Climbing a long hill: pelvic floor surgery and the need for geriatric urogynecology

Abstract

The topic of geriatric urogynecology is receiving much attention lately as a public health priority because of the global increase in female life expectancy and the significant risk of associated pelvic floor dysfunctions. Statistics from the USA project that in 2050, 25 % of the population will be >60 years and that those >85 will increase from a population of 1.9 % in 2010 to 4.3 % in 2050 [1]. The urogynecological community should thus expect to face a worldwide and progressively growing demand from patients seeking care for pelvic floor dysfunctions. One study predicted >50 % increased demand for urogynecological services over the next 40 years [2].The changing female demographics is accompanied by a considerable interest in the contemporary literature to standardize the indications, techniques, and outcomes of surgical treatment of pelvic floor dysfunctions. Only a few reports appreciate that increasing age of our female population is an intrinsic biological variable interfering with the standardization process [3]. Women aged >80 years undergoing urogynecological surgery have a 13.6 higher risk of postoperative death than their younger counterparts. In the majority of cases, the cause of death is not directly related to the procedure [4]. Despite the obvious need for operative intervention among these elderly women and the strong evidence for the inherent morbidity and mortality of this treatment option, there is scarce urogynecological data on the risks and specific perioperative management in this patient group. Ageing influences lower urinary tract symptoms (LUTS), pelvic floor function, and perioperative and postoperative courses. The higher postoperative morbidity rate is also an important factor that is often overlooked in most surgical studies. Main concerns when treating elderly women are:(1) Functional aging with myogenic and neurological changes (2) Polypharmacy (3) Impaired cognitive function and risk of delirium First, considering functional aging, it is traditionally believed that aging is simply a physiological phenomenon caused by a gradual and exponential decline in the functional reserve. Aging, however, is a complex and evolutionary spectrum of innate and progressive events affecting molecules, cells, and the entire organism and is caused by free radicals, nonenzymatic glycosylation, and apoptosis [5]. The entire process is under the control of the endocrine systems-mainly growth hormone, estrogens, and androgens-with significant acceleration of the pace of ageing in women than in men [5]. Aging induces ultrastructural alterations in the urinary bladder that include apoptosis of the detrusor muscle, widening of the intercellular tight junctions, and degeneration of the axonal innervation [6]. These lesions may contribute to the development of functional disorders such as higher postvoid residual volumes, postoperatively impaired voiding dysfunction, or sensory micturition disturbances. The mechanism by which aging changes in the pelvic organs, particularly the urinary bladder, can influen...

Gynaecological Prolapse Surgery in Very Old Female Patients

“…The post-operative morbidity was higher than that in the younger control group as shown by the comparison of complications of the groups CD II and CD III requiring treatment. This corresponds to the observations of other groups [24,28]. In a large retrospective cohort study with over 250 000 patients Sung et al found a 1.4-fold elevated risk for perioperative complications in patients aged 80 years or more [24] on comparison with younger patients.…”

“…No wound infections with problem-causing pathogens were observed in our examined cohorts. Although it is known that advanced age represents an independent risk factor for surgical complications [26], age alone should not be a contraindication for surgical therapy [26,28]. It has been observed in clinical trials that the type and number of co-morbidities determine the risk for surgical complications in elderly female patients.…”

Geriatric Pelvic Organ Prolapse Surgery: Going the Extra Mile

“…Vaginal route is preferable for pelvic reconstructive surgery in geriatric patients, as it usually takes shorter operating time and can be performed under regional anaesthesia [4]. Obliterative vaginal procedures are a good option for elderly patients who cannot tolerate extensive surgery and who are not planning future sexual activity [6].…”