Frailty is Linked to More Preoperative Pelvic Floor Distress but Similar Postoperative Outcomes

Objectives: Frailty is a known prognostic indicator for perioperative outcomes and has been associated with greater life impact from pelvic floor disorders (PFDs). However, frailty status is inconsistently assessed in urogynecologic surgical patients. We hypothesized that frailty in older women planning to undergo surgery for pelvic organ prolapse is associated with worse baseline PFD symptoms and greater postoperative complication rates.

Methods: This is a secondary analysis of a prospective study of postoperative cognitive dysfunction in women ≥60 years old undergoing prolapse surgery. We measured frailty using the Fried Frailty Index (FFI), which categorizes participants as not frail (FFI=0), pre-frail (FFI=1-2), or frail (FFI=3-5). Our primary outcome was baseline pelvic symptom distress assessed two weeks preoperatively by the Pelvic Floor Distress Inventory short-form (PFDI-20). Our secondary outcome was adverse events (AEs) within 6 weeks postoperative as classified by the Clavien-Dindo system (Grades 1-5). Multivariable linear regression evaluated the association between frailty status, PFDI-20 total score, and its components, controlling for age, body mass index (BMI), race, American Society of Anesthesiologists (ASA) score, Pelvic Organ Prolapse Quantification (POP-Q) stage, surgical approach, and history of prior prolapse repair. AEs were compared by frailty status.

Results: There were 165 women with mean ± standard deviation (SD) age of 72.5±6.1 years and BMI of 28.0±4.4 kg/m² (Table 1). Most participants were White (n=154, 93.3%), and 11.5% (n=19) met criteria for frailty. Frail women were more likely to be older, use an overactive bladder (OAB) medication, and have had prior incontinence surgery (p < 0.01). They were less likely to undergo a laparoscopic/robotic prolapse surgery or a concomitant hysterectomy and more likely to opt for an obliterative prolapse repair (p < 0.05). Pre-frail and frail status were associated with higher PFDI-20 scores, with frail women scoring higher in all 3 components of the PFDI-20 compared with non-frail women (Table 2). There were 172 postoperative AEs, and 67.3% (n=111) of women experienced at least one AE. Only 4 women had a serious (Grade 3+) AE. Postoperatively, there were 6 hospitalizations, 9 emergency room visits, and 26 urgent clinic visits. Frail women were not more likely to experience AEs, unplanned hospital or office visits, or postoperative inpatient admission.

Conclusions: Frail women present for prolapse surgery with worse pelvic floor symptoms despite experiencing comparable perioperative outcomes to non-frail counterparts. Larger prospective studies are needed to clarify the impact of frailty on urogynecologic surgical outcomes. Additionally, further research is required to explore factors unique to frail women which may contribute to delayed presentation for urogynecologic care and/or postponed decisions for surgical intervention.