The incidence of pelvic organ prolapse (POP) is reportedly near 50% and the lifetime risk of POP requiring surgery is approximately 20%.1 2 With the increasing lifespan and emphasis on quality of life worldwide, older women increasingly prefer surgical treatment, instead of vaginal pessaries, as definitive treatment for POP.3 Surgical treatment options are either reconstructive or obliterative. Reconstructive surgery comprises native tissue repair (mainly vaginal hysterectomy [VH]), pelvic floor repair, and mesh-related repair; obliterative surgery comprises colpocleisis with or without concomitant VH.

Older women who undergo urogynaecological surgery have a higher surgical risk, regardless of fragility index; they have lower risks of prolapse recurrence and repeated surgery.4 Although the World Health Organization has defined old age as ≥65 years,5 a threshold of ≥75 years may be more appropriate for older women in terms of fragility and need for care. A previous Hospital Authority ageing projection6 indicated that the number of individuals aged 75 to 84 years will substantially increase in Hong Kong, while the numbers of individuals aged ≥85 years or ≤74 years will remain comparatively stable. A threshold of ≥75 years for geriatric medicine may be reasonable because most chronic, complex disabling disease occurs among individuals in this age-group.7

To our knowledge, despite the increasing number of women aged ≥75 years and the need for surgical treatment of POP among these individuals, there is limited evidence regarding the risks and benefits of the available surgical options. This multicentre, retrospective study was performed to review the surgical treatment of POP in women aged ≥75 years; we aimed to characterise its safety, effectiveness, and the type most often selected. We hope that the findings will help clinicians to counsel older women with POP who are considering surgical treatment.

This multicentre, retrospective cohort study was conducted at Kwong Wah Hospital, Pamela Youde Nethersole Eastern Hospital, Princess Margaret Hospital, and Prince of Wales Hospital. We included patients aged ≥75 years, all of whom underwent surgical treatment of POP in one of the above four gynaecological units between 2013 and 2018. We reviewed patient information from the Clinical Data Analysis and Reporting System and Clinical Medical System; for patients with incomplete data in the Clinical Medical System, we reviewed paper-based medical records. Ethical approvals were obtained from the Institutional Review Boards of all four Clusters including Hong Kong East Cluster, Kowloon Central Cluster, Kowloon West Cluster and New Territories East Cluster.

Demographic data and symptoms of prolapse were collected during each patient’s first visit to a participating gynaecology unit. Physical examinations were conducted to confirm POP, stage of prolapse, and the compartments involved; all examinations were performed using the International Continence Society Pelvic Organ Prolapse Quantification (POP-Q) staging system.7 Patients were offered vaginal pessary management or surgical treatment. Patients who opted for surgical treatment were scheduled for surgery with or without a trial period of vaginal pessary management. Preoperative urodynamics studies were performed if indicated. During the preoperative assessment, each patient underwent a comprehensive evaluation that included patient-reported symptoms of prolapse, as well as urinary, intestinal, and sexual statuses; they also underwent prolapse assessment using POP-Q staging. Thorough counselling was provided regarding reconstructive and obliterative treatment options, including a discussion of the potential benefits and risks of both procedures, as well as the need for concomitant VH or mid-urethral sling transobturator tape (TVT-O) for urodynamic stress incontinence.

Reconstructive procedures involved native tissue repair and mesh-related surgery. Native tissue repair mainly comprised vaginal hysterectomy followed by pelvic floor repair (VHPFR; eg, anterior and/or posterior colporrhaphy). In addition, sacrospinous ligament fixation was performed for stage ≥III uterine prolapse or vaginal vault prolapse. Patients with stage ≥III anterior compartment prolapse were offered anterior vaginal mesh repair. Obliterative surgery comprised colpocleisis with or without concomitant VH. Anterior vaginal mesh repair and colpocleisis were only offered to patients who were sexually inactive before surgery or agreed not to engage in sexual intercourse. Combinations of concomitant procedures were performed in the following order, using only the procedures selected by each patient and their surgeon: VH, mesh placement and sacrospinous fixation, native tissue repair, and TVT-O placement. All native tissue repair procedures were performed or supervised by a gynaecological specialist; all sacrospinous ligament fixation or anterior vaginal mesh repair procedures were performed or supervised by urogynaecologists. One dose of prophylactic intravenous antibiotic was administered during anaesthesia induction. In patients who underwent reconstructive surgery, one piece of vaginal gauze was placed to achieve haemostasis for 1 day. A Foley catheter was placed to ensure urinary drainage for 1 to 2 days according to the procedures used in each unit. Operative time, intra-operative blood loss, perioperative complications, and postoperative adverse events were recorded. Postoperative fever was defined as ≥2 readings of temperature ≥38°C with no positive culture or identifiable cause. A diagnosis of urinary tract infection was made on the basis of positive midstream urine culture results. A diagnosis of urinary retention was made when a patient could not void and required catheterisation. All instances of postoperative haematoma were diagnosed by imaging (ultrasound or computed tomography scan). When available, pathology reports were also reviewed.

All patients underwent the same postoperative assessment, which was structured using a standardised datasheet. Follow-up visits were scheduled at 6 to 12 weeks and 1 year after surgery, then annually until 5 years after surgery. Each follow-up visit evaluation included assessments of urinary and intestinal function; symptoms of prolapse, vaginal pain and dyspareunia; and symptoms of mesh erosion. Vaginal examinations and POP-Q assessments were performed to identify instances of POP recurrence or mesh-related complications, in accordance with the recommendations of the International Continence Society and the International Urogynecological Association.9 Prolapse recurrence was defined as the presence of subjective symptoms of prolapse or a POP-Q stage of ≥II in a clinical examination.

We compared patient demographic characteristics, POP severity, and surgical outcomes between two groups: reconstructive and obliterative surgeries. These comparisons were also made among four subgroups: VHPFR, transvaginal mesh surgery (TVM), VH plus colpocleisis, and colpocleisis alone. Statistical analyses were performed using SPSS (Windows version 26.0; IBM Corp, Armonk [NY], United States). Descriptive statistics were used to summarise demographic and clinical characteristics. Continuous variables were expressed as mean (standard deviation) or median (interquartile range); they were analysed by independent-samples t tests or the Mann-Whitney U test (comparison of two groups)/one-way analysis of variance or Kruskal–Wallis H test (comparison of ≥3 groups), depending on the normality of the data assessed by Shaprio–Wilk test. Categorical data were expressed as numbers and percentages; the Chi squared test and Fisher’s exact test were used for categorical data analysis. A P value of <0.05 was considered statistically significant.

In total, 343 patients underwent surgery for POP from 2013 to 2018 in the study hospitals. The types of surgical treatment at each hospital are shown in Table 1. Vaginal hysterectomy plus pelvic floor repair procedures were evenly distributed among all four hospitals. However, 93% of TVM procedures, 95% of VH plus colpocleisis procedures, and 50% of procedures comprising colpocleisis alone were performed in Prince of Wales Hospital, Princess Margaret Hospital, and Pamela Youde Nethersole Eastern Hospital, respectively.

Among the 343 patients, 216 (63%), 90 (26.2%), and 37 (10.8%) had stages II, III, and IV POP, respectively (Table 2). Furthermore, 289 (84.3%) patients underwent reconstructive surgery and 54 (15.7%) patients underwent obliterative surgery. Of the 289 reconstructive surgeries, 246 (71.7%) were native tissue repair procedures (mainly VHPFR), while 43 (12.5%) were TVM (36 had concomitant VH); among the 54 obliterative surgeries, 20 (5.8%) were colpocleisis plus VH, while the remaining 34 (9.9%) were colpocleisis alone (Table 3).

Table 2 compares demographic and clinical characteristics between the reconstructive and obliterative surgery groups. Patients with more advanced age chose obliterative surgery, rather than reconstructive surgery (81.9 vs 79.6 y; P=0.001). Other variables including parity, number of vaginal births, number of instrumental deliveries, body mass index, smoking, and coital activity were comparable between the two groups.

More patients with vaginal vault prolapse opted for obliterative surgery, rather than reconstructive surgery (38.9% vs 3.5%; P<0.001) [Table 2]. The difference was more striking when the colpocleisis alone group was compared with all patients who underwent reconstructive surgery (61.8%; P<0.001) [Table 3]. Moreover, the number of patients who had medical co-morbidities (eg, hypertension, diabetes mellitus, heart disease, or history of stroke) was greater in the obliterative surgery group than in the reconstructive surgery group (37% vs 4.8%, P<0.001) [Table 2].

Concerning patients with stage III/IV POP, more patients underwent TVM, rather than VHPFR, in the reconstructive surgery group (100% vs 16.7%; P<0.001); in the obliterative surgery group, more patients with stage III/IV POP underwent VH plus colpocleisis, rather than colpocleisis alone (100% vs 67.6%; P<0.004) [Table 3].

One case of carcinoma of the corpus uteri (Ca corpus) was confirmed from the pathology report of a patient who underwent VH. Thus, the incidence of Ca corpus was 0.3% (1/312). The affected woman was an asymptomatic patient in the TVM group; she had incidental findings of endometrial thickening during preoperative assessment. The results of endometrial aspiration could not exclude a diagnosis of hyperplasia. The patient underwent postoperative contrast-enhanced computed tomography of the abdomen and pelvis 2 months after surgery; there were no signs of distant metastasis. After detailed counselling, the patient refused further surgery or adjuvant therapy. For 25 months of follow-up, the patient’s cancer has remained in remission.

Table 4 shows surgical outcomes in both groups and all subgroups. Compared with obliterative surgeries, fewer reconstructive surgeries were performed under spinal anaesthesia (57.4% vs 38.1%; P=0.008). Notably, 76.5% of procedures comprising colpocleisis alone were performed under spinal anaesthesia (P<0.001). Obliterative surgeries had a shorter operative time (73.5 min vs 107 min; P<0.001) and fewer surgical complications (9.3% vs 28.0%; P=0.003) than did reconstructive surgeries. Among the four subgroups, colpocleisis alone had the shortest operative time (60 min; P<0.001) and least blood loss (50 mL; P<0.001).

Analysis of surgical complications (Table 4) showed that the VHPFR group had the highest intra- and peri-operative complication rate (30.1%; P=0.01), compared with the other subgroups. In the VHPFR group, four (1.6%) patients required conversion to laparoscopy/laparotomy (two had dense adhesion, one had large uterine size, and one had difficulty achieving haemostasis). There were three (1.2%) bladder injuries; all underwent primary repair with good recovery and did not experience long-term consequences. Four (1.6%) patients in the VHPFR group required intensive care unit (ICU) admission after surgery (one had fluid overload, one had respiratory acidosis, one had cardiac problems, and one had metabolic acidosis). In all, 29 (11.8%) patients had fever of unknown cause; 90% of them resolved by oral antibiotics. Ten (4.1%) patients had postoperative wound or pelvic haematoma, and 10 (4.1%) patients had urinary tract infection. In the TVM group, one (2.3%) patient required ICU admission because of fluid overload, while three (7%) patients had urinary retention after surgery. The VH plus colpocleisis and colpocleisis alone groups both included one patient with wound haematoma. In the TVM group, 32.6% of patients had concomitant TVT-O placement; 12.2%, 5%, and 2.9% of patients had concomitant TVT-O placement in the VHPFR, VH plus colpocleisis, and colpocleisis alone groups, respectively (P=0.001) [Table 4].

The median durations of follow-up were 13 and 17 months in the reconstructive and obliterative surgery groups, respectively (Table 4). The TVM group had a significantly longer median follow-up duration (25 months; P<0.001); this was consistent with the need to monitor any mesh complications. There was only one patient was lost to follow-up throughout the study period. Although there tended to be fewer instances of recurrence in the obliterative surgery group than in the reconstructive surgery group (7.4% vs 16.3%; P=0.092), the difference was not statistically significant. There also tended to be a higher rate of prolapse recurrence in the VHPFR group than in the TVM, VH plus colpocleisis, or colpocleisis alone groups (VHPFR 18%, TVM 7%, VH plus colpocleisis 5%, and colpocleisis alone 8.8%), but this trend was not statistically significant (P=0.091). Finally, few patients in each group underwent surgery for prolapse recurrence or stress urinary incontinence after surgery.

To our knowledge, this is the first multicentre retrospective study in Hong Kong concerning POP surgery for women aged ≥75 years. Overall analysis of demographic characteristics indicated that most patients underwent VHPFR because the largest proportion of patients had stage II POP. Most patients were sexually inactive (only four of 343 patients reported sexual activity), multiparous (median of four births overall), and had a history of exclusively vaginal delivery. The mean body mass index overall was 25.3 kg/m². Compared with reconstructive surgery, obliterative surgery was more frequently selected by patients who were older, had medical co-morbidities, had a history of pelvic floor repair surgery, and had vaginal vault prolapse.

In this study, we found that surgical treatment was a safe option for older women who sought to improve their quality of life. The postoperative mortality rate was zero, consistent with the low mortality rate 4.1% in a previous study.4 Notably, prior studies10 11 in Chinese populations suggested that poor quality of life and complications associated with vaginal pessary management lead to an increased likelihood of surgical treatment. In our study, over 80% of patients in the obliterative surgery group had an unsatisfactory vaginal pessary outcome; nearly half of the patients also had urinary retention. Therefore, it is reasonable that these patients chose POP surgery, despite their advanced age.

In studies from other countries, the reported rates of surgical complications associated with POP surgery in women aged ≥75 years were 30% to 40%.12 13 Although the VHPFR group had the highest rate of surgical complications among all subgroups in the present study, the rate of 30.1% was comparable to the rates in studies from other countries. However, 1.7% of patients in the reconstructive surgery group were admitted to the ICU after surgery; this was higher than the reported rate of 0.45% in a large cohort study with a mean patient age of 62.7 years.14 Because older women are more likely to experience fluid overload—it was present in 40% of the patients who required postoperative ICU care in our study—perioperative fluid replacement should be cautiously administered.

Patients in the obliterative surgery group had fewer surgical complications than did patients in the reconstructive surgery group. When the four types of surgeries were compared, the proportion of surgeries performed under spinal anaesthesia was greatest for procedures comprising colpocleisis alone; these procedures also had the least blood loss, shortest operative time, and fewest complications. Furthermore, the hospital stay in the colpocleisis alone group was comparable with the lengths in other groups, although significantly larger proportions of patients in the colpocleisis alone group had medical co-morbidities and were older.

Theoretically, colpocleisis with concomitant VH is superior to colpocleisis alone because it avoids the possibility of missing Ca corpus during surgery or later in the patient’s life15 16; however, it is associated with a longer operative time and increased blood loss.17 18 Our results were consistent with the findings in previous studies from other countries. Patients aged ≥75 years are beyond the peak incidence of Ca corpus: according to the Hong Kong Cancer Registry, the median age of patients with Ca corpus is 55 years.19 In the present study, one patient in the TVM group had Ca corpus; thus, the rate of incidental malignancy was 0.3%, which was comparable to the rate of 0.26% previously reported in Hong Kong.20 Currently, pelvic ultrasound is not a routine component of preoperative assessment. To reduce the risk of missing Ca corpus, preoperative transvaginal ultrasound (to assess endometrial thickness) and endometrial aspiration should be considered in women who have abnormal vaginal bleeding or plan to undergo uterine-preserving surgery.20

Although TVM is a more complex surgery than VHPFR, the rate of perioperative surgical complications was lower in the TVM group; hospital stays were comparable between the two groups. However, the operative time was longer and blood loss was greater in the TVM group. Compared with patients in the VHPFR group, patients in the TVM group had a lower rate of POP recurrence (all recurrences occurred in patients with stage III/IV POP) and a significantly longer follow-up duration. The mesh erosion rate in this study (2.3%) was lower than in another study in Hong Kong (8.9%), which had a longer follow-up duration of 40 months and included younger patients.21 When proper counselling is provided, TVM is a safe option for healthier patients with stage III/IV POP because stage III/IV POP is a risk factor for recurrence.22

Notable strengths of this study included its multicentre design and focus on POP surgery among older women in the Hong Kong Chinese population, which has not been previously explored. Patients in this study included all women aged ≥75 years who underwent POP surgery in a 6-year period at four hospitals; these hospitals are jointly accredited as a single urogynaecological training centre under the Hong Kong College of Obstetricians and Gynaecologists, and they have extensive experience performing all types of POP surgery (Table 1). Furthermore, the electronic medical record system of the Hospital Authority facilitated complete data collection and retrieval. However, there were a few limitations in this study. First, it was a retrospective study. Second, we did not perform quality of life assessment or investigate the presence of guilt concerning colpocleisis surgery. Because few patients reported sexual activity before surgery, we presume that most older women in Hong Kong would not regret the selection of colpocleisis because of its effects on sexual activity. Third, although the median follow-up period was <18 months, it may have been insufficient to fully characterise prolapse recurrence and gynaecological malignancy. Finally, the levels of independence and family support may be important factors for older women to consider before making any surgical decision; however, we did not have access to such data. These factors could be examined in future studies.

This multicentre retrospective study showed that multiple types of POP surgeries were safe and effective for women aged ≥75 years. Most surgical complications were self-limiting and the recurrence rate was low. The excellent results suggest that colpocleisis may be appropriate as primary surgery for fragile older women. These findings will facilitate preoperative counselling for older women with POP who are considering surgical treatment.

Concept or design: D Wong, SSC Chan
Acquisition of data: All authors.
Analysis or interpretation of data: D Wong, SSC Chan.
Drafting of the article: D Wong, SSC Chan.
Critical revision for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

We would like to express our gratitude to Ms LL Lee, Dr TH Chan and Dr CW Chu for data collection and entry.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This study was approved by the Hong Kong East Cluster Ethics Committee (HKECREC-2020-069), the Kowloon Central Cluster Ethics Committee (KC/KE-20-0223/ER-2), the Kowloon West Cluster Ethics Committee (EX-20-108[150-02]), and the New Territories East Cluster Ethics Committee (NTEC-2020-138).

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