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Colpocleisis Technique

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

Approach Considerations

Colpocleisis involves the removal of vaginal epithelium and subsequent imbrication of the vaginal muscularis in anterior-to-posterior apposition, thereby creating a tissue septum of support. Variations in technique are based on the size and amount of epithelium removed.

Le Fort’s original description called for the creation of 2 trapezoids of the anterior and posterior vaginal epithelium with subsequent imbrication creating a tissue platform. The remaining lateral vaginal epithelium is contiguous with the cervix and creates 2 lateral tunnels, permitting postoperative drainage as well as a channel for any postmenopausal bleeding remote from surgery.

During dissection of the anterior vaginal epithelium, care is taken not to dissect beyond the urethrovesical junction because this can lead to inadvertent cystotomy. This is also performed in an effort not to cause downward traction at the bladder neck because this can potentially increase the risk of stress incontinence postoperatively.

Hematoma formation is the most common culprit in the breakdown or failure of colpocleisis. Hemostasis is therefore maintained throughout the procedure via use of Bovie cautery and the application of pressure to areas of bleeding. In addition, as bleeding often occurs at the leading edges of the trapezoids, the anterior and posterior segments are brought together with full-thickness purchase of tissue.

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Partial Colpocleisis

At the authors’ institution, the authors’ perform a partial colpocleisis as the vaginal epithelium is not completely denuded. First, the anterior and posterior compartments are inspected for any areas of irritation or ulcerations because they may need to be addressed prior to the start of the procedure. If a uterus is in place, the authors start by performing cervical dilation and uterine curettage to rule out any intrauterine pathology.

Next, we delineate equivalent trapezoids posteriorly and anteriorly with a marker (see the image below). The epithelium inside each trapezoid is then infiltrated with 1% lidocaine with epinephrine to aid in dissection.

Equivalent trapezoids are demarcated on the anteri Equivalent trapezoids are demarcated on the anterior and posterior aspect of the vagina. Image courtesy of Cleveland Clinic Florida.

A scalpel blade is used to incise the epithelial outlines previously made. On the anterior wall, the epithelium is then carefully dissected off the underlying muscularis bluntly and sharply with Metzenbaum scissors. Hemostasis is maintained with Bovie cautery. The same is performed on the posterior wall (see the image below).

Equivalent trapezoids are demarcated on the anteri Equivalent trapezoids are demarcated on the anterior and posterior aspect of the vagina. Image courtesy of Cleveland Clinic Florida.

The leading edges of the anterior and posterior rectangles are brought together with 2.0 Vicryl sutures in a running, non-locking fashion, taking full thickness with each pass of the needle. The muscularis layer is approximated in an anterior to posterior fashion using interrupted 2.0 Vicryl suture (see the image below).

Next, the vaginal epithelial layer is infiltrated Next, the vaginal epithelial layer is infiltrated with lidocaine with epinephrine, and the vaginal epithelium is denuded. Image courtesy of Cleveland Clinic Florida.

Simultaneously, interrupted sutures are placed laterally for the creation of the tunnels. Imbrication is performed until the most proximal edges of the anterior and posterior trapezoids are approximated. By doing this, the viscera is placed back into the pelvis. The 2 epithelial edges are then brought together with a series of interrupted 2.0 Vicryl sutures (see the image below).

The anterior and posterior trapezoids are brought 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.

Next, a high perineoplasty is performed. A diamond-shaped flap of the perineal/vulvar mucosa is identified. After infiltration with 1% lidocaine with epinephrine, the triangle is then excised with a scalpel. The perineal body is then reconstructed side to side with use of 1.0 Vicryl suture followed by skin closure with 2.0 Vicryl suture. Typically, after the perineorrhaphy, the genital hiatus should allow passage of one finger (see the image below).

The anterior and posterior trapezoids are then imb 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.

To complete the surgery, a cystoscopy is performed to ensure no ureteral kinking, cystotomy, or urethral or bladder pathology. Five- to ten minutes before cystoscopy, 5 mL of indigo carmine is given intravenously. A 70° scope is introduced into the bladder and a systematic surveillance is performed. Ureteral function is reassured by the peristalsis and efflux of indigo carmine-tinged urine from the ureteric orifices bilaterally. Lastly, a rectal examination is performed to detect the presence of suture within the rectum.

A video depicting this procedure can be seen below.

Colpocleisis procedure.
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Mid-Urethral Sling

Concomitant mid-urethral sling and colpocleisis appears to be quite effective. A small case series of 38 women demonstrated that colpocleisis with concomitant mid-urethral sling improves urinary symptoms without causing significant urinary retention.[10]

In a retrospective study, the complications and outcomes of 30 women undergoing colpocleisis and sling without general anesthesia was reviewed. With a follow-up of 19.1 months, no intraoperative complications were reported; however, 1 postoperative myocardial infarction and 3 women requiring reoperation for prolapse were reported. The cure rate for stress incontinence was reported at 94%.[11]

In another retrospective study, 210 women underwent colpocleisis, of which 161 had concurrent suburethral sling. Placement of the sling resulted in 92.5% stress continent rate and 91% resolution of voiding dysfunction postoperatively.[9] Collectively, these studies suggest that placement of a sling at the time of colpocleisis results in high rates of continence with minimal voiding dysfunction postoperatively. Currently, research in the concomitant use of prophylactic anti-incontinent procedure in those undergoing vaginal prolapse surgeries is ongoing. Note that if a continent procedure is to be performed at the same time of colpocleisis, it may be performed once half of the vaginal canal has been obliterated.

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Hysterectomy

Concomitant hysterectomy is often performed at the time of pelvic organ prolapse surgery. However, a retrospective study of 92 women who underwent colpocleisis with concomitant hysterectomy showed significant increase in operative duration and transfusion rates compared to no hysterectomy.[7] Those recommending hysterectomy at the time of colpocleisis reason that colpocleisis precludes future evaluation of the cervix or uterus. Hysterectomy also obviates the possibility of future pyometra, which is a rare complication. The surgical outcomes with or without hysterectomy is equivalent. Hysterectomy may be strongly considered, however, in cases of increased cervical or uterine cancer risk.

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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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