Pelvic floor reconstructive surgery is usually performed in a relatively advanced age group of women. Enhanced recovery after surgery pathway was developed for colorectal surgery to hasten the post-operative recovery, yet limited studies have been performed for urogynecological surgeries. Advanced age itself may look like an obstacles to this enhanced recovery pathway. Thus, our study was to investigate if age mattered in the early recovery after pelvic floor reconstructive surgery and to see if any associated factors affecting on the length of stay after operation.

This was a retrospective analysis of a prospectively collected database. All pelvic floor reconstructive surgeries were performed or in-charge by certified urogynecologists in a tertiary university hospital. Types of surgeries included both native tissue repair and abdominal or vaginal route of mesh surgery, which could be done with or without concomitant continence surgery. The approach of enhanced post-operative recovery and early discharge from in-patient hospital stay has been adopted in recent 5 years. All women who have undergone any pelvic reconstructive surgeries in recent 5 years were included in the analysis. Their demographics, operative procedures, postoperative recovery and any emergency or unplanned readmission were all recorded. An early recovery and discharge was defined as discharged within post-operative day 1. Different factors were also analyzed to see if any association with the length of post-operative stay. There is no good medical definition on “advanced age” or “elderly” (1).Thus, for the purpose of this study, primary outcome of chronological age of women, was defined with different “cut-off” to check on its potential influence on the post-operative stay, including younger women as being < 65 years old, elderly as between 65 and 70 years old, >70 years old or >80 years old.

Total 688 pelvic floor reconstructive surgeries were performed from Jan 2018 to Dec 2022. Hysterectomy were performed in most women (n=555), majority by vaginal route (n= 543, by laparoscopic route n=10, and open n=2). Remaining included obliterative surgery by colpoclesis (n=15) and uterine preserving surgery (n=8) as well as other types of prolapse repair surgery. Most were native tissue repair and 149 (21.7%) of them involved mesh repair surgery, involving abdominal route (n=78), namely sacrocolpopexy, mostly done laparoscopically (n=77) and laparoscopic hysterosacropexy (n=4); vaginal route by anterior vaginal mesh in 67 women. There were 197 (28.6%) concomitant continence surgeries, mainly mid-urethral sling surgery by tension free vaginal tape surgery (transobturator or retropubic route).
Mean age of women were 66.8 ± 8.7 years old and their mean length of stay was 2.2 ± 2.5 days, ranging 0-50 days and mode being 1 day. Up to 41.6% of women were discharged within post-operative day one, while 78.9% discharged within post-operative day two. Both the younger group of women or “elderly” with different definitions did not show significant association with the length of post-operative stay, <65 years old, p-value 0.21; between 65 and 70 years old, p-value 0.25; >70 years old, p-value 0.08; >80 years old, p-value 0.07. Concomitant continence surgery and mesh surgery, irrespective of route, were found to be associated with longer length of stay, p-value <0.01, with odds ratio (OR) 1.8, 95% confidence interval (C.I.) 1.2-2.5;  p-value < 0.01, OR 3.6, 95th C.I. 2.3-5.6 respectively. 
There were 35 unplanned emergency readmissions within 30 days after operation. Major reasons included vault, pelvic or vaginal hematoma (n=14), wound infection (n=5), minor complaints such as non-specific abdominal pain, vaginal bleeding or vaginal discharge (n=6), pain (n=4) and urinary or voiding symptoms (n=4). There was one admission due to post-operative adhesive intestinal obstruction and one caused by duodenal ulcer. Age, mesh or concomitant continence surgery were not associated with unplanned readmissions.

Age itself, disregarding being younger, elderly or advanced age was not found to have significant effect on the early discharge after operation though a trend of influence might be present for those older than 70 years old. Concomitant continence surgery or mesh surgery was found to be associated with relatively longer period of stay, which could be due to potential higher risks of voiding dysfunction and need of bladder training or adjustment of tape tension after mid-urethral sling surgery.

This observational study showed that age did not significantly affect the post-operative recovery. Enhanced recovery pathway seems to be applicable in most including advanced age of women undergoing pelvic reconstructive surgeries.

Defining 'elderly' in clinical practice guidelines for pharmacotherapy. Pharm Pract (Granada). 2014 Oct;12(4):489. doi: 10.4321/s1886-36552014000400007. Epub 2014 Mar 15. PMID: 25580172; PMCID: PMC4282767.

Continence 7S1 (2023) 101001
DOI: 10.1016/j.cont.2023.101001