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Colpocleisis: A simple, effective, and underutilized procedure

OBG Manag. 2009 June;21(6):19-28

OR time, hospitalization, recovery are brief; the success rate is high. As part of the outcome, the patient must forego coitus.

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IN THIS ARTICLE

Why choose colpocleisis over reconstruction?
The technique, illustrated in 10 steps
Quality of life typically improves; regret is unusual

References

1. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol. 2001;184:1496-1503.

2. FitzGerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H, Weber A. For the Pelvic Floor Disorders Network. Colpocleisis: a review. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17:261-271.

3. Wheeler TL, Jr, Richter HE, Burgio KL, et al. Regret, satisfaction, and symptom improvement: analysis of the impact of partial colpocleisis for the management of severe pelvic organ prolapse. Am J Obstet Gynecol. 2005;193:2067-2070.

4. Hullfish KL, Bovbjerg VE, Steers WD. Colpocleisis for pelvic organ prolapse: patient goals, quality of life, and satisfaction. Obstet Gynecol. 2007;110(2 Pt 1):341-345.

5. FitzGerald MP, Richter HE, Bradley CS, et al. For the Pelvic Floor Disorders Network. Pelvic support, pelvic symptoms, and patient satisfaction after colpocleisis. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:1603-1609.

6. Patel D, Gillespie B, Foxman B. Sexual behavior of older women: results of a random-digit-dialing survey of 2,000 women in the United States. Sex Transm Dis. 2003;30:216-220.

7. Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, Steegers-Theunissen RP, Burger CW, Vierhout ME. Symptomatic pelvic organ prolapse and possible risk factors in a general population. Am J Obstet Gynecol. 2009;200:184.e1-184.e7.

8. Berlin F. Three cases of complete prolapsus uteri operated upon according to the method of Leon LeFort. Am J Obstet Gynecol. 1881;14:866-868.

9. Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA. A survey of pessary use by members of the American Urogynecologic Society. Obstet Gynecol. 2000;95(6 Pt 1):931-935.

10. Esin S, Harmanli OH. Large vesicovaginal fistula in women with pelvic organ prolapse: the role of colpocleisis revisited. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:1711-1713.

11. Gerten KA, Markland AD, Lloyd LK, Richter HE. Prolapse and incontinence surgery in older women. J Urol. 2008;179:2111-2118.

12. Manku K, Bacchetti P, Leung JM. Prognostic significance of postoperative in-hospital complications in elderly patients. I. Long-term survival. Anesth Analg. 2003;96:583-589.

13. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 426: The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. Obstet Gynecol. 2009;113(2 Pt 1):462-464.

14. Moore RD, Miklos JR. Colpocleisis and tension-free vaginal tape sling for severe uterine and vaginal prolapse and stress urinary incontinence under local anesthesia. J Am Assoc Gynecol Laparosc. 2003;10:276-280.

15. Buchsbaum GM, Albushies DT, Schoenecker E, Duecy EE, Glantz JC. Local anesthesia with sedation for vaginal reconstructive surgery. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17:211-214.

16. Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso MF, Walters MD. The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol. 2006;194:1478-1485.

17. Goodall JR, Power RMH. A modification of the Le Fort operation for increasing its scope. Am J Obstet Gynecol. 1937;34:968-976.

18. Harmanli OH, Dandolu V, Chatwani AJ, Grody MT. Total colpocleisis for severe pelvic organ prolapse. J Reprod Med. 2003;48:703-706.

19. DeLancey JOL, Morley GW. Total colpocleisis for vaginal eversion. Am J Obstet Gynecol. 1997;176:1228-1232.

20. Goldman J, Ovadia J, Feldberg D. The Neugebauer-Le Fort operation: a review of 118 partial colpocleises. Eur J Obstet Gynecol Reprod Biol. 1981;12:31-35.

21. Ubachs JM, van Sante TJ, Schellekens LA. Partial colpocleisis by a modification of Le Fort’s operation. Obstet Gynecol. 1973;42:415-420.

22. Von Pechmann WS, Mutone MD, Fyffe J, Hale DS. Total colpocleisis with high levator plication for the treatment of advanced pelvic organ prolapse. Am J Obstet Gynecol. 2003;189:121-126.

23. Albo ME, Richter HE, Brubaker L, et al. For Urinary Incontinence Treatment Network. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;356:2143-2155.

Fast Track

Frail women with stage-III or -IV pelvic organ prolapse who don’t wish to preserve coital ability are candidates for colpocleisis

On the matter of self-image, colpocleisis eliminates prolapse, reduces the genital hiatus, and may improve the appearance of the external genital area

Preop, transvaginal US is crucial if the patient has a suspicious pelvic mass or uterine bleeding; endometrial sampling is indicated for unexplained vaginal bleeding

The sides of two denuded rectangles on the vagina—one on the anterior and one on the posterior wall—are sutured together, which creates bilateral channels that connect at the apex of the vagina

The two lateral channels created by the LeFort procedure allow any bleeding to escape the vagina; this may enable recognition of uterine or cervical malignancy

CASE 1: Problematic prolapse, but no incontinence

An 81-year-old multiparous woman, who has a history of recurrent stage-III pelvic organ prolapse (POP), reports worsening discomfort that makes it difficult for her to care for her ailing husband. She also has “trouble” with bladder emptying and constipation, but denies any loss of urine. She has not had vaginal intercourse in more than a decade because of her husband’s medical condition.

Aside from health issues—she suffers from obesity, coronary artery disease, hypertension, and diabetes—the patient is content with her marriage of 58 years.

Urodynamic testing fails to demonstrate detrusor overactivity, stress urinary incontinence, or intrinsic sphincteric deficiency. A cough stress test is repeated after reduction of her prolapse using a large cotton swab, and confirms the findings of the urodynamic tests.

Is reconstructive surgery appropriate for this patient?

Traditional reconstructive surgical procedures for treating POP fail in as many as 30% of patients, and new approaches—some involving grafts—are proposed every day, often without much data behind them.¹

Regardless of the approach, reconstructive surgery is a lengthy procedure that subjects patients who are already medically compromised to significant risk, including bleeding, infection, and fluid shifts. Delayed return to normal activity may be especially costly among elderly women because of the risk of venous thromboembolism.

Because of the high failure rate, slow recovery, and risk of complications, reconstructive surgery may not be as appropriate as colpocleisis for the woman described above. Colpocleisis—suturing the inside walls of the vagina together—has an efficacy rate exceeding 90%.² This relatively simple operation has been around for almost two centuries and has a good track record, but is often overlooked when counseling a patient about her options.

Any frail, elderly woman who has stage-III or -IV POP who does not desire to preserve coital ability is a candidate for colpocleisis (TABLE). Advantages include:

a short operating time
few complications
amenability of local anesthesia
short hospitalization
speedy recovery
high success rate
low rate of regret.^2-5

Because it precludes coital activity, however, colpocleisis may cause problems with self-image. It also may lead to de novo or worsening urinary incontinence and complicate or delay the diagnosis of cervical and endometrial pathology.

This article explores these issues through a case-based discussion of colpocleisis, including a detailed description of surgical technique.

TABLE

Requirements for colpocleisis

Both of the following must be present No desire for or likelihood of future coital activity Stage-III or -IV pelvic organ prolapse
Plus at least one of the following Severe coronary artery disease Severe pulmonary disease Severe dementia Advanced-stage cancer Multiple surgical failures

Why colpocleisis?

Colpocleisis, as noted, entails suturing the inside walls of the vagina together. It is controversial because of its impact on coital activity. With careful patient selection, however, colpocleisis is considered a valid option for frail and elderly women who have POP and do not desire or foresee the possibility of future vaginal intercourse. Such women may represent a surprising percentage of the elderly population. A community-based survey found that 78% of married women 70 to 79 years old are not sexually active,⁶ and a study from The Netherlands found a prevalence of symptomatic POP of 11.4% among white women 45 to 85 years old.⁷

The fundamental reason for choosing an obliterative procedure such as colpocleisis over total pelvic reconstruction is to treat the prolapse with the least invasive technique in the shortest time. Hysterectomy, which often adds 30 to 80 minutes to the procedure, should therefore be performed only in patients who have a suspicious finding upon initial evaluation. For the same reason, partial colpocleisis—performed using the LeFort technique with limited dissection—has become the most popular obliterative approach. We try to avoid a total colpocleisis procedure—also known as colpectomy—in which the entire vaginal epithelium is stripped, because it is feasible only when the uterus is already absent or scheduled to be removed concomitantly.