Key words
prolapse surgery - incontinence surgery - urogynaecological surgery - pelvic organ
prolapse - older patient
Introduction
Functional pelvic floor disorders in the form of prolapse and urinary incontinence
are common in the female population [1]. According to current data, the average lifetime risk of a woman developing urinary
incontinence for which treatment is indicated is 13.6%, the peak age group being 71 – 72
years. The average risk of developing prolapse for which treatment is indicated is
12.6% with the age-specific risk increasing up to the age of 75 years [2].
In older people, besides considerably impairing quality of life, prolapse and urinary
incontinence are often associated with a variety of medical, social and economic problems
and constraints which can even have a detrimental effect on the mental state of those
affected [3], [4].
In Germany, urinary incontinence represents the second most important reason for receiving
nursing care at home, after loss of mobility; up to 50% of admissions to elderly care
homes are as a direct or indirect result of incontinence, and approx. 25% of the working
day of the care staff in these homes is taken up by dealing with incontinence [5], [6], [7]. Going forward, there is reason to believe that the trend will continue as a result
of the anticipated continuing increase in life expectancy, since statistical data
illustrate the global demographic trend towards longevity [5], [8]. The higher life expectancy of women leads to a shift in the gender balance in favour
of women in old age and thus also to an increasing demand for treatment for urogynaecological
conditions [9].
Although conservative treatment is often not sufficient for prolapse or incontinence,
older patients are often denied access to surgical measures on age grounds alone and
because of fears of the possible complications of surgery [10]. Besides this reluctance to select patients for surgery, uncertainty exists with
regard to the anatomical and functional outcome of treatment to be expected in older
compared with younger patients. This also applies in particular to the outcome to
be expected with regard to bladder function after prolapse surgery. Not only is the
number of previously published studies on this subject small, but the results are
conflicting in some cases and there is insufficient comparability because of differences
in methodology [11], [12].
For this reason, the aim of this study is to compare both the anatomical outcome after
prolapse surgery and the functional outcome after incontinence surgery in the treatment
of stress urinary incontinence in older and younger patients.
Material and Methods
This retrospective study involved recording the data of all urogynaecological patients
who had undergone surgical treatment for symptomatic pelvic organ prolapse (POP-Q ≥ II,
B–W ≥ 2), pure stress urinary incontinence or both conditions simultaneously in the
Department of Gynaecology of Saarland University. As a general rule, the stress urinary
incontinence was diagnosed and further evaluated by means of urodynamic studies and
the Bonney test. In the case of borderline findings, a pad test was also used. The
single inclusion criterion for the study was surgical treatment performed for the
aforementioned indications. Patients with mixed urinary incontinence were excluded.
The patient data were collected consecutively.
Patient population
All data for the period from July 2012 to the end of December 2014 were evaluated.
The study period was therefore 2 ½ years. With the end of acquisition period on 30.06.2015,
the postoperative follow-up period, during which the surgical outcome was recorded
and assessed, is between 3 and 6 months.
The age cutoff for distinguishing between younger and older patients was 70. Over
the study period, a total of 407 women underwent surgery, 278 of whom were < 70 and
129 ≥ 70 years of age.
Procedures performed
For patients suffering from a combination of symptomatic prolapse and concomitant
stress urinary incontinence, we generally recommended a two-stage procedure. This
involves first surgically repairing the prolapse and then reassessing the stress urinary
incontinence and, if necessary, treating it by means of incontinence surgery. In selected
cases, e.g. where the level of suffering was very high or if a patient requested it
specifically, a one-stage procedure was also sometimes selected, i.e. the incontinence
and prolapse surgery were combined.
Three treatment groups were defined in this study to assess the outcome: patients
undergoing prolapse surgery, incontinence surgery or a combination of the two types
of surgery. The data were compared between the two age groups, the younger (< 70 years)
and the older (≥ 70 years) patients.
Data entry and evaluation
In all cases, prolapse quantification was carried out in accordance with the Baden–Walker
half-way system (B – W). Quantification in accordance with the Pelvic Organ Prolapse
Quantification System (POP-Q) was also carried out by the Head of the Urogynaecology
Section. It was the aim of this study to define treatment success after prolapse surgery
as POP-Q ≤ I based on the criteria of the International Continence Society (ICS).
The data were taken from both the digitised outpatient and the inpatient documentation.
Details of the applied procedures, the intraoperative course and potential complications
were obtained from the operative report in the patientʼs chart. The patientsʼ ASA
score was documented in the anaesthetic record. We defined the length of stay in hospital
as the time from postoperative day 1 up to and including the day of discharge.
The surgical outcome was derived from the findings of the postoperative examination
performed during the inpatient stay before discharge. As part of this final examination,
an ultrasound measurement of residual urine was also performed and specific questions
were asked about continence. All patients were asked to attend the Urogynaecology
Clinic for follow-up 3 months after surgery, to enable any early recurrences or postoperative
complications to be documented.
Any occurrence of occult stress urinary incontinence after prolapse surgery was also
assessed and the outcome of pre-existing stress urinary incontinence determined within
the context of postoperative follow-up.
The statistical analysis was performed using IBM SPSS Version 22. The t-test was used
for continuous variables, provided that they were approximately normally distributed,
and the Mann-Whitney U test when the data did not have an approximately normal distribution.
Descriptive statistics were described in terms of mean and standard deviation for
normally distributed data and median and interquartile range (IQR) for non-normally
distributed data. Group differences in the case of categorical variables were evaluated
using the χ2 test. If the expected frequency here was < 5 for at least one field, Fisherʼs exact
test was used. The distribution of the categorical variables was described in terms
of the absolute number and the percentage.
Results
Characteristics of the patient population
During the study period, 407 urogynaecological operations were evaluated in total,
with 278 of the patients (68.3%) falling into the younger and 129 (31.7%) into the
older (≥ 70 years) group. The mean age in both groups was 55.60 ± 8.94 and 75.41 ± 4.05
years respectively.
The ASA score was used as a proxy measure for pre-operative comorbidity. Overall,
significantly more younger patients were classified as ASA I (11.2 vs. 0.8%; p = 0.001)
or ASA II (77.3 vs. 60.9%; p = 0.003), and these patients were classified more rarely
as ASA III (11.5 vs. 37.5%; p < 0.001). In addition, the data relating to the detailed
obstetric and hormonal history were also collected ([Table 1]).
Table 1 General patient data.
|
Age group
|
< 70 years
|
≥ 70 years
|
p-value
|
|
Parameter
|
|
[n]
|
|
[n]
|
|
VE = vacuum extraction; BW = birth weight; PMP = post menopause; HRT = hormone replacement
therapy
[n] = reference data count; expressed as: mean ± standard deviation, median [IQR]
or number (%).
t = t-test; m = Mann-Whitney U; c = χ2; f = Fisherʼs exact test; p-values adjusted to “fdr”.
|
|
Age
|
55.60 ± 8.94
|
[278]
|
75.41 ± 4.05
|
[129]
|
|
|
BMI
|
27.20 ± 4.72
|
[278]
|
26.97 ± 4.05
|
[129]
|
0.658t
|
|
ASA score
|
|
[278]
|
|
[128]
|
|
|
|
31 (11.2)
|
|
1 (0.8)
|
|
0.001c
|
|
|
215 (77.3)
|
|
78 (60.9)
|
|
0.003c
|
|
|
32 (11.5)
|
|
48 (37.5)
|
|
< 0.001c
|
|
|
0 (0.0)
|
|
1 (0.8)
|
|
0.401f
|
|
Number of births
|
2 [1 – 2]
|
[277]
|
2 [2 – 3]
|
[125]
|
0.032m
|
|
Mode of delivery
|
|
|
|
|
|
|
|
2 [1 – 2]
|
[277]
|
2 [2 – 3]
|
[125]
|
0.005m
|
|
|
0 [0 – 0]
|
[277]
|
0 [0 – 0]
|
[125]
|
0.006m
|
|
|
0 [0 – 0]
|
[277]
|
0 [0 – 0]
|
[125]
|
0.098m
|
|
BW ≥ 4000 g
|
0 [0 – 0]
|
[277]
|
0 [0 – 0]
|
[125]
|
0.628m
|
|
BW ≥ 4500 g
|
0 [0 – 0]
|
[277]
|
0 [0 – 0]
|
[125]
|
0.717m
|
|
Multipara (≥ 3)
|
68 (24.5)
|
[277]
|
46 (36.8)
|
[125]
|
0.029c
|
|
Years PMP
|
6.74 ± 6.88
|
[196]
|
24.36 ± 6.57
|
[74]
|
< 0.001t
|
|
Current HRT
|
33 (16.1)
|
[205]
|
10 (8)
|
[125]
|
0.066c
|
Patientsʼ previous surgical history
Overall, 14.7% of the younger and 26.4% of the older patients had had at least one
operation for prolapse in the anterior compartment (p = 0.026). The most frequent
previous procedure in both age groups was anterior colporrhaphy. The use of mesh in
the anterior vaginal compartment was found more frequently in the history of the older
patients (2.2 vs. 4.7%).
7.2% of the younger and 12.4% of the older patients (p = 0.142) reported at least
one previous operation for prolapse in the middle compartment. With regard to differences
in history of surgery in the posterior compartment, no statistical significance could
be established despite a higher incidence in older compared with younger patients
(15.5 vs. 8.3%).
On the other hand, only 7.2% of the younger and 6.2% of the older patients had undergone
surgical treatment for stress urinary incontinence prior to the study (p = 0.887).
At 48.8%, the percentage of patients with a history of hysterectomy was significantly
higher in the older patient group than in the younger group (34.2% [p = 0.002]). The
most frequent surgical approach in both groups was the vaginal approach ([Table 2]).
Table 2 Surgical history.
|
Age group
|
< 70 years
|
≥ 70 years
|
p-value
|
|
[n = 278]
|
[n = 129]
|
|
* open and laparoscopic colposuspension; ** Marshall-Marchetti-Krantz; LASH = laparoscopic
supracervical hysterectomy; TLH = total laparoscopic hysterectomy; n = reference data
count; expressed as number and (%).
c = χ2; f = Fisherʼs exact test; p-values adjusted for “fdr”.
|
|
Previous surgery for incontinence
|
|
|
14 (5)
|
3 (2.4)
|
|
|
|
6 (2.2)
|
3 (2.3)
|
|
|
|
0 (0.0)
|
2 (1.6)
|
|
|
|
20 (7.2)
|
8 (6.2)
|
0.887c
|
|
|
0 (0.0)
|
2 (1.6)
|
0.142f
|
|
Previous surgery for prolapse
|
|
In the anterior compartment
|
|
|
6 (2.2)
|
6 (4.7)
|
|
|
|
32 (11.5)
|
26 (20.2)
|
|
|
|
3 (1.1)
|
2 (1.6)
|
|
|
|
41 (14.7)
|
34 (26.4)
|
0.026c
|
|
|
6 (2.2)
|
4 (3.1)
|
0.829f
|
|
In the middle compartment
|
|
|
11 (4.0)
|
6 (4.7)
|
|
|
|
8 (2.9)
|
10 (7.8)
|
|
|
|
1 (0.4)
|
0 (0.0)
|
|
|
|
20 (7.2)
|
16 (12.4)
|
0.142c
|
|
|
2 (0.7)
|
0 (0.0)
|
1f
|
|
In the posterior compartment
|
|
|
5 (1.8)
|
4 (3.1)
|
|
|
|
17 (6.1)
|
14 (10.9)
|
|
|
|
1 (0.4)
|
2 (1.6)
|
|
|
|
23 (8.3)
|
20 (15.5)
|
0.104c
|
|
|
2 (0.7)
|
4 (3.1)
|
0.141f
|
|
History of hysterectomy
|
|
|
59 (21.2)
|
38 (29.5)
|
|
|
|
22 (7.9)
|
23 (17.8)
|
|
|
|
9 (3.2%)
|
2 (1.6%)
|
|
|
|
5 (1.8)
|
0 (0.0)
|
|
|
|
95 (34.2)
|
63 (48.8)
|
0.002c
|
Pre-operative prolapse findings
The most frequently diagnosed form of prolapse was in the anterior and middle compartment,
the distribution of prolapse between the different compartments remaining the same
regardless of age group.
The severity of anterior and middle compartment prolapse did differ significantly
between the younger and older groups, however. The descent in the anterior compartment
corresponded to Baden–Walker grade 4 in 15.6% of the younger and 28.8% of the older
women (p = 0.033). Grade 4 prolapse in the middle compartment was found in 5.7% of
the younger and 23.7% of the older women (p < 0.001) ([Table 3]).
Table 3 Pre-operative findings for prolapse.
|
Parameter
|
Total
|
n
|
|
|
|
|
|
n = number and (%); c = χ2; f = Fisherʼs exact test; p-values adjusted for “fdr”.
|
|
According to Baden–Walker
|
|
|
|
|
1
|
2
|
3
|
4
|
|
Anterior compartment
|
|
|
[192]
|
160 (83.3)
|
32 (16.7)
|
59 (30.7)
|
39 (20.3)
|
30 (15.6)
|
|
|
[118]
|
101 (85.6)
|
12 (10.2)
|
26 (22.0)
|
29 (24.6)
|
34 (28.8)
|
|
|
|
|
0.264c
|
0.264c
|
0.638c
|
0.033c
|
|
Middle compartment
|
|
|
[192]
|
153 (79.7)
|
35 (18.2)
|
63 (32.8)
|
44 (22.9)
|
11 (5.7)
|
|
|
[118]
|
93 (78.8)
|
12 (10.2)
|
28 (23.7)
|
25 (21.2)
|
28 (23.7)
|
|
|
|
|
0.230c
|
0.256c
|
0.959c
|
< 0.001c
|
|
Posterior compartment
|
|
|
[192]
|
109 (56.8)
|
52 (27.1)
|
34 (17.7)
|
16 (8.3)
|
7 (3.6)
|
|
|
[118]
|
68 (57.6)
|
29 (24.6)
|
20 (16.9)
|
10 (8.5)
|
9 (7.6)
|
|
|
|
|
0.920c
|
1c
|
1c
|
0.328c
|
|
In accordance with POP-Q stage after ICU
|
|
|
|
I
|
II
|
III
|
IV
|
|
|
[87]
|
87 (100)
|
1 (1.1)
|
30 (34.5)
|
51 (58.6)
|
5 (5.7)
|
|
|
[54]
|
54 (100)
|
11 (1.9)
|
7 (13.0)
|
35 (64.8)
|
10 (18.5)
|
|
|
|
|
1f
|
0.033c
|
0.703c
|
0.095c
|
Depending on the examiner, an additional quantification of the prolapse was also carried
out in accordance with POP-Q. This was available for analysis for 45.3% of the younger
and 45.8% of the older patients. [Table 3] also provides a comparison of the different stages between the age groups.
Surgical procedures used
Younger patients presented more frequently with stress urinary incontinence for which
treatment was indicated, whereas the older patients presented more frequently with
prolapse for which treatment was indicated. As a result, 30.9% of the younger and
just 8.5% of the older patients underwent incontinence surgery (p < 0.001). On the
other hand, 60.1% of the < 70-year-olds and as many as 85.3% of the ≥ 70-year-olds
underwent prolapse surgery (p < 0.001).
With regard to the choice of procedure, the method used most frequently to treat stress
urinary incontinence was suburethral sling implantation in both groups (76.7 and 90.9%).
Significant differences were identifiable between the two age groups in terms of the
choice of prolapse surgery, however. Vaginal mesh implantation was less frequent among
the younger than among the older patients (19.8 vs. 42.7%; p < 0.001), with anterior
mesh being the most common form in both groups.
Laparoscopic sacropexy was performed significantly more frequently in the younger
patients, on the other hand (40.1 vs. 24.5%; p = 0.016). The most common type of sacropexy
performed was cervicosacropexy.
With regard to procedures performed with autologous tissue and also in respect of
concurrent procedures carried out, no statistically significant difference could be
identified between the two groups ([Table 4]).
Table 4 The surgical procedures used.
|
Surgical procedures
|
< 70
|
≥ 70
|
p-value
|
|
n = number; expressed as n = number and (%); percentages relate to the next higher
category in each case
* percentage relates to the entire age group; ** percentage relates to prolapse surgery
TVT = tension free vaginal tape; TVT-O = transobturator TVT; LSC = laparoscopic; p-value
adjusted for “fdr”.
Statistical test methods: c = χ2; p-values adjusted for “fdr”.
|
|
All procedures
|
n = 278
|
n = 129
|
|
|
Incontinence surgery
|
86 (30.9)*
|
11 (8.5)*
|
< 0.001c
|
|
|
79 (91.9)
|
11 (100)
|
|
|
7 (8.1)
|
0 (0.0)
|
|
Prolapse surgery
|
167 (60.1)*
|
110 (85.3)*
|
< 0.001c
|
|
Vaginal meshes
|
33 (19.8)
|
47 (42.7)
|
< 0.001c
|
|
|
17 (51.5)
|
23 (48.9)
|
|
|
6 (18.2)
|
5 (10.6)
|
|
|
10 (30.3)
|
19 (40.4)
|
|
LSC sacropexy
|
67 (40.1)
|
27 (24.5)
|
0.016c
|
|
|
16 (23.9)
|
11 (40.7)
|
|
|
43 (64.2)
|
13 (48.1)
|
|
|
8 (11.9)
|
3 (11.1)
|
|
Repair with autologous tissue
|
67 (40.1)
|
36 (32.7)
|
0.354c
|
|
|
31 (46.3)
|
18 (49.9)
|
|
|
14 (20.9)
|
13 (36.1)
|
|
|
22 (32.8)
|
5 (13.9)
|
|
Combined prolapse and incontinence surgery
|
25 (9.0)*
|
8 (6.2)*
|
0.509c
|
|
|
4 (16.0)
|
3 (37.5)
|
|
|
9 (36.0)
|
5 (62.5)
|
|
|
3 (12.0)
|
0 (0.0)
|
|
|
7 (28.0)
|
0 (0.0)
|
|
|
2 (8.0)
|
0 (0.0)
|
|
Concurrent procedures
|
140 (50.4)
|
60 (46.5)
|
0.523c
|
The percentage of patients who underwent a combined procedure was 90% in the < 70-year-old
and 6.2% in the ≥ 70-year-old age group. In both age groups, the most frequent combination
was colporrhaphy with a form of suburethral sling, followed by laparoscopic sacropexy
and Burch colposuspension as a single-stage procedure ([Table 4]).
Peri-operative data
The average operative time was 91.06 ± 65.57 minutes for the younger patients and
96.64 ± 64.35 minutes for their older counterparts (p = 0.643). In the comparison
of both groups, we found the operative time respectively, 109.32 ± 59.75 and 101.24 ± 60.93
minutes (p = 0.643) for prolapse and 39.84 ± 35.09 and 33.09 ± 21.05 minutes for incontinence.
The postoperative reduction in the Hb level was 1.13 ± 0.77 g/dl in the younger and
1.24 ± 0.89 g/dl in the older group (p = 0.343). There was therefore no significant
difference either in the length of surgery or the reduction in the Hb level.
The length of stay in hospital did differ between the two age groups, however. The
median was 5 [3.50 – 7.00] days for the younger and 6 [2.25 – 8.75] days for the older
patients (p < 0.001) ([Table 5]).
Table 5 Peri-operative patient data.
|
Age group
|
< 70 years
|
≥ 70 years
|
p-value
|
|
Parameter
|
|
[n]
|
|
[n]
|
|
[n] = reference data count; min = minutes; IC = incontinence
Expressed as mean ± standard deviation, median and [IQR]
t = t-test; m = Mann-Whitney U; p-values adjusted for “fdr”.
|
|
Length of surgery (min)
|
|
|
|
|
|
|
|
91.06 ± 65.57
|
[278]
|
96.64 ± 64.35
|
[129]
|
0.643t
|
|
|
109.32 ± 59.75
|
[167]
|
101.24 ± 60.93
|
[110]
|
0.643t
|
|
|
39.84 ± 35.09
|
[86]
|
33.09 ± 21.05
|
[11]
|
0.634t
|
|
|
140 [67.5 – 219.5]
|
[25]
|
60.50 [40.8 – 233.8]
|
[8]
|
0.643m
|
|
Hb reduction (g/dl)
|
1.13 ± 0.77
|
[247]
|
1.24 ± 0.89
|
[125]
|
0.343t
|
|
Length of stay (d)
|
5 [3.5 – 7.0]
|
[278]
|
6 [2.3 – 8.8]
|
[129]
|
< 0.001m
|
Success after prolapse surgery
In this study, success after prolapse surgery was defined as POP-Q ≤ I. Only those
cases in which pre- and postoperative POP-Q findings were recorded were used for the
analysis. This applied to 77 patients in the younger and 46 in the older age group,
the success rate being 93.5% in the < 70-year-old and 84.8% in the ≥ 70-year-old patients
(p = 0.204). Separate assessment of prolapse surgery alone and in combination with
incontinence surgery also failed to reveal any significant difference between the
two age groups. The success rate in younger vs. older patients was 93.8 and 84.1%
respectively after prolapse surgery alone (p = 0.204) and 92.3 and 100% respectively
after combined surgery (p = 1).
Success after incontinence surgery
The success rate after incontinence surgery, defined as complete cure of incontinence
and restoration of voiding without residual urine (residual urine < 50 ml), was 92.8%
among < 70-year-old and 84.2% among ≥ 70-year-old patients (p = 0.261). The assessment
was carried out as part of the discharge examination on the basis of a cough stress
test with natural bladder filling and ultrasound measurement of postvoid residual
urine. The same investigations were repeated as part of the follow-up examination.
Separate assessment of incontinence surgery alone and in combination with prolapse
surgery failed to reveal any significant difference between the two age groups. The
success rates for younger vs. older patients were thus 94.2 and 100% respectively
after incontinence surgery alone (p = 1) and 88 and 62.5% respectively after combined
surgery (p = 0.204).
Urinary incontinence after prolapse surgery alone
In order to assess bladder function after prolapse surgery, the data of all 167 < 70-year-old
and 110 ≥ 70-year-old patients who had undergone prolapse surgery alone were analysed.
This revealed pre-existing stress urinary incontinence in 27.5% of the younger and
27.3% of the older patients. After prolapse surgery, the pre-existing stress urinary
incontinence was cured in 80.4% of the younger and 50% of the older patients (p = 0.030).
In other words, the persistence of stress urinary incontinence was 19.6% in the younger
and 50% in the older patient group ([Table 6]).
Table 6 Postoperative outcome.
|
Age group
|
< 70 years
|
≥ 70 years
|
p-value
|
|
Parameter
|
|
[n]
|
|
[n]
|
|
[n] = reference data count; POP = pelvic organ prolapse; IC = incontinence; SIC = stress
urinary incontinence
Expressed as number (%)
Success is defined: after POP surgery in accordance with POP-Q ≤I/Baden–Walker ≤ grade
1; success after SIC surgery restoration of continence.
c = χ2; f = Fisherʼs exact test; p-values adjusted for “fdr”.
|
|
Success after IC surgery
|
103 (92.8)
|
[111]
|
16 (84.2)
|
[19]
|
0.261f
|
|
|
81 (94.2)
|
[86]
|
11 (100)
|
[11]
|
1f
|
|
|
22 (88.0)
|
[25]
|
5 (62.5)
|
[8]
|
0.204f
|
|
Success after POP surgery
|
72 (93.5)
|
[77]
|
39 (84.8)
|
[46]
|
0.204c
|
|
|
60 (93.8)
|
[64]
|
37 (84.1)
|
[44]
|
0.204f
|
|
|
12 (92.3)
|
[13]
|
2 (100)
|
[2]
|
1f
|
|
Development of SIC after POP surgery
|
|
[167]
|
|
[110]
|
|
|
|
37 (80.4)
|
[46]
|
15 (50)
|
[30]
|
0.030c
|
|
|
9 (19.6)
|
[46]
|
15 (50)
|
[30]
|
0.030c
|
|
|
9 (7.4)
|
[121]
|
16 (20)
|
[80]
|
0.030c
|
The occurrence of occult (de novo) stress urinary incontinence was identified considerably
more frequently in older than in younger patients (7.4 vs. 20%, p = 0.03) ([Table 6]).
Discussion
This study examined the effect of patient age on the outcome of vaginal and laparoscopic
procedures in urogynaecology, taking a closer look at the fact that, as a rule, older
women have been and continue to be denied the opportunity of urogynaecological surgery.
In addition, the influence of prolapse surgery on bladder function was studied and
compared between younger and older patients.
These investigations show that the caution exercised in the past in selecting older
patients for such operations needs to be reconsidered because these patients are clearly
just as likely as their younger counterparts to benefit greatly. Furthermore, the
results obtained in a large patient population within the scope of this study also
indicate that the separation of prolapse and incontinence surgery into a two-stage
procedure remains a sensible approach as a rule – a single-stage procedure appears
at best to be an alternative treatment option for the elderly patient.
The choice of 70 years as the age cutoff for distinguishing between younger and older
patients is based on the definition of geriatric patients applied in Germany, which
uses an age cutoff of 70 years in addition to the presence of other criteria to make
the distinction [13].
What is unusual about the data presented here is the extraordinarily high proportion
of older patients in the study population. Unlike most other of the other studies
[14], [15] on this subject, the percentage of ≥ 70-year-olds in this study is 31.7%. Because
these older patients, despite often having poorer general health, were offered the
same range of treatments as their younger counterparts, the statements that can be
made about the older patient group on the basis of these data are particularly valid.
The range of comorbidities existing prior to treatment was similar to that in other
studies, both in terms of the ASA classification and with regard to the pre-operative
local findings. In other words, within the study population, older patients were classified
more frequently as ASA III and had significantly more severe prolapse in the anterior
and middle compartment than their younger counterparts [15], [16], [17], [18], [19].
Regarding the surgical procedure used, older patients with prolapse also underwent
reconstructive procedures (maintaining coital function), both for primary and recurrent
prolapse. This means that, unlike in other studies [15], [19], obliterative procedures such as colpocleisis were avoided as a rule in favour of
functional reconstruction. In terms of the choice of mesh-based reconstructive procedure,
however, vaginal mesh implantation was performed more frequently in the older patients
and laparoscopic sacropexy in their younger counterparts. The reason for this was
that the use of vaginal mesh implants tends to be indicated in more severe forms of
prolapse and recurrences, which occur more frequently in the ≥ 70-year-old age group.
In addition, vaginal mesh implantation can be carried out under spinal anaesthesia,
thereby avoiding general anaesthesia in very old patients ([Tables 3] and [4]).
The procedure most used for treating stress urinary incontinence was the suburethral
sling for all patients, with a retropubic, transobturator or adjustable sling being
indicated on the basis of clinical criteria alone, not age. Because of the much longer
duration of the operation and the need for general anaesthesia, laparoscopic colposuspension
was offered only to younger patients, however ([Table 4]).
Regardless of the age group, analysis of the pre-operative data shows that, as expected,
there is no difference between the two groups in terms of the length of surgery and
the postoperative reduction in Hb levels. This is also confirmed by other authors
in this way [16], [18], [19], [20].
The length of stay in hospital was admittedly longer for the older than for the younger
patients. This was not for medical or surgery-related reasons in most cases, however,
but was due to the logistical situation at home. Because of the different comorbidities
and definitions of age in the published data, the literature on this subject is somewhat
heterogeneous. For example, some authors have also reported longer stays in hospital
for older patients [14], [19], [21], and others not [18].
The main focus of this study is postoperative outcomes, however. It was thus possible
to show that, in specialist Urogynaecology Departments with a high level of expertise,
≥ 70-year-old patients can be offered the same surgical procedures as their younger
counterparts and a similar success rate can be expected, in the short and medium term
at least. Despite the greater severity of pre-operative prolapse generally found in
≥ 70-year-old patients, the postoperative outcome achieved was as good as in younger
patients. Other authors have reached a similar conclusion in some cases, although
in much smaller patient populations. For example, the success rate following prolapse
surgery in one study, at 84.4%, was similar to that in this study with the same definition
of success as POP-Q stage ≤ stage I, or slightly higher (93%) with a less strict definition
of success as POP-Q stage ≤ stage II [20], [22], [23].
Other recent studies on outcome and patient safety following prolapse and incontinence
surgery have, like our study, been able to show that a similarly good outcome can
be achieved in very old patients to that in younger patients. Of particular significance
in this respect are the studies which have selected a very high age cutoff of 80 years
for the comparison [24], [25].
Similar results were observed for incontinence surgery. Despite a strict definition
of success as complete restoration of urinary continence and voiding without residual
urine, a good success rate was observed in both groups with no statistically significant
difference based on age. Taking into account other studies, this quite clearly indicates
that the clinical practice applied in many cases should be reconsidered and that older
patients should not be denied access to appropriate surgery [11], [26].
It is generally unclear in the literature whether, in patients with existing prolapse
with concomitant incontinence, normal bladder function is more likely to be restored
by a single- or two-stage surgical approach. It therefore seems that neither approach
will always be the right one and for all patients. What does seem clear on the basis
of these data, however, is that patient age has a direct influence on bladder function
after prolapse surgery. Of course, the poorer incontinence rate after prolapse surgery
frequently cited in discussions on the subject might in principle also be caused by
the higher rate of revision surgery in the older patient group.
In the case of a differentiated approach, the results for pre-existing and de novo
stress urinary incontinence must be considered separately.
With regard to pre-existing stress urinary incontinence, the available data show that
incontinence resolved as a result of prolapse treatment in the majority of cases involving
young and as many as half of the cases involving older patients. Consideration should
therefore be given to a combined procedure.
According to Dwyer (2012), 10 women would have to receive TVT concurrently with prolapse
surgery in order to prevent just one patient from needing follow-up surgery for this
2 – 4 years after the prolapse surgery [27].
The incidence of de novo stress urinary incontinence was also considerably higher
among the older patients. The data of Lo et al. (2015) point to a similar result:
The risk of de novo stress urinary incontinence after prolapse surgery was 2.86 times
higher in women > 66 years of age than in their younger counterparts [28].
A certain bias is possible in the interpretation of the data because the procedures
performed are, of course, generally of an elective nature. It must therefore be assumed
that a selection bias existed in the elderly patient group based on their general
state of health, because seriously ill patients do not generally attend Urogynaecology
Clinics. Nevertheless, our results show clearly that postoperative success can also
be achieved in older patients. Provided that they were healthy enough, surgery should
not be ruled out due to high age alone. In the case of prolapse, these patients should
also not be offered obliterative surgery automatically either.
In summary, it can be said that the data presented here make an important contribution
to answering the question of urogynaecological surgery outcome in elderly patients.
Going forward, the evaluation needs to be confirmed on a prospective basis. Until
these results are available, however, there are good reasons on the basis of our data
to suggest that both prolapse and stress urinary incontinence can be treated surgically
in ≥ 70-year-old women with good results and that these patients should be offered
the same range of surgical options as their younger counterparts. In principle, a
combined surgical procedure cannot be recommended generally, although it should be
considered for older patients on a case-by-case basis.
