Colpocleisis

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]

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 engaged in, 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. ^[7] 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. ^[7]

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. ^[8]  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]

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.

Clinicians should consider the frequent association of advanced pelvic organ prolapse with urinary retention and urinary incontinence. ^[8] 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.

A retrospective study by Song et al of 35 women who underwent LeFort colpocleisis found that at median 5-year follow-up, 33 patients (94.3%) reported satisfaction with the surgery, with two patients, one of whom suffered postoperative overactive bladder syndrome and another of whom had vaginal hematoma, characterizing themselves as “neither satisfied nor dissatisfied.” Using the Chinese version of the Pelvic Floor Distress Inventory-short form 20, the investigators also found significant improvement in pelvic symptoms (from a preoperative score of 60.5 to a postoperative score of 14.1). ^[9]

In a long-term follow-up study by Winkelman et al that included 73 patients, 78% were satisfied with the results of colpocleisis a median of 6 years after the procedure. Among the 13% who had strong feelings of regret, most of the women reported urinary frequency (63%) and urgency urinary incontinence (56%). Only 19% had prolapse symptoms. None of the women expressed regret about the loss of sexual function after colpocleisis. ^[10]

A population-based cohort study by Dallas et al found that among 2707 women who underwent colpocleisis, 47 (1.8%) required reoperation for prolapse. About 11% of the women in the cohort experienced at least one complication, and serious complications occurred in 2%. Complications were most common in frail patients. ^[11]