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Current Geriatrics Reports

Erschienen in:

07.04.2017 | Geriatric Urology (H Richter, Section Editor)

Perioperative Management of Older Women in Urogynecologic Surgery

verfasst von: Angela S. Yuan, Cydney A. Siggins, Elisabeth Erekson

Erschienen in: Current Geriatrics Reports | Ausgabe 2/2017

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Abstract

Purpose of Review

Preoperative measurements of frailty and mobility predict surgical outcomes in older patients better than measurements of medical comorbidities or American Society of Anesthesiologists (ASA) status alone. The purpose of this review is to summarize updated evidence for optimal preoperative assessment, perioperative management, and postoperative care for elective gynecologic surgery in older women.

Recent Findings

Two joint best-practice guideline statements from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the American Geriatrics Society (AGS) focus on preoperative (2012) and perioperative care (2016) of the geriatric patient.

Summary

Preoperative identification of frailty, cognitive impairment, and functional disability in older women may be an important way to improve outcomes. Preoperative identification has the potential to allow surgeons to better counsel patients about unique postoperative risks, tailor the aggressiveness of the surgical approach, and facilitate shared decision-making. Finally, preoperative identification can help identify patients who need extra support at hospital discharge with transitions of care. Future research is necessary to assess the impact of preoperative geriatric screening for frailty, cognitive impairment, and mobility disorders with treatment success and postoperative outcomes in older women undergoing surgical correction of pelvic floor disorders (PFDs) and other elective gynecologic procedures.

Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, Spino C, Whitehead WE, Wu J, Brody DJ, Pelvic Floor Disorders Network. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300:1311–6. doi:10.1001/jama.300.11.1311.CrossRefPubMedPubMedCentral

Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol. 2001;98:1004–10.PubMed

Hannestad YS, Rortveit G, Sandvik H, Hunskaar S, Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trondelag. A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of incontinence in the county of Nord-Trondelag. J Clin Epidemiol. 2000;53:1150–7.CrossRefPubMed

Yip SO, Dick MA, McPencow AM, Martin DK, Ciarleglio MM, Erekson EA. The association between urinary and fecal incontinence and social isolation in older women. Am J Obstet Gynecol. 2013;208:146.e1–7. doi:10.1016/j.ajog.2012.11.010.CrossRef

Melville JL, Fan MY, Rau H, Nygaard IE, Katon WJ. Major depression and urinary incontinence in women: temporal associations in an epidemiologic sample. Am J Obstet Gynecol. 2009;201:490.e1–7. doi:10.1016/j.ajog.2009.05.047.CrossRef

Sung VW, West DS, Hernandez AL, Wheeler 2nd TL, Myers DL, Subak LL, Program to Reduce Incontinence by Diet and Exercise (PRIDE). Association between urinary incontinence and depressive symptoms in overweight and obese women. Am J Obstet Gynecol. 2009;200:557.e1–5. doi:10.1016/j.ajog.2008.11.008.CrossRef

Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014;123:1201–6. doi:10.1097/AOG.0000000000000286.CrossRefPubMedPubMedCentral

•• Robinson TN, Eiseman B, Wallace JI, Church SD, McFann KK, Pfister SM, Sharp TJ, Moss M. Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg. 2009;250:449–55. doi:10.1097/SLA.0b013e3181b45598. This article is the original description of the Robinson Frailty Index to predict postoperative outcomes after major surgery in a mostly male population PubMed

Robinson TN, Wallace JI, Wu DS, Wiktor A, Pointer LF, Pfister SM, Sharp TJ, Buckley MJ, Moss M. Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient. J Am Coll Surg. 2011;213:37–42. discussion 42-4 doi:10.1016/j.jamcollsurg.2011.01.056.CrossRefPubMedPubMedCentral

10.

Robinson TN, Wu DS, Stiegmann GV, Moss M. Frailty predicts increased hospital and six-month healthcare cost following colorectal surgery in older adults. Am J Surg. 2011;202:511–4. doi:10.1016/j.amjsurg.2011.06.017.CrossRefPubMedPubMedCentral

11.

Hamel MB, Henderson WG, Khuri SF, Daley J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc. 2005;53:424–9. doi:10.1111/j.1532-5415.2005.53159.x.CrossRefPubMed

12.

Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M. Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr. 2009;48:78–83. doi:10.1016/j.archger.2007.10.007.CrossRefPubMed

13.

Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210:901–8. doi:10.1016/j.jamcollsurg.2010.01.028.CrossRefPubMed

14.

Kim SW, Han HS, Jung HW, Kim KI, Hwang DW, Kang SB, Kim CH. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA Surg. 2014;149:633–40. doi:10.1001/jamasurg.2014.241.CrossRefPubMed

15.

• Robinson TN, Wu DS, Pointer L, Dunn CL, Cleveland Jr JC, Moss M. Simple frailty score predicts postoperative complications across surgical specialties. Am J Surg. 2013;206:544–50. doi:10.1016/j.amjsurg.2013.03.012. This article further explores the use of the Robinson Frailty Index after colorectal and cardiovascular surgery in a mostly male population CrossRefPubMedPubMedCentral

16.

Robinson TN, Wu DS, Sauaia A, Dunn CL, Stevens-Lapsley JE, Moss M, Stiegmann GV, Gajdos C, Cleveland Jr JC, Inouye SK. Slower walking speed forecasts increased postoperative morbidity and 1-year mortality across surgical specialties. Ann Surg. 2013;258:582–8. discussion 588-90 doi:10.1097/SLA.0b013e3182a4e96c.PubMedPubMedCentral

17.

•• Cooper Z, Rogers Jr SO, Ngo L, Guess J, Schmitt E, Jones RN, Ayres DK, Walston JD, Gill TM, Gleason LJ, Inouye SK, Marcantonio ER. Comparison of frailty measures as predictors of outcomes after orthopedic surgery. J Am Geriatr Soc. 2016;64:2464–71. doi:10.1111/jgs.14387. The Successful Aging after Elective Surgery (SAGES) study is an ongoing prospective cohort study of older adults (≥70 years old) undergoing elective surgery. In this work, preoperative frailty was associated with postoperative complications after orthopedic surgery including prolonged length of stay, discharge to post-acute care facilities, and 30-day readmissions CrossRefPubMed

18.

•• Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF, American College of Surgeons National Surgical Quality Improvement Program, American Geriatrics Society. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215:453–66. doi:10.1016/j.jamcollsurg.2012.06.017. This 2012 best practices guideline was a joint consensus statement on preoperative evaluation of geriatric patients from the American Geriatrics Society and the American College of Surgeons CrossRefPubMed

19.

•• Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal perioperative management of the geriatric patient: a best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222:930–47. doi:10.1016/j.jamcollsurg.2015.12.026. This 2016 best practices guideline was a follow-up joint consensus statement on perioperative management of geriatric patients from the American Geriatrics Society and the American College of Surgeons CrossRefPubMed

20.

Robinson TN, Walston JD, Brummel NE, Deiner S, Brown 4th CH, Kennedy M, Hurria A. Frailty for surgeons: review of a National Institute on Aging conference on frailty for specialists. J Am Coll Surg. 2015;221:1083–92. doi:10.1016/j.jamcollsurg.2015.08.428.CrossRefPubMedPubMedCentral

21.

Wozniak SE, Coleman J, Katlic MR. Optimal preoperative evaluation and perioperative care of the geriatric patient: a surgeon's perspective. Anesthesiol Clin. 2015;33:481–9. doi:10.1016/j.anclin.2015.05.012.CrossRefPubMed

22.

Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA, Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–56.CrossRefPubMed

23.

Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003;51:1451–4.CrossRefPubMed

24.

Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.CrossRefPubMed

25.

Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983;31:721–7.CrossRefPubMed

26.

Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–8.CrossRefPubMed

27.

Erekson EA, Fried TR, Martin DK, Rutherford TJ, Strohbehn K, Bynum JP. Frailty, cognitive impairment, and functional disability in older women with female pelvic floor dysfunction. Int Urogynecol J. 2014; doi:10.1007/s00192-014-2596-2.PubMedPubMedCentral

28.

• Greer JA, Harvie HS, Andy UU, Smith AL, Northington GM, Arya LA. Short-term postoperative functional outcomes in older women undergoing prolapse surgery. Obstet Gynecol. 2015;125:551–8. doi:10.1097/AOG.0000000000000644. In women undergoing surgery for prolapse, deficits in basic activities of daily living were not seen. However, deficits were seen in instrumental activities of daily living and these deficits were predictive of postoperative complications CrossRefPubMedPubMedCentral

29.

• Stewart CM, Wheeler 2nd TL, Markland AD, Straughn Jr JM, Richter HE. Life-space assessment in urogynecology and gynecological oncology surgery patients: a measure of perioperative mobility and function. J Am Geriatr Soc. 2009;57:2263–8. doi:10.1111/j.1532-5415.2009.02557.x. The Life-Space Assessment demonstrated that women undergoing gynecologic surgery do not return to their preoperative baseline mobility and activity level outside of the home by 6 weeks after surgery CrossRefPubMedPubMedCentral

30.

Trowbridge ER, Kim D, Barletta K, Fitz V, Larkin S, Hullfish KL. Prevalence of positive screening test for cognitive impairment among elderly urogynecologic patients. Am J Obstet Gynecol. 2016;215:663.e1–6.CrossRef

31.

Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, Donaldson MC, Whittemore AD, Sugarbaker DJ, Poss R. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994;271:134–9.CrossRefPubMed

32.

McAlpine JN, Hodgson EJ, Abramowitz S, Richman SM, Su Y, Kelly MG, Luther M, Baker L, Zelterman D, Rutherford TJ, Schwartz PE. The incidence and risk factors associated with postoperative delirium in geriatric patients undergoing surgery for suspected gynecologic malignancies. Gynecol Oncol. 2008;109:296–302. doi:10.1016/j.ygyno.2008.02.016.CrossRefPubMed

33.

Steffens DC, Fisher GG, Langa KM, Potter GG, Plassman BL. Prevalence of depression among older Americans: the Aging, Demographics and Memory Study. Int Psychogeriatr. 2009;21:879–88. doi:10.1017/S1041610209990044.CrossRefPubMedPubMedCentral

34.

Nath B, Li Y, Carroll JE, Szabo G, Tseng JF, Shah SA. Alcohol exposure as a risk factor for adverse outcomes in elective surgery. J Gastrointest Surg. 2010;14:1732–41. doi:10.1007/s11605-010-1350-4.CrossRefPubMed

35.

Raats JW, Steunenberg SL, de Lange DC, van der Laan L. Risk factors of post-operative delirium after elective vascular surgery in the elderly: a systematic review. Int J Surg. 2016;35:1–6.CrossRefPubMed

36.

Blazer DG, Wu LT. The epidemiology of at-risk and binge drinking among middle-aged and elderly community adults: National Survey on Drug Use and Health. Am J Psychiatry. 2009;166:1162–9. doi:10.1176/appi.ajp.2009.09010016.CrossRefPubMedPubMedCentral

37.

Hinkin CH, Castellon SA, Dickson-Fuhrman E, Daum G, Jaffe J, Jarvik L. Screening for drug and alcohol abuse among older adults using a modified version of the CAGE. Am J Addict. 2001;10:319–26.CrossRefPubMed

38.

Volk RJ, Cantor SB, Steinbauer JR, Cass AR. Item bias in the CAGE screening test for alcohol use disorders. J Gen Intern Med. 1997;12:763–9.CrossRefPubMedPubMedCentral

39.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 422: at-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2008;112:1449–60. doi:10.1097/AOG.0b013e318192499b.CrossRef

40.

Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215–45. doi:10.1161/CIR.0000000000000105.CrossRefPubMed

41.

Erekson EA, Yip SO, Ciarleglio MM, Fried TR. Postoperative complications after gynecologic surgery. Obstet Gynecol. 2011;118:785–93. doi:10.1097/AOG.0b013e31822dac5d.CrossRefPubMedPubMedCentral

42.

Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.CrossRefPubMed

43.

Folstein MF, Robins LN, Helzer JE. The mini-mental state examination. Arch Gen Psychiatry. 1983;40:812.CrossRefPubMed

44.

Tariq SH, Tumosa N, Chibnall JT, Perry 3rd MH, Morley JE. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry. 2006;14:900–10. doi:10.1097/01.JGP.0000221510.33817.86.CrossRefPubMed

45.

Li C, Friedman B, Conwell Y, Fiscella K. Validity of the Patient Health Questionnaire 2 (PHQ-2) in identifying major depression in older people. J Am Geriatr Soc. 2007;55:596–602.CrossRefPubMed

46.

Lyness JM, Noel TK, Cox C, King DA, Conwell Y, Caine ED. Screening for depression in elderly primary care patients. A comparison of the Center for Epidemiologic Studies-Depression Scale and the Geriatric Depression Scale. Arch Intern Med. 1997;157:449–54.CrossRefPubMed

47.

Lachs MS, Feinstein AR, Cooney Jr LM, Drickamer MA, Marottoli RA, Pannill FC, Tinetti ME. A simple procedure for general screening for functional disability in elderly patients. Ann Intern Med. 1990;112:699–706.CrossRefPubMed

48.

Warner DF, Brown TH. Understanding how race/ethnicity and gender define age-trajectories of disability: an intersectionality approach. Soc Sci Med. 2011;72:1236–48. doi:10.1016/j.socscimed.2011.02.034.CrossRefPubMedPubMedCentral

49.

Peel C, Sawyer Baker P, Roth DL, Brown CJ, Brodner EV, Allman RM. Assessing mobility in older adults: the UAB Study of Aging Life-Space Assessment. Phys Ther. 2005;85:1008–119.PubMed

50.

Robinson TN, Rosenthal RA. Optimizing the geriatric preoperative assessment: the use of functional dependence and beyond. Ann Surg. 2015;261:438–9. doi:10.1097/SLA.0000000000001132.CrossRefPubMed

51.

• Kalogera E, Dowdy SC. Enhanced recovery pathway in gynecologic surgery: improving outcomes through evidence-based medicine. Obstet Gynecol Clin N Am. 2016;43:551–73. doi:10.1016/j.ogc.2016.04.006. Using Enhanced Recovery Pathways after gynecologic surgery (ovarian cancer debulking, vaginal prolapse repair) was effective in reducing hospital length of stay and improving postoperative pain control CrossRef

52.

Nelson G, Kalogera E, Dowdy SC. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol. 2014;135:586–94. doi:10.1016/j.ygyno.2014.10.006.CrossRefPubMed

53.

Kalogera E, Bakkum-Gamez JN, Jankowski CJ, Trabuco E, Lovely JK, Dhanorker S, Grubbs PL, Weaver AL, Haas LR, Borah BJ, Bursiek AA, Walsh MT, Cliby WA, Dowdy SC. Enhanced recovery in gynecologic surgery. Obstet Gynecol. 2013;122:319–28. doi:10.1097/AOG.0b013e31829aa780.CrossRefPubMedPubMedCentral

54.

Ballard AC, Parker-Autry CY, Markland AD, Varner RE, Huisingh C, Richter HE. Bowel preparation before vaginal prolapse surgery: a randomized controlled trial. Obstet Gynecol. 2014;123:232–8. doi:10.1097/AOG.0000000000000081.CrossRefPubMedPubMedCentral

55.

By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227–46. doi:10.1111/jgs.13702.CrossRef

56.

•• American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015;63:142–50. doi:10.1111/jgs.13281. This 2015 clinical practice guideline from the American Geriatric Society focused on evidence-based recommendations for the prevention and treatment of postoperative delirium in older adults CrossRef

57.

The American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2014; doi:10.1111/jgs.13281.

58.

Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The confusion assessment method: a systematic review of current usage. J Am Geriatr Soc. 2008;56:823–30. doi:10.1111/j.1532-5415.2008.01674.x.CrossRefPubMedPubMedCentral

59.

Robinson TN, Raeburn CD, Angles EM, Moss M. Low tryptophan levels are associated with postoperative delirium in the elderly. Am J Surg. 2008;196:670–4. doi:10.1016/j.amjsurg.2008.07.007.CrossRefPubMedPubMedCentral

60.

Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13:142–5.CrossRefPubMed

61.

Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg. 2009;249:173–8. doi:10.1097/SLA.0b013e31818e4776.CrossRefPubMed

62.

Church S, Robinson TN, Angles EM, Tran ZV, Wallace JI. Postoperative falls in the acute hospital setting: characteristics, risk factors, and outcomes in males. Am J Surg. 2011;201:197–202. doi:10.1016/j.amjsurg.2009.12.013.CrossRefPubMed

63.

Jones TS, Dunn CL, Wu DS, Cleveland Jr JC, Kile D, Robinson TN. Relationship between asking an older adult about falls and surgical outcomes. JAMA Surg. 2013;148:1132–8. doi:10.1001/jamasurg.2013.2741.CrossRefPubMedPubMedCentral

64.

Tinetti ME, Kumar C. The patient who falls: “It’s always a trade-off”. JAMA. 2010;303:258–66. doi:10.1001/jama.2009.2024.CrossRefPubMedPubMedCentral

65.

•• Sanses TV, Schiltz NK, Couri BM, Mahajan ST, Richter HE, Warner DF, Guralnik J, Koroukian SM. Functional status in older women diagnosed with pelvic organ prolapse. Am J Obstet Gynecol. 2016;214:613.e1–7. doi:10.1016/j.ajog.2015.11.038. By combining measurements from a large population-based cohort of older adults (Health and Retirement Survey (HRS)) with Medicare claims data (n = 890), the authors demonstrated that functional disability is prevalent in older women receiving medical treatment for pelvic organ prolapse (4.5% Basic ADLs and 13.6%) CrossRef

66.

Toglia MR, Nolan TE. Morbidity and mortality rates of elective gynecologic surgery in the elderly woman. Am J Obstet Gynecol. 2003;189:1584–7. discussion 1587-9 CrossRefPubMed

67.

AlHilli MM, Tran CW, Langstraat CL, Martin JR, Weaver AL, McGree ME, Mariani A, Cliby WA, Bakkum-Gamez JN. Risk-scoring model for prediction of non-home discharge in epithelial ovarian cancer patients. J Am Coll Surg. 2013;217:507–15. doi:10.1016/j.jamcollsurg.2013.04.036.CrossRefPubMedPubMedCentral

68.

Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646–51.CrossRefPubMedPubMedCentral

69.

Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005;20:317–23.CrossRefPubMedPubMedCentral

70.

Li LT, Barden GM, Balentine CJ, Orcutt ST, Naik AD, Artinyan A, Sansgiry S, Albo D, Berger DH, Anaya DA. Postoperative transitional care needs in the elderly: an outcome of recovery associated with worse long-term survival. Ann Surg. 2015;261:695–701. doi:10.1097/SLA.0000000000000673.CrossRefPubMed

71.

Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613–20.CrossRefPubMed

Titel: Perioperative Management of Older Women in Urogynecologic Surgery
verfasst von: Angela S. Yuan
Cydney A. Siggins
Elisabeth Erekson
Publikationsdatum: 07.04.2017
Verlag: Springer US
Erschienen in: Current Geriatrics Reports / Ausgabe 2/2017
Elektronische ISSN: 2196-7865
DOI: https://doi.org/10.1007/s13670-017-0199-8

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Perioperative Management of Older Women in Urogynecologic Surgery

Abstract

Purpose of Review

Recent Findings

Summary

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