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. 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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: [email protected] 95