Colpocleisis Technique

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.