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Colpocleisis

  • Author: Leon N Plowright, MD; Chief Editor: Kris Strohbehn, MD  more...
 
Updated: Mar 31, 2014
 

Background

Pelvic organ prolapse (POP) affects millions of women in the United States, with more than 300,000 surgeries performed annually to address conditions of the pelvic floor. The lifetime risk of having surgery for prolapse or incontinence by age 80-85 is 11-19%, with 30% of women requiring additional prolapse procedures.[1] With the rapid rise in the elderly population, the number of surgeries performed yearly is projected to increase dramatically.

Surgical intervention for vaginal prolapse can take on multiple approaches. Patients may undergo extensive pelvic reconstructive surgery or simple obliterative procedures. The goal of reconstructive surgery is to restore the normal anatomy, while obliterative surgery is used to correct prolapse by closing off a portion of the vaginal canal, thereby reducing the viscera back into the pelvis. Although complex pelvic surgeries such as abdominal sacrocolpopexy, sacrospinous fixation, or iliococcygeus fixation have high rates of success, they are associated with surgical risks that may render them unsuitable for some elderly patients. Colpocleisis, an obliterative procedure, is a viable alternative for those who cannot tolerate extensive surgery and no longer desire preservation of coital function.

The term colpocleisis is derived from the Greek words kolpos, which means folds or hollow, and cleisis, which means closure. The first report of colpocleisis occurred in 1823 when Gerardin described denuding the anterior and posterior vaginal wall at the introitus and suturing them. The technique currently used, however, is a modification of that first described in 1877 by Leon Lefort.

In Lefort’s publication, he describes a partial colpocleisis technique that left the uterus in situ, after which a perineorrhaphy was performed 8 days postoperatively.[2, 3] His technique was based on the premise that apposition of the vaginal walls could prevent uterine prolapse and that a widened genital hiatus may lead to unsuccessful outcomes. His theory holds true today; this obliterative procedure is associated with high rates of satisfaction.[3]

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Indications

Patients seeking care for symptomatic vaginal prolapse should be given options for surgical correction as well as conservative measures. Surgical intervention is indicated in those who decline or fail conservative therapy such as a pessary. Patients who are ideal candidates for colpocleisis usually have poor functional status with medical comorbidities rendering them unsuitable for extensive reconstructive procedures. Because this procedure precludes sexual intercourse, it should be reserved only for those who are not, and do not plan future coital activity.

Advantages to this approach include shorter operative time, decreased morbidity, decreased blood loss, faster recovery, and high anatomic success rates. A retrospective cohort study of women(mean age 80) who had advanced prolapse reported comparable satisfaction after obliterative versus reconstructive surgery.[4] In another study, women with mean age of 79 reported significant improvement in pelvic symptoms and related bother after having colpocleisis performed. Ninety five percent of those patients reported that they were either “very satisfied” or “satisfied” with the outcome of their surgery.[5, 6]

The previously mentioned findings are supported in more recent publications. In a multicenter study by Crisp et al, colpocleisis as a definitive surgical intervention resulted in a positive impact on bowel, bladder, and prolapse symptoms. A high rate of satisfaction and low levels of regret were reported.[15] In another study of 310 women, the largest case series to date, Zebede et al reported a 98.1% anatomic success with a 92.9% patient satisfaction. The complication rate was low (15.2%) and the mortality rate was 1.3%; this suggests that colpocleisis is a low-risk, effective procedure.[15]

The primary disadvantage to obliterative procedures is loss of the ability to have vaginal intercourse. In addition, the procedure precludes the ability to evaluate the cervix or uterus for pathologic changes. Evaluating candidates for cervical or uterine abnormalities prior to surgery is therefore important. This entails reviewing previous pap smears and cervical biopsies and asking targeted questions regarding patients with postmenopausal bleeding who may require endometrial biopsy or ultrasound to evaluate endometrial thickness.

With regards to sexual activity, a study of older adults on their sexuality reported that the prevalence of sexual activity decreased with age. Sexual activity amongst women ages 57 to 64 was 62% and decreased to 17% in women ages 75 to 85.[7] As the number of women older than age 60 years seeking care for pelvic floor disorders is projected to increase at least 45% over the next few decades, many patients may forego preservation of vaginal function for a minimally invasive approach with long-lasting outcomes.[4]

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Contraindications

Although this surgery is minimally invasive, patients with severe cardiopulmonary risk factors leading to increased anesthetic risk may not be able to undergo this surgery. This surgery is contraindicated in patients with cervical and uterine pathology requiring extensive surgical resection and staging of disease. The ideal patient would therefore have negative pap smears and no history of postmenopausal bleeding with uterine pathology.

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Technical Considerations

Clinicians should consider the frequent association of advanced pelvic organ prolapse with urinary retention and urinary incontinence.[7] This evaluation is important because 13-65% of continent women who undergo surgical correction for prolapse are reported to experience stress incontinence postoperatively.[1] Some have postulated that advance prolapse can cause kinking of the urethra leading to obstruction; therefore, anatomic correction may relieve such kinking, resulting in stress incontinence.

To investigate for incontinence or retention, a cough stress test or cystometry may be used. In the case of urinary retention, a simple postvoid residual (PVR) test can be performed. If PVR is less than 100 mL, then the patient does not have urinary retention. If PVR is greater than 200 mL, the patient has retention and will likely benefit from prolapse surgery because 90% of women with elevated PVR volumes experience resolution after prolapse correction.[3] Additionally, multichannel urodynamic testing prior to surgery may prove helpful in unveiling voiding dysfunction or incontinence.

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Contributor Information and Disclosures
Author

Leon N Plowright, MD Fellow in Urogynecology, Cleveland Clinic Florida

Leon N Plowright, MD is a member of the following medical societies: American Urogynecologic Society, International Urogynaecology Association

Disclosure: Nothing to disclose.

Coauthor(s)

G Willy Davila, MD Chairman, Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida

G Willy Davila, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Colorado Medical Society, Florida Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: AMS/Astora; Astellas, Uroplasty/Cogentix<br/>Received research grant from: Pfizer; A-Cell; Coloplast; Cook Myocyte.

Chief Editor

Kris Strohbehn, MD Professor of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth; Director, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center

Kris Strohbehn, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Urogynecologic Society, Society of Gynecologic Surgeons

Disclosure: Nothing to disclose.

References
  1. Kenton K, Brubaker L, Falk S. Pelvic organ prolapse in women: Surgical repair of the apical prolapse (uterine or vaginal vault prolapse). UpToDate 2011.

  2. FitzGerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H. Colpocleisis: a review. Int Urogynecol J Pelvic Floor Dysfunct. 2006 May. 17(3):261-71. [Medline].

  3. Neimark M, Davila GW, Kopka S. LeFort Colpocleisis. J Pelvic Med Surg 2003; 9:83-.

  4. Abbasy S, Kenton K. Obliterative procedures for pelvic organ prolapse. Clin Obstet Gynecol. 2010 Mar. 53(1):86-98. [Medline].

  5. Murphy M, Sternschuss G, Haff R, van Raalte H, Saltz S, Lucente V. Quality of life and surgical satisfaction after vaginal reconstructive vs obliterative surgery for the treatment of advanced pelvic organ prolapse. Am J Obstet Gynecol. 2008 May. 198(5):573.e1-7. [Medline].

  6. Fitzgerald MP, Richter HE, Bradley CS, Ye W, Visco AC, Cundiff GW, et al. Pelvic support, pelvic symptoms, and patient satisfaction after colpocleisis. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Dec. 19(12):1603-9. [Medline].

  7. Hullfish KL, Bovbjerg VE, Steers WD. Colpocleisis for pelvic organ prolapse: patient goals, quality of life, and satisfaction. Obstet Gynecol. 2007 Aug. 110(2 Pt 1):341-5. [Medline].

  8. Kenton K, Brubaker L, Falk S. Pelvic organ prolapse in women: Obliterative procedures (colpocleisis). UpToDate 2011.

  9. 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 May. 10(2):276-80. [Medline].

  10. FitzGerald MP, Brubaker L. Colpocleisis and urinary incontinence. Am J Obstet Gynecol. 2003 Nov. 189(5):1241-4. [Medline].

  11. Abbasy S, Lowenstein L, Pham T, Mueller ER, Kenton K, Brubaker L. Urinary retention is uncommon after colpocleisis with concomitant mid-urethral sling. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Feb. 20(2):213-6. [Medline].

  12. Gerten KA, Markland AD, Lloyd LK, Richter HE. Prolapse and incontinence surgery in older women. J Urol. 2008 Jun. 179(6):2111-8. [Medline]. [Full Text].

  13. Gutman RE, Bradley CS, Ye W, Markland AD, Whitehead WE, Fitzgerald MP. Effects of colpocleisis on bowel symptoms among women with severe pelvic organ prolapse. Int Urogynecol J. 2010 Apr. 21(4):461-6. [Medline].

  14. Smith AL, Karp DR, Lefevre R, Aguilar VC, Davila GW. LeFort colpocleisis and stress incontinence: weighing the risk of voiding dysfunction with sling placement. Int Urogynecol J. 2011 Nov. 22(11):1357-62. [Medline].

  15. Crisp CC, Book NM, Smith AL, Cunkelman JA, Mishan V, Treszezamsky AD, et al. Body image, regret, and satisfaction following colpocleisis. Am J Obstet Gynecol. 2013 Nov. 209(5):473.e1-7. [Medline]. [Full Text].

  16. Zebede, Salomon MD; Smith, Aimee L. MD; Plowright, Leon N. MD; Hegde, Aparna MD; Aguilar, Vivian C. MD; Davila, et al. Obliterative LeFort Colpocleisis in a Large Group of Elderly Women. Obstet Gynecol. Feb/ 2013. 121:279-284. [Medline]. [Full Text].

 
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Equivalent trapezoids are demarcated on the anterior and posterior aspect of the vagina. Image courtesy of Cleveland Clinic Florida.
Equivalent trapezoids are demarcated on the anterior and posterior aspect of the vagina. Image courtesy of Cleveland Clinic Florida.
Next, the vaginal epithelial layer is infiltrated with lidocaine with epinephrine, and the vaginal epithelium is denuded. Image courtesy of Cleveland Clinic Florida.
The anterior and posterior trapezoids are brought together with 2.0 Vicryl sutures in a running, nonlocking fashion, taking full thickness with each pass of the needle. Image courtesy of Cleveland Clinic Florida. Image courtesy of Cleveland Clinic Florida.
The anterior and posterior trapezoids are then imbricated, thereby approximating the edges of the anterior and posterior trapezoids. The 2 epithelial edges are then brought together with a series of interrupted 2.0 Vicryl sutures. Image courtesy of Cleveland Clinic Florida.
The anterior and posterior trapezoids are then imbricated, thereby approximating the edges of the anterior and posterior trapezoids. The 2 epithelial edges are then brought together with a series of interrupted 2.0 Vicryl sutures. Image courtesy of Cleveland Clinic Florida.
The anterior and posterior trapezoids are then imbricated, thereby approximating the edges of the anterior and posterior trapezoids. The 2 epithelial edges are then brought together with a series of interrupted 2.0 Vicryl sutures. Image courtesy of Cleveland Clinic Florida.
A high perineoplasty is performed. Image courtesy of Cleveland Clinic Florida.
A high perineoplasty is performed. Image courtesy of Cleveland Clinic Florida.
Colpocleisis procedure.
 
 
 
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