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]

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.

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.

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.

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.

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.

LeFort’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.

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.

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).

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).

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).

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).

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.

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.[13]

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%.[14]

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.[12] 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.

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.[8] 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.