Influence of Patientʼs Age on the Outcome of Vaginal and Laparoscopic Procedures in Urogynaecology

Abstract

Introduction In the treatment of prolapse and incontinence, the choice of surgical procedure often depends not only on the clinical findings but also on the age of the patient. Uncertainty exists at present regarding the effect of patient age on treatment outcomes for both vaginal and laparoscopic procedures. The aim of this study is therefore to compare both the anatomical outcome after prolapse surgery and the functional outcome after incontinence surgery in the context of the treatment of stress urinary incontinence in older and younger patients.

Patients/Methods This is a retrospective single-centre study conducted at a university site. Over the study period, a total of 407 women underwent surgery, 278 of whom were < 70 and 129 ≥ 70 years of age. They were assigned to one of three treatment groups (prolapse surgery, incontinence surgery or a combination of both types of surgery) and were then subjected to statistical analysis after assessment of the anatomical and functional outcome after 3 – 6 months.

Results The most common form of prolapse among the 407 evaluated patients was in the anterior and middle compartment, with a higher degree of severity being diagnosed in the older patients. Grade 4 prolapse according to the Baden–Walker system was thus present in the anterior compartment in 15.6 vs. 28.8% (p = 0.033) and in the middle compartment in 5.7 vs. 23.7% (p < 0.001) of cases. Younger women underwent vaginal mesh implantation less frequently and laparoscopic sacropexy more frequently for this overall. The proportion of cases of combined prolapse and incontinence surgery was the same in both groups. Overall, high success rates were observed in both younger and older patients following prolapse and incontinence surgery. These rates were 93.5 vs. 84.8% (p = 0.204) after prolapse surgery and 92.8 vs. 84.2% (p = 0.261) after incontinence surgery. A significant disadvantage for the older patients was the persistence of stress urinary incontinence after prolapse surgery alone (19.6 vs. 50%, p = 0.030) and the rate of occult (de novo) stress urinary incontinence (7.4 vs. 20%, p = 0.030).

Conclusion Our data show that both pelvic organ prolapse and stress urinary incontinence can be treated with surgery with good results in women aged ≥ 70 years. It was thus possible to show for the first time in a large patient population that older women should not be denied appropriate surgery but can be offered the same range of surgical options as younger patients.

Key words

prolapse surgery - incontinence surgery - urogynaecological surgery - pelvic organ prolapse - older patient

• References/Literatur

• 1 Tinelli A, Malvasi A, Rahimi S. Age-related pelvic floor modifications and prolapse risk factors in postmenopausal women. Menopause 2010; 17: 204-212 doi:10.1097/gme.0b013e3181b0c2ae
• 2 Wu JM, Matthews CA, Conover MM. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol 2014; 123: 1201-1206 doi:10.1097/AOG.0000000000000286
• 3 Digesu GA, Chaliha C, Salvatore S. The relationship of vaginal prolapse severity to symptoms and quality of life. BJOG 2005; 112: 971-976
• 4 Chiang CH, Wu MP, Ho CH. Lower Urinary Tract Symptoms Are Associated with Increased Risk of Dementia among the Elderly: A Nationwide Study. Biomed Res Int 2015; 2015: 187819 doi:10.1155/2015/187819
• 5 Statistisches Bundesamt. Bevölkerung Deutschlands bis 2060 – 13. koordinierte Bevölkerungsvorausberechnung. Online: https://www.destatis.de/DE/Publikationen/Thematisch/Bevoelkerung/VorausberechnungBevoelkerung/Bevoelkerung-Deutschland-2060-Presse-5124204159004.pdf?blob=publicationFile last access: 05.11.2017
• 6 Füsgen I. Kostenproblem Harninkontinenz. J Urol Urogynäkol 1998; 5: 7-12
• 7 Welz-Barth A. [Incontinence in old age: a social and economic problem]. Urologe A 2007; 46: 363-364 366–367
• 8 United Nations. Population ageing and development (2009). Online: http://www.unpopulation.org last access: 15.07.2010
• 9 Pizarro-Berdichevsky J, Clifton MM, Goldman HB. Evaluation and Management of Pelvic Organ Prolapse in Elderly Women. Clin Geriatr Med 2015; 31: 507-521 doi:10.1016/j.cger.2015.06.008
• 10 Joukhadar R, Wöckel A, Herr D. Challenges of Longevity: Safety of Vaginal and Laparoscopic Urogynecological Procedures in Septuagenarians and Older Patients. BioMed Research International 2016; 2016: 5184595 doi:10.1155/2016/5184595
• 11 Malek J, Ellington DR, Jauk V. The effect of age on stress and urgency incontinence outcomes in women undergoing primary midurethral sling. Int Urogynecol J 2015; 26: 831-835
• 12 van der Ploeg JM, van der Stehen A, Oude Rengerink K. Prolapse surgery with or without stress incontinence surgery for pelvic organ prolapse: a systematic review and meta-analysis of randomised trials. BJOG 2014; 121: 537-547
• 13 Borchelt M, Kolb G, Lübke N. Abgrenzungskriterien der Geriatrie. Version V1.3. Essener Konsensus-Konferenz; 2004. Online: http://www.geriatrie-drg.de/public/docs/Abgrenzungskriterien_Geriatrie_V13_16-03-04.pdf last access: 05.11.2017
• 14 Richter HE, Goode PS, Kenton K. The effect of age on short-term outcomes after abdominal surgery for pelvic organ prolapse. J Am Geriatr Soc 2007; 55: 857-863
• 15 Sze EHM, Jain P, Hobbs G. Aretrospective cohort study of perioperative management on the morbidity of urogynecologic surgery. Int Urogynecol J 2012; 23: 1207-1214
• 16 Oh S, Shin SH, Kim JY. et al. Perioperative and postoperative morbidity after sacrocolpopexy according to age in Korean women. Obstet Gynecol Sci 2015; 58: 59-64
• 17 Greer JA, Northington GM, Harvie HS. Functional status and postoperative morbidity in older women with prolapse. J Urol 2013; 190: 948-952
• 18 Turner LC, Kantartzis K, Lowder JL. The effect of age on complications in women undergoing minimally invasive sacral colpopexy. Int Urogynecol J Pelvic Floor Dysfunct 2014; 25: 1251-1256
• 19 Bretschneider CE, Robinson B, Geller EJ. The effect of age on postoperative morbidity in women undergoing urogynecologic surgery. Female Pelvic Med Reconstr Surg 2015; 21: 236-240
• 20 Tan YL, Lo TS, Khanuengkitkong S. Comparison of outcomes after vaginal reconstruction surgery between elderly and younger women. Taiwan J Obstet Gynecol 2014; 53: 348-354
• 21 Sung VW, Weitzen S, Sokol ER. et al. Effect of patient age on increasing morbidity and mortality following urogynecologic surgery. Am J Obstet Gynecol 2006; 194: 1411-1417
• 22 Mohammed N, Raschid Hoda M, Fornara P. Prolapse surgery in octogenarians: are we pushing the limits too far?. World J Urol 2013; 31: 623-628
• 23 Fünfgeld C, Stehle M, Henne B. et al. Quality of Life, Sexuality, Anatomical Results and Side-effects of Implantation of an Alloplastic Mesh for Cystocele Correction at Follow-up after 36 Months. Geburtsh Frauenheilk 2017; 77: 993-1001 doi:10.1055/s-0043-116857
• 24 Farthmann J, Watermann D, Zamperoni H. et al. Pelvic organ prolapse surgery in elderly patients. Arch Gynecol Obstet 2017; 295: 1421-1425 doi:10.1007/s00404-017-4367-z
• 25 Mothes AR, Lehmann T, Kwetkat A. et al. Gynaecological Prolapse Surgery in Very Old Female Patients: A Case-Control Study on Co-Morbidity and Surgical Complications. Geburtsh Frauenheilk 2016; 76: 869-874
• 26 Pugsley H, Barbrook C, Mayne CJ. et al. Morbidity of incontinence surgery in women over 70 years old: a retrospective cohort study. BJOG 2015; 112: 786-790
• 27 Dwyer PL. Women with occult stress urinary incontinence should not routinely have a midurethral sling with prolapse surgery. Int Urogynecol J 2012; 23: 827-829
• 28 Lo TS, Bt Karim N, Nawawi EA. et al. Predictors for de novo stress urinary incontinence following extensive pelvic reconstructive surgery. Int Urogynecol J 2015; 26: 1313-1319 doi:10.1007/s00192-015-2685-x