gynecological Surgery in women Over 70 Years of Age

Gynecological Surgery in Women Over 70 Years of Age
Gynecological Surgery in Women
Over 70 Years of Age
Mirna Erman-Vlahovic1, Dubravko Habek2, Davor Franicevic2, Ivan Vlahovic1
Department of Gynecology and Obstetrics, Clinical Hospital, Osijek, Croatia1
Department of Obstetrics and Gynecology, School of Medicine, Sveti Duh General
Hospital Zagreb, Croatia2
ORIGINAL PAPER
SUMMARY
OBJECTIVE: To determine the indications, operative procedures and outcome in elderly women of 70 years of age or
older. METHODS: There were 1651 surgeries performed at the Department of Gynecology and Obstetrics, Clinical Hospital
in Osijek. The study includes 60 women (3.6 %), aged 70-81 (median age 74), who underwent surgery. RESULTS: Ovarian
cancer was present in 13 (21.6 %), benign ovarian tumor in 3 (5.0%), ovarian cancer of a borderline malignancy in 1 (1.6 %),
endometrial cancer in 16 (26.6 %), complex hyperplasia in 2 (3.3 %), nonneoplastic pyometra in 1 (1.6 %), cervical cancer
I A 1 in 1 (1.6 %), descensus or prolapse of the uterus in 18 (30.0 %), and vulvar cancer in 5 (8.3 %) patients. Abdominal
hysterectomy was carried out in 32 (53.3 %); vaginal hysterectomy in 16 (26.6%), supravaginal hysterectomy in 2 (3.3%),
colpocleisis in 2 (3.3 %), explorative laparotomy in 3 (5.0 %) and radical vulvectomy in 5 (8.3 %) patients. CONCLUSION:
One third od the patients had a corrective surgery and others due to their life- threatening condition as a result of cancer.
Keywords: gynecological diseases, surgery, aging, late postmenopause.
1. INTRODUCTION
Due to the prolonged life expectancy in Croatia, we
can expect a higher incidence of diseases typical for older
age, what affects health care, especially for older patients.
Average life expectancy in Croatia in 1999 was 68.92 years
for men and 76.55 years for women. Therefore we can
anticipate an increasing number of women over 70 years
of age, so in 2001. out of all female population there were
5.3 % of women at the age from 70 to 74 years and 7.2 %
older than 75 (1).
Consequently, even a bigger number of patients with
endometrial and ovarian cancer can be predicted for the
future (1-3) In the case of life threatening disease that
requires gynecological surgery, the patients condition
is affected by other diseases typical for elderly, such as
diabetes mellitus, hypertension, arteriosclerosis, cardiac
diseases, chronic pulmonary disease, musculosceletal
disorders and genital prolapse (1,4,5)
The aim of the study was to determine indications and
operative procedures in women older than 70.
2.MATERIAL AND METHODS
In this retrospective clinical study, data were obtained
from patient files and operative protocols. The indications
were classified according to emergency status and electivity of the surgical procedures performed at patients of refered age. There were 1651 surgeries performed at the DeProfessional papers
partment of Gynecology and Obstetrics, Clinical Hospital
in Osijek in 2001. and 2002. There were 60 patients (3.6
%) aged between 70 and 81 (average 74, median 74). Prior
to indicated surgery, all patients underwent preoperative
procedures, including routine blood and urine tests, heart
and lung x-ray, ECG, medical and anesthesiologic examination. In patients with malignant conditions, abdominal
ultrasound, irigography, intravenous urography computerised tomography (CT) or magnetic imaging (MRI), and
urologic examination were performed.
3.RESULTS
Indications for surgical procedures are shown in table
1. and surgical procedures in table 2. Endometrial cancer,
previously verified by fractionated curettage, has been
found in 16 (26.6 %) of all patients included in study.
Surgical-pathologic stages were:I B in 10 (62.5 %), I C in 3
(18.75 %), II A in 1 (6.25 %), II B in 1 (6.25 %), III in 1 (6.25
%) patients. Postoperative radiation therapy undervent 5
(31.25 %) patients.
Pathohystologic findings after the operation were:
Adenocarcinoma endometrioides endometrii 11 (68.7 %),
Carcinosarcoma 4 (24.9 %), Adenocarcinoma clarocellulare endometri 1 (6.2 %).
The reasons for performing tota l abdomina l
hysterectomy+bilateral salpingoophorectomy (TAH +
BSO) were: due to the complex hyperplasia in 2 (3.3,%)
93
TABLE 1.
Indications
and surgical
in elderly
women
surgically treated at the Department of
Gynecological
Surgeryprocedures
in Women Over
70 Years
of Age
Gynecology and Obstetrics during 2001 and 2002
Surgical procedure
No
%
patients, because of nonneo- Indications
plastic pyometra in 1(1.6 %),
TAH+BSO
3
5,0
and because of cervical can- Benign ovarian tumor
Ovarian cancer of border line malignancy TAH+BSO
1
1,6
cer I A 1 in 1 (1.6 %). Ovarian
Ovarian cancer
TAH+BSO+OM+AP
9
cancer was found in 13 (21.6
TAH+BSO
2
%) patients, ovarian cancer
LE
2
of border-line malignancy in
Total
13
21,6
TAH+BSO
13
1 (1.6 %) and benign serous Endometrial cancer
TAH+BSO suprav.
2
cystadenoma in 3 (5.0 %) paLE
1
tients. Distribution accordTotal
16
26,6
ing to the stages was: I A in
Complex hyperplasia
TAH+BSO
2
3,3
1 (7.7 %), II in 3 (23.0 %), III Pyometra
TAH+BSO
1
1,6
in 8 (61.6 %), and IV in 1 (7.7 Cervical cancer I A 1
TAH+BSO
1
1,6
%). Pathohystologic findings Uterine prolapse
TVH+BSO
16
were: Cystadenocarcinoma
Colpocleisis
2
Total
18
30,0
serosum in 7 (53.8 %), Tumor
VR
5
8,3
granulosacellularis in 1 (7.6 %), Vulvar cancer
Carcinoma transitiocellulare TABLE 1. Indications and surgical procedures in elderly women surgically treated at the
9
in 1 (7.6 %), Adenocarcinoma Department of Gynecology and Obstetrics during 2001 and 2002. Legend: TAH - total abdominal
hysterectomy,
TVH - total vaginal hysterectomy, BSO - bilateral salpingoophorectom, LE LEGEND:
endometrioides in 1 (7.6 %), explorative laparotomy, APP - appendectomy, VR - radical vulvectomy, OM - omentectomy
Adenocarcinoma metastati- TAH - total abdominal hysterectomy
cum in 1 (7.6 %) and poorely TVH - total vaginal hysterectomy stage of disease is the most significant variable affecting
- bilateral salpingoophorectomy
diferentiated adenocarcinoma in 2BSO
(15.3
%).
survival, a number of other individual prognostic facLE - explorative laparotomy
Multiagent chemotherapy was APP
used- to
treat 5 (38.4 %)
tors, including patient age, tumor grade, histopathology,
appendectomy
VR multiagent
- radical vulvectomy
patients. Because of reccurence after
chemodepth of myometrial invasion and evidence of extrauterine
TABLE 2.
OM - omentectomy
therapy radiation therapy has been performed in 1 (7.6
disease spread are also implicated as having prognostic
SURGICAL
IN ELDERLY
WOMEN
%)
case.TwoPROCEDURES
(15.3%) patients
with ovarian
cancer died
importance for reccurence and survival (6).
fifteenth and twentieth day after the surgery.
Tumor size, peritoneal cytology, hormone receptor
status, flow cytometric analysis are additional prognostic
Surgical procedures
No
%
factors (6,7). Younger women have a better prognosis.
Older age group is associated with increased risk of
Total abdominal hysterectomy
32
53,3
extrauterine
spread, deep myometrial invasion, grade 3,
Total vaginal hysterectomy
16
26,6
and
unfavourable
histologic types (6).
Supravaginal hysterectomy
2
3,3
Endometrial
cancer
incidence continually rises, so at
Colpocleisis
2
3,3
the
age
group
70-74
is
31.5,
in the age group 75-79 is 28.0
Explorative laparotomy
3
5,9
and in the age group 80-84 is 34.7 per 100,000 women.
Vulvectomy
5
8,3
Endometrial cancer has been succecsfully surgically
Table 2. Surgical procedures in elderly women
treated in 13 (81.2 %) patients. There were two cases of
Vulvar cancer was present in 5 (8.3 %) cases. All of
supracervical abdominal hysterectomy (12.5 %) and one
8
these patients undewent radical vulvectomy. Distribution
case of explorative
laparotomy (6.2 %). Ovarian maligaccording to the stages was: stage I in 1 (20.0 %), stage II in
nancies represent the greatest clinical challenge in gy2 (40.0 %) and stage III in 2 (40.0 %) patients. All patients
necological cancer treatments. Epithelial cancers are the
pathohystologic finding was Carcinoma planocellulare
most common,and since they are usually asymptomatic
until they have metastasized, patients in advanced stage
corneum. Three patients (60.0 %) underwent radiation
makes up to two-thirds of the case with this type of distherapy. Complete radiation has been performed on one
ease. Ovarian cancer is a surgical challenge, thus requiring
patient with dose of 60 Gy.Two patients had radiation
intensive and complex postoperational therapy, not mentherapy interrupted because of strong side-effects and
tioning patients psychological and physical requirements
their bad physical condition.
(1,2,6). Speaking of the most occuring diseases at that age,
4.DISCUSSION
we can see that ovarian cancer has maximal incidence of
Operative procedures in elderly women are quite risk
56.5 per 100,000 in the age group 70-74 and its incidence
because of preexisting diseases and postoperative mordeclines progressively with the age, but it remains high
talitiy rate. Recently, certain factors, as declining incitill the age of 85. In the majority of our patients, successdence of cervical cancer, prolonged life expectancy and
ful surgical procedure has been performed in total of 8
earlier diagnosis have led to increased incidence of endo(61.5 %) patients.
metrial cancer. The role of estrogen in the development of
The types of surgical procedure were TAH / BSO,
the most endometrial cancers has been established. Any
omentectomy and appendectomy in 2 (15.4 %), TAH/BSO
factor that increases exposure to unopposed estrogen inin 2 (15.4 %) and explorative laparotomy in 2 (15.4 %) pacreases the risk of endometrial cancer (6). Although the
tients. One patient (7.7 %) had multiagent chemotherapy
94
Professional papers
Gynecological Surgery in Women Over 70 Years of Age
after explorative laparotomy (paclitaxel and carboplatin)
and later TAH+BSO, omentectomy and appendectomy.
The surgery and postoperative period were well tolerated by the majority of the patients. Two patients (15.4 %)
died in the hospital fifteenth and twentieth day after the
surgery due to their poor general medical condition and
advanced stage of malignant disease.
Vulvar and vaginal cancers are mostly postmenopausal
diseases with the maximum incidence at the very old age
and are distributed according to the age groups as follows:
7.9 in the age group 70- 74, 16.9 in the group 75-79, 6.1 in
the group 80-85, and 32.8 in the group of women older
than 85 (2). Vulvar cancer is rather uncommon, representing about 4 % of malignancies of the female genital system.
Squamous cell cancer accounts for about 90 % of all
cases. In the last 15 years this type of cancer has been
successfully treated. However these changes have not improved the survival rate, but have decreased the physical
and psychological morbidity associated with the treatment (2,3,4).
Despite the age and general medical condition of the
most patients with vulvar cancer, surgery is usually well
tolerated. A postoperative mortality rate of about 2 % can
be expected, usually as a result of pulmonary embolism
or myocardial infarction. All our 5 patients (8.3 %) had
radical vulvectomy with separate groin incisions. Surgery
was remarkably well tolerated.
The indications for radiation therapy were present in
3 (60.0 %) patients. For the rest of eighteen patients (30.5
%), the operation has not been of vital importance.
Nonneoplastic pyometra (or other inflammatory pelvic disesases) is uncommon in postmenopausal women.
Nonneoplastic pyometra caused by specific or nonspecific
inflammation, necrotic endometrial polyp or submucous
myoma). Rare case of the pyometra and pyotuboovarium
in postmenopausal women were described (8,9) and such
a rare incidence of pelvic inflammatory disesases is the results of involuted urogenital atrophy and sexual inatcivity.
Urogenital prolapse, the most frequent indication for
the surgery and it’s most common types are displacement of the bladder, descent of the uterus and cervix, followed by the protrusion of the rectum into the posterior
vaginal lumen, occasionally accompanied with urinary
incontinence (1,3,5). The surgery has been indicated due
to hygienic-social inconvenience (urinary incontinence,
prolapse of the uterus). Sixteen patients were submitted
to vaginal hysterectomy and BSO. Colpocleisis was carried out in 2 patients because of the poor general medical
condition. The patients were in good mental and physical
condition and surgery improved their life quality. Surgical
procedures were successfully performed in all patients,
without complications observed during postoperative
course.
In postmenopausal women, sexuall or accidental genital trauma is significantly more than the younger women,
because postmenopausal hipoestrogenic changes including thinning and atrophy of the vulvovaginal epithelium
and reduced vaginal lubrication. The skin loses its subcutaneous fat and collagen is reduced, which results in
Professional papers
skin that is easily traumatized and slow to heal (10,11).
In our study during the two-years period, did’not verified
sexual or accidental genital injury in late postmenopausal
women.
We believe that surgery indicated due to the life threatening conditions, or some o
ther reasons, can be performed in elderly women under the condition of egzistance of a proper preoperative
and intensive postoperative care. Two patients died in
postoperative period as a result of their poor health and
advanced malignant disease. High quality health care
among elderly can be evaluated according to decreased
number of health problems typical for older age and according to causes of death experienced in this age group.
REFERENCES
1.
Klarić P, Bolf-Benković I, Habek D. Gynecologic operative
procedures in women over the age of seventy. Croatian Med
J 1997;38:271-272.
2. DiSaia PJ, Creasman WJ. Invasive cancer of the vulva. In:
DiSaia PJ, Creasman WJ, eds. Clinical gynecologic oncology.
St Louis-London-Philadelphia:CV Mosby Co 2002; 211-241.
3. Wall LL. Incontinence, prolapse and disorders of the pelvic
floor. In:Berek JS, Adashi EY, Hillard PA. Novak’s gynecology. Baltimore-Philadelphia-London:Williams&Wilkins A
Waverly Company 1996;619-677.
4. Byny RL, Speroff L. A clinical guide for the care of older
women. Primary and preventive care. 2nd ed. BaltimoreHong Kong-London-Sydney-Tokio; Wiliams&Wilkins; 1996.
5. Goepel C, Hefler L, Methfessel HD, Koelbl H. Periurethral
connective tissue status of postmenopausal women with
genital prolapse with and without stress incontinence. Acta
Obstet Gynecol Scand 2003; 82:659-64.
6. Hacker NF. Uterine Cancer. In: Berek JS, Hacker NF, eds.
Practical gynecologic oncology. Baltimore: Williams &
Wilkins Baltimore; 1989:285-364.
7. Varras M, Akrivis Ch, Polyzos D, Frakala S, Samara Ch. A voluminous twisted paraovarian cyst in a 74-year-old patient:
case report and review of the literature. Clin Exp Obstet
Gynecol 2003;30:253-6.
8. Habek D. Pyometra and bilateral pyotuboovarium in
84-Year Old Women. Eur J Obstet Gynecol Reprod Biol
2005;123:258-260.
9. Hoffman M, Molpus K, Roberts WS, Lyman GH, Cavanagh D.
Tuboovarian abscess in postmenopausal women. J Reprod
Med 1990;35:525-528.
10. Habek D, Kulaš T. Nonobstetrics vulvovaginal injuries: mechanism and outcome. Arch Gynecol Obstet 2006
11. Templeton DJ. Sexual assault of a postmenopausal woman.
J Clin Forens Med 2005;12:98-100.
Corresponding author: Dubravko Habek, M.D., Ph.D. Department of Obstetrics and Gynecology, School of Medicine, Zagreb University, Sveti Duh
Hospital Zagreb Sveti Duh 64, HR-10000 Zagreb Croatia Phone: ++385 1
3712111 Fax: ++385 1 3745534 E-mail: dubravko.habek@os.t-com.hr
95