Gynecologic Surgery in the Geriatric Patient

A multiparous woman in her mid 80s with complete uterine procidentia and difficulty with urination presented to a tertiary care center for surgery. She denied urinary incontinence. She lived by herself and walked with a cane. She had a medical history significant for hypertension, osteoporosis with vertebral fracture, and hypercholesterolemia. She had no history of acute myocardial infarction, cerebral vascular accident, or malignancy. Medications included a beta-blocker, a thiazide diuretic, an HMG-CoA reductase inhibitor, and a bisphosphonate. She denied using vitamins or herbal medications. Physical examination revealed complete uterine procidentia with vaginal atrophy but no ulcerations. Simple uroflow demonstrated an interrupted voiding pattern. No urine leakage was seen with stress maneuvers with a full bladder with the prolapse reduced. Pap test and endometrial biopsy results were negative for malignancy. The patient elected to proceed with an obliterative procedure to correct her pelvic organ prolapse. Preoperatively, her serum sodium, serum creatinine, and estimated glomerular filtration rates were 132 mEq/L, 0.8 mg/dL, and more than 60 mL/min, respectively. Beyond noting her living arrangements, history of falls, and walking with assistance, her functional and cognitive status were not formally assessed preoperatively. The patient underwent an uncomplicated modified LeFort colpocleisis, perineorrhaphy, and cystoscopy under general endotracheal anesthesia. Regional anesthesia was not chosen because of to her vertebral fracture. Total anesthesia time was 106 minutes and estimated blood loss was 50 mL. On the morning of postoperative day 1, she ambulated to the bathroom, tolerated a regular diet, and reported adequate pain control. Physical therapy staff, consulted to evaluate her balance and gait, recommended a rolling walker to use with ambulation. She could stand independently and navigate five stairs without assistance. Her serum sodium was 130 mEq/L. She was discharged home on postoperative day 1. On postoperative day 5, the patient fell in her home and was found by her daughter on the floor approximately 30 minutes later. She had used no narcotic pain medication since her surgery. She was readmitted to the hospital for dehydration and hyponatremia (serum sodium 127 mEq/L), which were believed to have been the cause of her fall. Fortunately, no fracture was observed. She moved to her daughter’s house. She continued to have hyponatremia despite discontinuation of thiazide diuretic. Eighteen months after surgery she reported having regained her strength and energy level. She experienced one additional fall with no major injury.