Operating on the "Oldest Old": Perioperative Complications in Women over 90

Objectives: Women aged 90 and older (“oldest old”) represent a small, but growing population who may experience bothersome prolapse. We sought to determine whether perioperative adverse events (AEs) are increased in the oldest old. We hypothesized that compared to young patients, women ≥90 years would experience greater perioperative complications within 8 weeks of prolapse surgery.

Methods: This was a secondary analysis of a retrospective dual-center study on perioperative AEs in women ≥61 years old undergoing major prolapse surgery from January 2016 to May 2023. We identified all women ≥90 years and created a 1:4 matched cohort of women < 90 years based on Charlson Comorbidity Index (CCI) score and surgery type (colpectomy/colpocleisis vs. anterior and/or posterior colporrhaphy). The primary outcome was a composite 8-week AE outcome which included intraoperative complications, return to operating room, emergency room evaluation, re-admission, discharge to skilled nursing facility (SNF), cardiac complications, venous thromboembolism, surgical site infections, wound dehiscence, blood transfusion, hematoma, ileus or small bowel obstruction, postoperative urinary tract infection, death, and other complications. Demographic and clinical variables were compared between the matched cohorts using t-test (Mann-Whitney U) and chi-square analyses (Fisher’s exact) as appropriate. Multivariable logistic regression analyses were performed for the primary outcome, controlling for variables with p< 0.05 on univariate analysis.

Results: There were 24 “oldest old” undergoing prolapse surgery who were matched to 96 women < 90 years. The majority of women underwent colpectomy/colpocleisis for prolapse repair (92.7%). Women ≥90 years were more likely to have lower body mass index (BMI) (p < 0.01), greater preoperative prolapse stage (p=0.049), and were less likely to have general anesthesia (p < 0.01) (Table 1). Patients did not differ in medical comorbidities (hypertension, diabetes, history of cancer, history of myocardial infarction), frailty (defined by Modified Frailty Index score), concomitant hysterectomy or incontinence procedure, estimated blood loss, or ability to be discharged on the day of surgery.

On univariate analysis, older age was not significantly associated with perioperative AEs (33.3% vs 24.0%, p=0.35) (Table 2). The oldest old did not experience any intraoperative complications and had low rates of re-admission (8.3%) and discharge to SNF (4.2%). There remained no significant association between the composite AE outcome and age ≥90 years on multivariable analysis controlling for BMI, preoperative prolapse stage, and general anesthesia (adjusted odds ratio (aOR) 1.78, 95% CI [0.42-7.50]).

Conclusions: In this select group of “oldest old” women, there was a low incidence of perioperative AEs after major prolapse surgery. Age ≥90 years does not appear to increase risk of AEs when women have similar comorbidities and frailty status. Urogynecologic surgeons should strive to assess patients holistically rather than relying solely on age to determine surgical candidacy.