Journal of Obstetrics and Gynaecology, January 2015; 35: 82–84 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.936840
GYNAECOLOGY
Surgical treatment for pelvic organ prolapse in elderly women J. Manonai & R. Wattanayingcharoenchai
J Obstet Gynaecol Downloaded from informahealthcare.com by Gazi Univ. on 01/10/15 For personal use only.
Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
The objective was to analyse the feasibility, safety and outcome of surgical treatment for pelvic organ prolapse in women ⱖ 65 years of age. A single-centre retrospective, cohort study was performed through a medical records review and telephone interview. Women ⱖ 65 years of age, who underwent a surgical operation for pelvic organ prolapse, were considered. Overall, 305 women were included. The following procedures (alone or in combination) were performed: 168 (52.1%) vaginal hysterectomy; 264 (81.9%) anterior colporrhaphy; 261 (81.0%) posterior colpoperineorrhaphy and 45 (13.8%) Manchester operation. There were two cases of bladder injury (0.6%) and two cases of vaginal haematoma (0.6%). Urinary retention and febrile morbidity were found in 33 (10.8%) and 35 (11.5%) of women, respectively. Clinical follow-up, median 10 months, showed that 178 of 200 (89.0%) women had anatomical success. Traditional reconstructive surgical operation for pelvic organ prolapse is a viable treatment option in elderly women. Keywords: Elderly women, pelvic organ prolapse, surgery
Introduction Pelvic organ prolapse (POP) is a common disease in elderly women. The lifetime risk of surgery for POP in the Western Australia female population is 19% (Smith et al. 2010), a figure higher than the 11–12% reported from US populations (Fialkow et al. 2008). The prevalence of POP in Thai women attending the menopause clinic in King Chulalongkorn Memorial Hospital has been reported to be 43.3% (Chuanchompoonut et al. 2005). The prevalence in elderly women (age ⱖ 60 years old) who lived within a 10-km radius of Siriraj Hospital was 70% (Piya-Anant et al. 2003). The differences in prevalence rates might be due to different definitions of pelvic organ prolapse. Consideration of conservative treatment modalities is recommended, however, surgery should not be avoided based on the woman’s age alone. Fukuda et al. (2012) report good restoration of support and quality of life (QoL) following traditional POP surgery. The anatomic and subjective recurrence rates were 21.0% and 6.0% during the 3-year follow-up. Unfortunately, the geriatric population is usually regarded as a suboptimal candidate for surgery. The obvious consequence is that older patients, who would experience the greatest advantages from pelvic floor reconstructive procedures, are usually denied surgical options to correct pelvic organ prolapse just on the basis of their age. The outcomes and safety of prolapse surgery may be different in this population. The objective of this study was to analyse the
feasibility, safety and outcome of surgical treatment for pelvic organ prolapse in women ⱖ 65 years of age.
Materials and methods A single-centre, retrospective, cohort study was performed through a medical records review and telephone interviews. Women ⱖ 65 years of age, who underwent a surgical operation for pelvic organ prolapse in Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibidi Hospital, Bangkok, Thailand, from January 2000 to December 2009, were considered. Outcome measures (intraoperative and postoperative complications, prolapse recurrence and satisfaction) were determined by medical record review and verified by follow-up phone interviews. This study was approved by the Faculty of Medicine Ramathibodi Hospital, Mahidol University Institutional Review Board. During the study period, there were no significant differences in women’s care and in surgical techniques in our institute. Surgical techniques for apical compartment repair were vaginal hysterectomy and Manchester operation. Manchester operation was indicated in patients with an elongated cervix. The mesh type used was tailor-made polypropylene and the suture type was polyglactin. Mesh augmentation was indicated in recurrent anterior wall prolapse. Postoperative urinary retention has been defined in the presence of a failed first voiding trial 6 h after catheter removal, with a residual volume of ⱖ 200 ml on catheterisation (Ghezzi et al. 2007). Operative times were recorded from first incision to last suture. Blood loss was estimated from the contents of suction devices and swabs used. Hospital stay was counted starting on the first postoperative day. Adjacent organ injuries and blood loss exceeding 500 ml were considered as intraoperative complications. Postoperative complications were defined as any event that required intravenous drug administration, blood transfusions, secondary readmission or another surgical operation. Women underwent a clinical evaluation, including pelvic examination at 2, 6 and 12 months after surgical operation and annually thereafter. Anatomical success was defined as no evidence of POP-Q stage 2 (Bump et al. 1996) or higher prolapse at clinical examination. For the purpose of this study, we also used the subjective success rate, which reflects a woman’s satisfaction to assess their postoperative outcome. Subjective recurrence was defined as a perception of prolapse by the patient. The principle investigator (JM) made follow-up telephone calls to the women who did not receive clinical evaluation, to determine their symptoms and prolapse perception. If we could not contact a
Correspondence: J. Manonai, Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Rama VI Road, Bangkok 10400, Thailand. E-mail: [email protected], [email protected]
Surgical treatment for pelvic organ prolapse in elderly women 83 woman by the follow-up time, she was deemed lost to follow-up and excluded from the outcome analysis. No validated questionnaires were used to measure patient’s satisfaction or quality of life. Frequencies and descriptive statistics were used to describe the population and outcomes of surgery. Subjective and objective success rates were analysed using the Kaplan–Meier method.
J Obstet Gynaecol Downloaded from informahealthcare.com by Gazi Univ. on 01/10/15 For personal use only.
Results Overall, 305 women with a mean age of 71.27 ⫾ 4.95 years (range 65–86) were included in the study. Mean BMI was 24.61 ⫾ 3.71 (range 14.66–37.72) and median parity was 5 (range 0–13). The median menopausal time was 20 years (range 2–40). Most of them (72.5%) had medical diseases and were diagnosed with having pelvic organ prolapse stage III or IV. Six patients (2.0%) had previously undergone hysterectomy and eight patients (2.6%) had previously undergone prolapse repair. The procedures performed are shown in Table I. The following procedures (alone or in combination) were performed: 159 (52.1%) vaginal hysterectomies; 250 (82.0%) anterior colporrhaphies; 247 (81.0%) posterior colpoperineorrhaphies; 42 (14.3%) Manchester operations and 11 (3.8%) colpocleisis. Almost all women had pelvic surgery with traditional techniques without using grafts or meshes. Surgical mesh was used in 19 women (6.2%). Median operative time was 100 min (range 30–210). Spinal anaesthesia was most often used (62.9%) and the median hospital stay was 5 days (range 2–15). With regard to immediate complications, there were two cases of bladder injury and two cases of vaginal haematoma (Table II). Intraoperative complications occurred in four (1.3%) women, which were identified and carefully repaired intraoperatively. Median estimated blood loss was 100 ml (range 10–700). Two women had blood loss exceeding 500 ml and there was one woman who received blood transfusion. Urinary retention and febrile morbidity were found in 33 (10.8%) and 35 (11.5%) women, respectively (Table II). One woman developed nonfatal pulmonary embolism 1 month after surgery. Mesh exposure was found in two women (10.5%), and both of them had mesh excision. Complete data, including clinical evaluation, were available for 227 (74.4%) women. The other women were considered lost to follow-up. Clinical (pelvic examination) follow-up, median 10 months (range 2–143), showed that 89.0% (178 from 200 cases) of women had anatomical success after prolapse surgery. The shortest time of recurrent prolapse was 3 months. Median follow-up for a subjective success rate was 58 months (range 6–144). The objective and subjective success rates are shown in Figure 1. A total of 199 women (87.7%) reported satisfaction with the surgery. A total of 10 women experienced prolapse recurrences, the subjective rate of prolapse recurrence was 4.4%. Nine of these 10 women needed a second surgical intervention, and the remaining one woman with recurrence was successfully treated with vaginal pessary.
Table II. Surgical complications (n ⫽ 305).
Intraoperative Bladder injury Vaginal haematoma Postoperative Febrile morbidity Urinary retention Infection
n
(%)
2 2
0.6 0.6
35 33 11
11.5 10.8 3.6
Discussion Ageing is associated with several physiological changes, including cardiovascular, respiratory, renal, hepatic and cerebral changes. Appreciation of these changes will allow for anticipation and prevention of common postoperative complications in the older surgical patient. Few studies have tried to address the question of whether surgical management is safe in older women with pelvic floor disorders, including pelvic organ prolapse (Anger 2007; Ghezzi et al. 2011; Hellberg et al. 2007). From a single centre experience, we thus demonstrated that elderly women aged ⱖ 65 years may undergo traditional pelvic floor surgery safely with moderately effective results. Intraoperative and postoperative complication rates were acceptable. Therefore, older women undergoing pelvic floor surgery can expect operative risks as well as subjective and objective anatomical and QoL outcomes similar to those of younger women. Chronological age per se should not be considered as a limitation to this type of surgical procedure, provided that patient selection is appropriate and a surgical team with expertise is available. Non-surgical modalities exist for the treatment of pelvic organ prolapse, however, patients not satisfied with conservative treatments may seek surgical correction as an option. The ideal procedure in the older woman would robustly repair symptomatic pelvic floor defects, be performed efficiently, allow for rapid postoperative recovery, including return to baseline or improved functional status. Our findings confirmed that traditional procedures for pelvic organ prolapse correction are feasible and safe (Ghezzi et al. 2011). Colpocleisis under regional anaesthesia can be offered to an older woman who has no desire for vaginal function with minimal blood loss, short operative time and early ambulation (Sung et al. 2006). Several studies in the past have supported the use of obliterative surgical operation in older women (Fitzgerald
Table I. Type of vaginal procedures (n ⫽ 305). Complications Vaginal hysterectomy Anterior colporrhaphy Posterior colpoperineorrhaphy Manchester operation Colpocleisis
n
(%)
159 250 247 42 11
52.1 81.9 81.0 13.8 3.6
Figure 1. Objective and subjective success rates of pelvic organ prolapse surgery in elderly women. (mo. ⫽ months).
J Obstet Gynaecol Downloaded from informahealthcare.com by Gazi Univ. on 01/10/15 For personal use only.
84
J. Manonai & R. Wattanayingcharoenchai
et al. 2006). This option resolves pelvic organ prolapse with a low complication rate. Although Huang et al. (2009) estimated that around 30% of American women 65 years or older have at least moderate sexual desire, we did not find the same finding in our population. The use of mesh or graft inlays at the time of anterior vaginal wall repair has been proved to reduce the risk of recurrent anterior vaginal wall (Maher et al. 2010). The surgical correction of POP with use of polypropylene mesh in elderly women appears to be a successful method with an acceptable morbidity, adverse events rate and high satisfaction of the patients (Rzepka et al. 2010). The previous study showed that treatment of advanced prolapse using Prolift in very elderly women (ⱖ 80 years) is a feasible, safe and effective surgical option, preserving a functional vagina (Gabriel et al. 2010). However, transvaginal mesh use significantly increases the complication rates over non-mesh repairs. Our were to also confirm that statement. Some of these complications are irreversible pelvic pain, vaginal shortening, severe vaginal pain and dyspareunia (Elliott 2012). Furthermore, a recent review concluded that polypropylene mesh use results in better anatomical results in the short term but at a cost of repeated surgeries because of erosions and other complications (Ostergard 2012). Modern definitions of success based on the absence of vaginal bulge symptoms reconfirm that anterior colporrhaphy is an excellent surgical option with a lower risk of complications than mesh-augmented prolapse repair. Our study has several limitations. We did not directly compare this elderly population to younger women who had pelvic floor surgery. It would have been more useful if we had compared the elderly cohort with a matched younger cohort and analysed the complications, recovery and prolapse recurrence. Outcome measures were subjective outcome and satisfaction, while objective outcome could not be evaluated in most patients. Finally, the findings of our study cannot be generalised to non-traditional procedures for pelvic organ prolapse, since traditional procedures were performed in most patients in this study and the types of surgery were not wide ranging. Further research is required to understand the impact that surgery for pelvic organ prolapse has on anatomical, physiological and functional outcomes in older women. In conclusion, the present study reports good restoration of support and a high satisfaction rate following traditional POP surgery in women ⱖ 65 years of age. In particular, we observed a very low complication rate and favourable long-term outcomes in terms of anatomical and subjective success rates. Surgical management of pelvic organ prolapse can be safely and effectively offered to elderly women. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Anger JT, Litwin MS, Wang Q, Pashos CL, Rodríguez LV. 2007. The effect of age on outcomes of sling surgery for urinary incontinence. Journal of the American Geriatrics Society 55:1927–1931. Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, Shull BL, Smith AR. 1996. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. American Journal of Obstetrics and Gynecology 175:10–17. Chuanchompoonut V, Bunyavejchevin S, Wisawasukmongchol W, Thechakraichana N. 2005. Prevalence of genital prolapse in Thai menopausal women (using new standardization classification). Journal of the Medical Association of Thailand 88:1–4. Elliott DS. 2012. Con: mesh in vaginal surgery: do the risks outweigh the benefits? Current Opinion in Urology 12:276–281. Fialkow MF, Newton KM, Lentz GM, Weiss NS. 2008. Lifetime risk of surgical management for pelvic organ prolapse or urinary incontinence. International Urogynecology Journal and Pelvic Floor Dysfunction 19:437–440. Fitzgerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H; Ann Weber for the Pelvic Floor Disorders Network. 2006. Colpocleisis: a review. International Urogynecology Journal 17:261–271. Fukuda T, Sumi T, Yasui T, Koyama M, Ishiko. 2012. Outcomes of traditional prolapse surgery for pelvic organ prolapse repair at a single center. International Journal of Gynaecology and Obstetrics 119:277–280. Gabriel B, Rubod C, Cordova LG, Lucot JP, Cosson M. 2010. Prolapse surgery in women of 80 tears and older using the Prolift technique. International Urogynecology Journal and Pelvic Floor Dysfunction 21:1463–1470. Ghezzi F, Cromi A, Uccella S, Colombo G, Salvatore S, Tomera S, et al. 2007. Immediate Foley removal after laparoscopic and vaginal hysterectomy: determinants of postoperative urinary retention. Journal of Minimally Invasive Gynecology 14:706–711. Ghezzi F, Uccella S, Cromi A, Bogani G, Candeloro I, Serati M, et al. 2011. Surgical treatment for pelvic floor disorders in women 75 years or older: a single-center experience. Menopause 18:314–318. Hellberg D, Holmgren C, Lanner L, Nilsson S. 2007. The very obese woman and the very old woman: tension-free vaginal tape for the treatment of stress urinary incontinence. International Urogynecology Journal and Pelvic Floor Dysfunction 18:423–429. Huang AJ, Subak LL, Thom DH, Van Den Eeden SK, Ragins AI, Kuppermann M, et al. 2009. Sexual function and aging in racially and ethnically diverse women. Journal of the American Geriatrics Society 57:1362–1368. Maher C, Feiner B, Baessler K, Adams EJ, Hagen S, Glazener CM. 2010. Surgical management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews (4):CD004014. Ostergard DR. 2012. Evidence-based medicine for polypropylene mesh use compared with native tissue vaginal prolapse repair. Urology 79:12–14. Piya-Anant M, Therasakvichya S, Leelaphatanadit C, Techatrisak K. 2003. Integrated health research program for the Thai elderly: prevalence of genital prolapse and effectiveness of pelvic floor exercise to prevent worsening of genital prolapse in elderly women. Journal of the Medical Association of Thailand 86:509–515. Rzepka J, Brocker K, Alt C, Corteville C, Sohn C, Lenz F. 2010. Pelvic organ prolapse: does the postoperative course of mesh-repair surgery differ in elderly women when compared with younger patients? Journal of Obstetrics and Gynaecology 30:852–856. Smith FJ, Holman CD, Moorin RE, Tsokos N. 2010. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstetrics and Gynecology 116:1096–1100. Sung VW, Weitzen S, Sokol ER, Rardin CR, Myers DL. 2006. Effect of patient age on increasing morbidity and mortality following urogynecologic surgery. American Journal of Obstetrics and Gynecology 194:1411–1417.
GYNAECOLOGY
Surgical treatment for pelvic organ prolapse in elderly women J. Manonai & R. Wattanayingcharoenchai
J Obstet Gynaecol Downloaded from informahealthcare.com by Gazi Univ. on 01/10/15 For personal use only.
Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
The objective was to analyse the feasibility, safety and outcome of surgical treatment for pelvic organ prolapse in women ⱖ 65 years of age. A single-centre retrospective, cohort study was performed through a medical records review and telephone interview. Women ⱖ 65 years of age, who underwent a surgical operation for pelvic organ prolapse, were considered. Overall, 305 women were included. The following procedures (alone or in combination) were performed: 168 (52.1%) vaginal hysterectomy; 264 (81.9%) anterior colporrhaphy; 261 (81.0%) posterior colpoperineorrhaphy and 45 (13.8%) Manchester operation. There were two cases of bladder injury (0.6%) and two cases of vaginal haematoma (0.6%). Urinary retention and febrile morbidity were found in 33 (10.8%) and 35 (11.5%) of women, respectively. Clinical follow-up, median 10 months, showed that 178 of 200 (89.0%) women had anatomical success. Traditional reconstructive surgical operation for pelvic organ prolapse is a viable treatment option in elderly women. Keywords: Elderly women, pelvic organ prolapse, surgery
Introduction Pelvic organ prolapse (POP) is a common disease in elderly women. The lifetime risk of surgery for POP in the Western Australia female population is 19% (Smith et al. 2010), a figure higher than the 11–12% reported from US populations (Fialkow et al. 2008). The prevalence of POP in Thai women attending the menopause clinic in King Chulalongkorn Memorial Hospital has been reported to be 43.3% (Chuanchompoonut et al. 2005). The prevalence in elderly women (age ⱖ 60 years old) who lived within a 10-km radius of Siriraj Hospital was 70% (Piya-Anant et al. 2003). The differences in prevalence rates might be due to different definitions of pelvic organ prolapse. Consideration of conservative treatment modalities is recommended, however, surgery should not be avoided based on the woman’s age alone. Fukuda et al. (2012) report good restoration of support and quality of life (QoL) following traditional POP surgery. The anatomic and subjective recurrence rates were 21.0% and 6.0% during the 3-year follow-up. Unfortunately, the geriatric population is usually regarded as a suboptimal candidate for surgery. The obvious consequence is that older patients, who would experience the greatest advantages from pelvic floor reconstructive procedures, are usually denied surgical options to correct pelvic organ prolapse just on the basis of their age. The outcomes and safety of prolapse surgery may be different in this population. The objective of this study was to analyse the
feasibility, safety and outcome of surgical treatment for pelvic organ prolapse in women ⱖ 65 years of age.
Materials and methods A single-centre, retrospective, cohort study was performed through a medical records review and telephone interviews. Women ⱖ 65 years of age, who underwent a surgical operation for pelvic organ prolapse in Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibidi Hospital, Bangkok, Thailand, from January 2000 to December 2009, were considered. Outcome measures (intraoperative and postoperative complications, prolapse recurrence and satisfaction) were determined by medical record review and verified by follow-up phone interviews. This study was approved by the Faculty of Medicine Ramathibodi Hospital, Mahidol University Institutional Review Board. During the study period, there were no significant differences in women’s care and in surgical techniques in our institute. Surgical techniques for apical compartment repair were vaginal hysterectomy and Manchester operation. Manchester operation was indicated in patients with an elongated cervix. The mesh type used was tailor-made polypropylene and the suture type was polyglactin. Mesh augmentation was indicated in recurrent anterior wall prolapse. Postoperative urinary retention has been defined in the presence of a failed first voiding trial 6 h after catheter removal, with a residual volume of ⱖ 200 ml on catheterisation (Ghezzi et al. 2007). Operative times were recorded from first incision to last suture. Blood loss was estimated from the contents of suction devices and swabs used. Hospital stay was counted starting on the first postoperative day. Adjacent organ injuries and blood loss exceeding 500 ml were considered as intraoperative complications. Postoperative complications were defined as any event that required intravenous drug administration, blood transfusions, secondary readmission or another surgical operation. Women underwent a clinical evaluation, including pelvic examination at 2, 6 and 12 months after surgical operation and annually thereafter. Anatomical success was defined as no evidence of POP-Q stage 2 (Bump et al. 1996) or higher prolapse at clinical examination. For the purpose of this study, we also used the subjective success rate, which reflects a woman’s satisfaction to assess their postoperative outcome. Subjective recurrence was defined as a perception of prolapse by the patient. The principle investigator (JM) made follow-up telephone calls to the women who did not receive clinical evaluation, to determine their symptoms and prolapse perception. If we could not contact a
Correspondence: J. Manonai, Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Rama VI Road, Bangkok 10400, Thailand. E-mail: [email protected], [email protected]
Surgical treatment for pelvic organ prolapse in elderly women 83 woman by the follow-up time, she was deemed lost to follow-up and excluded from the outcome analysis. No validated questionnaires were used to measure patient’s satisfaction or quality of life. Frequencies and descriptive statistics were used to describe the population and outcomes of surgery. Subjective and objective success rates were analysed using the Kaplan–Meier method.
J Obstet Gynaecol Downloaded from informahealthcare.com by Gazi Univ. on 01/10/15 For personal use only.
Results Overall, 305 women with a mean age of 71.27 ⫾ 4.95 years (range 65–86) were included in the study. Mean BMI was 24.61 ⫾ 3.71 (range 14.66–37.72) and median parity was 5 (range 0–13). The median menopausal time was 20 years (range 2–40). Most of them (72.5%) had medical diseases and were diagnosed with having pelvic organ prolapse stage III or IV. Six patients (2.0%) had previously undergone hysterectomy and eight patients (2.6%) had previously undergone prolapse repair. The procedures performed are shown in Table I. The following procedures (alone or in combination) were performed: 159 (52.1%) vaginal hysterectomies; 250 (82.0%) anterior colporrhaphies; 247 (81.0%) posterior colpoperineorrhaphies; 42 (14.3%) Manchester operations and 11 (3.8%) colpocleisis. Almost all women had pelvic surgery with traditional techniques without using grafts or meshes. Surgical mesh was used in 19 women (6.2%). Median operative time was 100 min (range 30–210). Spinal anaesthesia was most often used (62.9%) and the median hospital stay was 5 days (range 2–15). With regard to immediate complications, there were two cases of bladder injury and two cases of vaginal haematoma (Table II). Intraoperative complications occurred in four (1.3%) women, which were identified and carefully repaired intraoperatively. Median estimated blood loss was 100 ml (range 10–700). Two women had blood loss exceeding 500 ml and there was one woman who received blood transfusion. Urinary retention and febrile morbidity were found in 33 (10.8%) and 35 (11.5%) women, respectively (Table II). One woman developed nonfatal pulmonary embolism 1 month after surgery. Mesh exposure was found in two women (10.5%), and both of them had mesh excision. Complete data, including clinical evaluation, were available for 227 (74.4%) women. The other women were considered lost to follow-up. Clinical (pelvic examination) follow-up, median 10 months (range 2–143), showed that 89.0% (178 from 200 cases) of women had anatomical success after prolapse surgery. The shortest time of recurrent prolapse was 3 months. Median follow-up for a subjective success rate was 58 months (range 6–144). The objective and subjective success rates are shown in Figure 1. A total of 199 women (87.7%) reported satisfaction with the surgery. A total of 10 women experienced prolapse recurrences, the subjective rate of prolapse recurrence was 4.4%. Nine of these 10 women needed a second surgical intervention, and the remaining one woman with recurrence was successfully treated with vaginal pessary.
Table II. Surgical complications (n ⫽ 305).
Intraoperative Bladder injury Vaginal haematoma Postoperative Febrile morbidity Urinary retention Infection
n
(%)
2 2
0.6 0.6
35 33 11
11.5 10.8 3.6
Discussion Ageing is associated with several physiological changes, including cardiovascular, respiratory, renal, hepatic and cerebral changes. Appreciation of these changes will allow for anticipation and prevention of common postoperative complications in the older surgical patient. Few studies have tried to address the question of whether surgical management is safe in older women with pelvic floor disorders, including pelvic organ prolapse (Anger 2007; Ghezzi et al. 2011; Hellberg et al. 2007). From a single centre experience, we thus demonstrated that elderly women aged ⱖ 65 years may undergo traditional pelvic floor surgery safely with moderately effective results. Intraoperative and postoperative complication rates were acceptable. Therefore, older women undergoing pelvic floor surgery can expect operative risks as well as subjective and objective anatomical and QoL outcomes similar to those of younger women. Chronological age per se should not be considered as a limitation to this type of surgical procedure, provided that patient selection is appropriate and a surgical team with expertise is available. Non-surgical modalities exist for the treatment of pelvic organ prolapse, however, patients not satisfied with conservative treatments may seek surgical correction as an option. The ideal procedure in the older woman would robustly repair symptomatic pelvic floor defects, be performed efficiently, allow for rapid postoperative recovery, including return to baseline or improved functional status. Our findings confirmed that traditional procedures for pelvic organ prolapse correction are feasible and safe (Ghezzi et al. 2011). Colpocleisis under regional anaesthesia can be offered to an older woman who has no desire for vaginal function with minimal blood loss, short operative time and early ambulation (Sung et al. 2006). Several studies in the past have supported the use of obliterative surgical operation in older women (Fitzgerald
Table I. Type of vaginal procedures (n ⫽ 305). Complications Vaginal hysterectomy Anterior colporrhaphy Posterior colpoperineorrhaphy Manchester operation Colpocleisis
n
(%)
159 250 247 42 11
52.1 81.9 81.0 13.8 3.6
Figure 1. Objective and subjective success rates of pelvic organ prolapse surgery in elderly women. (mo. ⫽ months).
J Obstet Gynaecol Downloaded from informahealthcare.com by Gazi Univ. on 01/10/15 For personal use only.
84
J. Manonai & R. Wattanayingcharoenchai
et al. 2006). This option resolves pelvic organ prolapse with a low complication rate. Although Huang et al. (2009) estimated that around 30% of American women 65 years or older have at least moderate sexual desire, we did not find the same finding in our population. The use of mesh or graft inlays at the time of anterior vaginal wall repair has been proved to reduce the risk of recurrent anterior vaginal wall (Maher et al. 2010). The surgical correction of POP with use of polypropylene mesh in elderly women appears to be a successful method with an acceptable morbidity, adverse events rate and high satisfaction of the patients (Rzepka et al. 2010). The previous study showed that treatment of advanced prolapse using Prolift in very elderly women (ⱖ 80 years) is a feasible, safe and effective surgical option, preserving a functional vagina (Gabriel et al. 2010). However, transvaginal mesh use significantly increases the complication rates over non-mesh repairs. Our were to also confirm that statement. Some of these complications are irreversible pelvic pain, vaginal shortening, severe vaginal pain and dyspareunia (Elliott 2012). Furthermore, a recent review concluded that polypropylene mesh use results in better anatomical results in the short term but at a cost of repeated surgeries because of erosions and other complications (Ostergard 2012). Modern definitions of success based on the absence of vaginal bulge symptoms reconfirm that anterior colporrhaphy is an excellent surgical option with a lower risk of complications than mesh-augmented prolapse repair. Our study has several limitations. We did not directly compare this elderly population to younger women who had pelvic floor surgery. It would have been more useful if we had compared the elderly cohort with a matched younger cohort and analysed the complications, recovery and prolapse recurrence. Outcome measures were subjective outcome and satisfaction, while objective outcome could not be evaluated in most patients. Finally, the findings of our study cannot be generalised to non-traditional procedures for pelvic organ prolapse, since traditional procedures were performed in most patients in this study and the types of surgery were not wide ranging. Further research is required to understand the impact that surgery for pelvic organ prolapse has on anatomical, physiological and functional outcomes in older women. In conclusion, the present study reports good restoration of support and a high satisfaction rate following traditional POP surgery in women ⱖ 65 years of age. In particular, we observed a very low complication rate and favourable long-term outcomes in terms of anatomical and subjective success rates. Surgical management of pelvic organ prolapse can be safely and effectively offered to elderly women. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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