all aspects of the work.

Funding

The authors received no specific funding for this work.

Data availability

The data that support the findings of this study are available from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), but restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available. Data are, however, available from the authors upon reasonable request and with permission from ACS-NSQIP, parties interested in getting access to the data used in the study should contact the principal investigator Rami Nasr by e-mail (rn05@aub.edu.lb). The data of the NSQIP database is subject to a data use agreement, and can be accessed publicly by request from the ACS-NSQIP participant use form (https://www.facs.org/quality-programs/acs-nsqip/participant-use).

Declarations

Ethics approval and consent to participate

The data used in this study were obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), a de-identified database. This study was reviewed by the Institutional Review Board of the American University of Beirut Medical Center and was determined to be exempt from formal review. Therefore, no ethics approval code was issued. Individual informed consent was not required due to the use of de-identified data. The study was conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable. The study does not include any individual person’s data in any form. Consent for publication was not required as confirmed by the Institutional Review Board.

Competing interests

The authors declare no competing interests.