Patient Education & Consent
The counseling and education of patients involves a thorough history and physical examination. The goals and expectations of the patient should be discussed at length.
All surgical options should be reviewed, addressing surgery duration, recovery time, postoperative complications, risks, and benefits. All care providers are to be involved, including family members, especially if issues with cognition or need for rehabilitation postoperatively exist.
Pre-Procedure Planning
Women seeking care for pelvic floor symptoms should undergo a thorough evaluation before having surgery. Those with pelvic organ prolapse may have coexisting pelvic floor disorders that may include defecatory dysfunction or urinary symptoms such as stress incontinence. Patients must therefore be questioned about any associated bothersome urinary or bowel symptoms because this may affect surgical planning.
In addition, a thorough physical examination should be conducted. Typically, a speculum and bimanual examination are performed. In doing so, the quality of the vaginal tissue is characterized and areas of ulceration or irritation noted. Areas of ulceration can be addressed with use of Bovie cautery. Furthermore, the application of local estrogen 6-8 weeks prior to surgery can strengthen the vaginal tissues, thereby decreasing the chances of ulceration and improving the healing process. The pelvic organ prolapse quantification system or the Baden-Walker scale can be used to objectively evaluate the degree of prolapse.
Patient Preparation
Colpocleisis can be performed under general, regional, or local anesthetic. Prophylactic broad spectrum antibiotics should be given in accordance with the most recent guidelines. Patients with cardiovascular risk factors should receive beta blockade during the perioperative time frame. Patients should also be stratified in accordance to thromboembolic risk. Compression stockings and/or pharmacologic prophylaxis should be used to prevent clot formation. [12] Being mindful when placing the patient in dorsal lithotomy is important because inappropriate patient positioning can result in nerve injury.
Monitoring & Follow-up
At the authors’ institution, this procedure requires only an overnight stay in the hospital; select patients without too many comorbidities may be able to be discharged the same day. Patients typically stay within the hospital for 23-hour observation and are discharged on postoperative day 1. Prior to discharge, a voiding trial is performed.
For patients with preoperative urinary retention, the authors use a suprapubic catheter. Those going home with a catheter are given nitrofurantoin or ciprofloxacin to prevent infection and are seen in the office within 5-6 days for catheter removal and subsequent bladder challenge. Pain control is usually accomplished with intravenous and oral medications, with a rare need for patient-controlled analgesia. Patients are discharged home with ibuprofen and acetaminophen with hydrocodone.
A follow-up postoperative visit is scheduled at 2 weeks. At this time, uterine pathology is reviewed if the patient had concomitant cervical dilation and curettage. A postvoid residual is also assessed to evaluate for urinary retention. Patients then have subsequent visits at 6 weeks, 3 months, and 1 year, and as needed thereafter.
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Equivalent trapezoids are demarcated on the anterior and posterior aspect of the vagina. Image courtesy of Cleveland Clinic Florida.
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Equivalent trapezoids are demarcated on the anterior and posterior aspect of the vagina. Image courtesy of Cleveland Clinic Florida.
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Next, the vaginal epithelial layer is infiltrated with lidocaine with epinephrine, and the vaginal epithelium is denuded. Image courtesy of Cleveland Clinic Florida.
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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.
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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.
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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.
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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.
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A high perineoplasty is performed. Image courtesy of Cleveland Clinic Florida.
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A high perineoplasty is performed. Image courtesy of Cleveland Clinic Florida.
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Colpocleisis procedure.
