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Home , Colpocleisis, Enema, Pessary

SURGICAL TECHNIQUES

FOR PELVIC ORGAN Colpocleisis: A simple, effective, and underutilized procedure OR time, hospitalization, recovery are brief; the success rate is high. As part of the outcome, the patient must forego coitus.

Oz Harmanli, MD Problematic® Dowden prolapse, but noHealth incontinence Media Dr. Harmanli is Director of An 81-year-old multiparous woman, who has a history of and Pelvic at Baystate Medical Center and recurrent stage-III (POP), reports Associate Professor of ObstetricsCopyright and worsening discomfort that makes it diffi cult for her to care Gynecology at Tufts University School For personal use only of Medicine in Springfi eld, Mass. for her ailing husband. She also has “trouble” with bladder IN THIS ARTICLE emptying and , but denies any loss of urine. The author reports no fi nancial She has not had vaginal intercourse in more than a decade Why choose relationships relevant to this article. because of her husband’s medical condition. colpocleisis over Aside from health issues—she suffers from , reconstruction? coronary artery , hypertension, and diabetes—the page 20 patient is content with her marriage of 58 years. Urodynamic testing fails to demonstrate detrusor over- The technique, activity, stress , or intrinsic sphincteric illustrated in defi ciency. A cough stress test is repeated after reduction of her prolapse using a large cotton swab, and confi rms the 10 steps fi ndings of the urodynamic tests. page 26 Is reconstructive surgery appropriate for this patient? Quality of life raditional reconstructive surgical procedures for typically improves; treating POP fail in as many as 30% of patients, and regret is unusual T new approaches—some involving grafts—are pro- page 27 posed every day, often without much data behind them.1 Regardless of the approach, reconstructive surgery ›› SHARE YOUR COMMENTS is a lengthy procedure that subjects patients who are al- Do you offer colpocleisis as an alternative to reconstructive ready medically compromised to signifi cant risk, includ- surgery? ing , , and fl uid shifts. Delayed return

E-MAIL [email protected] to normal activity may be especially costly among elderly FAX 201-391-2778 women because of the risk of venous thromboembolism. Because of the high failure rate, slow recovery, and risk of complications, reconstructive surgery may not be

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TABLE Requirements for troversial because of its impact on coital colpocleisis activity. With careful patient selection, how- Both of the following must be present ever, colpocleisis is considered a valid option for frail and elderly women who have POP • No desire for or likelihood of future coital activity and do not desire or foresee the possibility of future vaginal intercourse. Such women • Stage-III or -IV pelvic organ prolapse may represent a surprising percentage of Plus at least one of the following the elderly population. A community-based survey found that 78% of married women 70 • Severe coronary artery disease to 79 years old are not sexually active,6 and a • Severe pulmonary disease study from Th e Netherlands found a preva- • Severe dementia lence of symptomatic POP of 11.4% among • Advanced-stage white women 45 to 85 years old.7 • Multiple surgical failures Th e fundamental reason for choosing an obliterative procedure such as colpo- cleisis over total pelvic reconstruction is to as appropriate as colpocleisis for the woman treat the prolapse with the least invasive described above. Colpocleisis—suturing the technique in the shortest time. Hysterec- inside walls of the together—has an tomy, which often adds 30 to 80 minutes effi cacy rate exceeding 90%.2 Th is relatively to the procedure, should therefore be per- simple operation has been around for almost formed only in patients who have a suspi- two centuries and has a good track record, cious fi nding upon initial evaluation. For but is often overlooked when counseling a the same reason, partial colpocleisis—per- patient about her options. formed using the LeFort technique with Any frail, elderly woman who has stage- limited dissection—has become the most III or -IV POP who does not desire to preserve popular obliterative approach. We try to Frail women coital ability is a candidate for colpocleisis avoid a total colpocleisis procedure—also with stage-III or -IV (TABLE). Advantages include: known as colpectomy—in which the en- pelvic organ pro- • a short operating time tire vaginal is stripped, because lapse who don’t wish • few complications it is feasible only when the is al- to preserve coital • amenability of local anesthesia ready absent or scheduled to be removed • short hospitalization concomitantly. ability are candidates • speedy recovery (Note: Th e term should be for colpocleisis • high success rate reserved for gynecologic oncology proce- • low rate of regret.2–5 dures performed to remove vaginal cancer. Because it precludes coital activity, Vaginectomy entails full-thickness excision however, colpocleisis may cause problems of the vaginal walls, including the fi bromus- with self-image. It also may lead to de novo cular layer, as opposed to excision of the ep- or worsening urinary incontinence and com- ithelial layer only, as in colpocleisis. In this plicate or delay the diagnosis of cervical and article, we present the LeFort method, a par- endometrial pathology. tial colpocleisis technique, because we be- Th is article explores these issues through lieve it is more easily adapted by the general a case-based discussion of colpocleisis, in- gynecologist.8) cluding a detailed description of surgical technique. CASE 1 RESOLVED After detailed counseling, which includes fam- ily members, the patient opts to undergo col- Why colpocleisis? pocleisis. The procedure takes 45 minutes. Colpocleisis, as noted, entails suturing the She is discharged on postoperative Day 1, and inside walls of the vagina together. It is con- reports substantially improved quality of life.

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20_OBGM0609 20 5/21/09 12:05:17 PM any perioperative complication in a patient Recurrent prolapse and problems 70 years of age or older doubles the risk of with a discharge to a care facility.11,12 Women who A 72-year-old multiparous, widowed woman have already undergone several or experiences recurrent stage-III isolated api- who have advanced medical problems such cal prolapse. She has already undergone two as coronary artery disease or cancer should reconstructive procedures, and was discour- be counseled thoroughly about the safety aged from undergoing a third because of her and effi cacy of colpocleisis. chronic obstructive lung disease. She tried to As for self-image, colpocleisis eliminates use a Gellhorn-type pessary, which required prolapse and reduces the genital hiatus. If the a doctor’s intervention to insert and remove. patient understands that colpocleisis is ob- Frustrated by the many offi ce visits involved literative for the vagina but may improve the in having the pessary checked, she now external appearance of the genital area, she demands surgical therapy. Another gynecolo- may be more accepting of the procedure. One gist has offered to repair the prolapse using recent prospective, multicenter study found mesh, but the patient has concerns about the that only 2% of women thought their body safety and effi cacy of the procedure because it looked worse 1 year after colpocleisis; 60% is a relatively new approach. thought their body looked better.5 In addition to the recurrent prolapse, she When reviewing treatment options, in- loses urine with stress and urge. She often form the patient that the pessary is a pallia- has a postvoid residual volume >100 cc; uro- tive option, whereas surgical therapy aims to dynamic assessment confi rms mixed urinary be defi nitive. incontinence. The patient does not foresee any change in her social status (unmarried, sexu- CASE 2 RESOLVED ally inactive). After comprehensive counseling, the patient Is colpocleisis a reasonable option? elects to undergo colpocleisis, along with placement of a midurethral sling. She is dis- On the matter Although the pessary is a helpful conserva- charged 1 day after surgery, and reports sub- of self-image, tive alternative for women who are either stantially improved urinary function, including colpocleisis unable or unwilling to undergo complex bladder emptying, and quality of life. She says eliminates prolapse, surgical pelvic repair and is considered fi rst- she would recommend the procedure to any reduces the line treatment by a majority of urogynecolo- woman who has a similar condition. genital hiatus, gists, it sometimes becomes more diffi cult to and may improve maintain than the patient is willing to toler- the appearance ate.9 When a woman cannot remove and re- Pessary-related complications, incontinence, of the external insert the device herself, the pessary requires and underlying medical conditions genital area a lifelong commitment to doctor’s visits every A 92-year-old multiparous widow, whose 2 or 3 months. Th is commitment is especially stage-IV uterovaginal prolapse has been man- problematic for patients who become unable aged by a pessary, develops vaginal ulcers to drive or who lack social support. in both anterior and posterior walls. After Maintenance of the pessary becomes removal of the pessary and 4 weeks of treat- more frustrating as the patient becomes ment with vaginal estrogen, a smaller pessary more dependent. Many gynecologists have is inserted, but she again develops ulcers and seen a patient who developed a serious com- bleeding. plication such as vesicovaginal or rectovagi- The patient’s medical condition is com- nal fi stula because of a neglected pessary.10 plicated by hypertension and generalized In Case 2, the patient appears to be a po- arthritis. She has urodynamically confi rmed tential candidate for colpocleisis, given her mixed urinary incontinence. She lives with her age and single status. Although pelvic fl oor daughter and does not want to be placed in a repair appears to be safe in older women, nursing home. CONTINUED ON PAGE 22

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What treatment options should you offer genital hiatus. Th e following description to her? incorporates perineorraphy into the LeFort technique. Because of this patient’s advanced age, poor health, and pessary-related problems, she is Patient positioning an ideal candidate for colpocleisis, provided Place the patient in the dorsal lithotomy she consents to the procedure after thorough position, using stirrups to support the en- counseling about its benefi ts and limitations. tire leg up to the knee. Let the patient’s but- tocks overhang the edge of the table by 1 to 2 inches. A slight Trendelenburg position is Preoperative concerns imperative, especially when operating on A thorough history, physical examination, the anterior compartment of the vagina. Th e and normal are necessary. If a sus- bladder should be only partially emptied be- picious pelvic mass or uterine bleeding is cause the leakage of urine from the bladder present, transvaginal ultrasonography (US) makes it easier to identify inadvertent cysto- is crucial. In-offi ce endometrial sampling tomy. Infi ltration of local anesthetic also is necessary in any woman who has un- to develop the surgical planes is acceptable. explained vaginal bleeding. More invasive procedures such as dilatation and curettage Initiating the procedure and are needed only when the Remove a rectangular piece of vaginal epi- biopsy is inadequate or endometrial thick- thelium from the anterior vaginal wall, be- ness exceeds 4 mm on transvaginal US.13 ginning 2 to 3 cm distal to the vaginal apex All elderly women who have high-risk (or , if the uterus is present) and ending medical problems must be cleared for surgery, immediately proximal to the urethrovesical with the necessary cardiac and pulmonary junction to leave space for midurethral sling workup completed before the procedure. placement. Remove a similarly sized piece of Preop, transvaginal Because colpocleisis is an extraperi- epithelium from the posterior vaginal wall. US is crucial if toneal procedure, we have adapted use of Th is posterior rectangle is an almost geomet- the patient has over-the-counter products on the day ric projection of the anterior rectangle, but is a suspicious before surgery in lieu of mechanical bowel somewhat longer (2 to 3 cm) (FIGURE 1). pelvic mass or preparation, which may lead to dehydration When removing the vaginal epithelium, in very elderly women. it may be helpful to use the skills developed uterine bleeding; Coordinated consultation between the for anterior and posterior colporraphy. Our endometrial surgeon and anesthesiologist is necessary to operation begins with a 5- to 6-cm transverse sampling is indicated determine the type of anesthesia to be used. incision at the anterior vaginal apex, which for unexplained Sedation and local anesthesia can be adequate creates the proximal side of the anterior rect- vaginal bleeding for extremely high-risk women.14,15 Antibiotic angle described above (FIGURE 2A, page 26). prophylaxis is conventional for all patients. As you develop the plane between the epithelium and fi bromuscular layer, make a midline sagittal incision and extend it to Surgical technique the urethrovesical junction (FIGURE 2B). Dis- Th e LeFort method involves denudation sect the epithelium off the fi bromuscular and approximation of the midportions of layer approximately 3 cm bilaterally, then the anterior and posterior vaginal walls.8 make a transverse incision at the urethro- Th is operation creates a longitudinal vagi- vesical junction. Finally, remove the ante- nal septum with bilateral channels on each rior rectangle in two pieces by cutting along side, which serve as conduits for any se- the lateral sides (FIGURE 2C AND D). Remove cretion or bleeding from the apical vagina the posterior rectangle using the same tech- (FIGURE 1A AND B, page 24). Aggressive peri- nique, but also excise a triangular piece of neorraphy is also needed to shorten the skin from the posterior fourchette for the

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FIGURE 1 Principles of LeFort colpocleisis

The depiction here is not anatomically precise: The vagina is illustrated as a rectangular prism to clarify the relationship between tissues.

A B

Two rectangular pieces of vaginal The corresponding sides of these rectangles are epithelium are removed, one each from sutured together, creating bilateral channels that the anterior and posterior vaginal walls. connect at the vaginal apex. (Three short transverse lines represent row-by-row suturing of the raw surfaces.)

C D

The sides of two denuded rectangles on the vagina— one on the anterior and one on the posterior wall—are sutured together, which creates bilateral Sagittal representation of the denuded The procedure is completed by suturing channels that rectangular areas on the anterior and the corresponding sides of the rectangles posterior vaginal walls (highlighted in yellow). and denuded surfaces in three rows. connect at the apex of the vagina ROB FLEWELL

perineorraphy portion of the procedure To ensure adherence of the anterior and (FIGURE 2E, page 26). posterior rectangles, stitch the raw surfaces together in three rows (FIGURE 2G). Do not in- Suturing clude the distal 2 cm of the posterior vagina Suture the apical sides of the anterior and because you will need to leave room for peri- posterior rectangles together using a con- neorraphy. tinuous running technique (FIGURE 2F). Th en Using several sutures, reapproximate approximate the lateral sides bilaterally us- the torn perineal fi bromuscular structures ing continuous sutures. in the midline to perform perineorraphy

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FIGURE 2 LeFort technique, step by step

A Begin with a B Dissect the 5–6 cm transverse epithelium off incision at the anterior the fi bromuscular vaginal apex. layer, with a midline sagittal incision extending to the urethrovesical junction.

C After dissection is D Denude the posterior completed, make a rectangle using the transverse incision same technique. In at the urethrovesical addition, excise a junction, and remove triangular piece of skin the anterior rectangle from the perineum. in two pieces by cutting along the lateral sides.

E The posterior F Suture all but the rectangle is ready distal sides of the for removal. rectangles between the anterior and posterior vaginal walls.

G Also stitch H Perform together the perineorraphy. raw surfaces in three rows in an imbricating fashion.

I Close the distal J Final appearance. vagina, starting at the midpoint of the anterior transverse side. If indicated, place a midurethral sling. ROB FLEWELL FOR OBG MANAGEMENT

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26_r1_OBGM0609 26 5/27/09 9:52:05 AM (FIGURE 2H). Close the distal vagina, begin- terectomized woman, no lateral channel ning at the midpoint of the anterior transverse is necessary. Th erefore, it is appropriate side, which lies at the urethrovesical junction to do total colpocleisis.18,19 (FIGURE 2I). Continue this suture on the pos- • When a patient with POP has a recto- terior vagina and then the perineal body, vaginal or vesicovaginal fi stula caused sagittally, creating a small invagination in the by a neglected pessary, the addition of distal vagina (FIGURE 2J). LeFort colpocleisis to the fi stula repair may provide an eff ective treatment for Sling procedure both problems.10 We place a midurethral sling as part of most colpocleisis operations. It is best to do this after the colpocleisis but before the Surgical outcomes perineorraphy. Success rate In our cases, cystoscopy with simulta- Evidence concerning colpocleisis comes neous intravenous indigo carmine injec- from case series, some of which are more tion is standard before perineorraphy, even than 30 years old. Although the defi nition when a sling procedure is not planned. Th is of success is not clear in some series, the re- safeguard ensures ureteral patency, which ported success rate has always exceeded 90% can be compromised (although rarely) in over the past three decades.2,18–22 Moreover, these procedures. Cutting and replacement some of these reports involve as many as 30 of one of the sutures that approximate the years of follow-up. raw tissues typically resolve the problem.16 Perioperative complication In a recent review of the literature, the pro- Special considerations cedure-related mortality rate was 0.025%.2 Here are additional key points about colpo- When the authors focused only on studies cleisis, based on our experience: published since 1980, major complications The two lateral • If an ulcer lies within the area designat- due to the patient’s underlying cardiovas- channels created ed to be denuded, some debridement cular and pulmonary condition were seen by the LeFort to freshen up the surface will suffi ce. An in 2% of cases. Major surgical complications procedure allow ulcer is not an indication to deviate from such as pyelonephritis and bleeding requir- any bleeding to the standard procedure. ing transfusion occurred in 4% of cases, and escape the vagina; • A modifi cation developed by Goodall less severe complications occurred in 15%. this may enable and Power may allow coitus by remov- In a study that included women who un- recognition of ing only a triangular piece of epithelium derwent concomitant vaginal , uterine or cervical from each wall, leaving more room for hysterectomy prolonged the surgery by 52 the channels.17 minutes, with a 5% rate of laparotomy as a malignancy • We have been unable to fi nd any report result of intraoperative bleeding.22 of uterine or cervical cancer after col- pocleisis, despite a MEDLINE search Quality of life of the literature in English. Even so, the In our series of 40 colpocleisis cases, we noted lateral channels created by the LeFort no instance in which a patient regretted the procedure allow any bleeding to escape procedure.18 Others have also reported a low the vagina, and may therefore enable rate of regret—the highest being 9%.3–5,19–21 recognition of malignancy. When non- Using validated questionnaires, FitzGer- invasive imaging techniques such as US ald and colleagues found signifi cant im- or magnetic resonance are inadequate, provement in mental and physical quality of vaginoscopy and hysteroscopy may be life, as well as urinary, colorectal, and bulge- accomplished via these channels. related pelvic fl oor symptoms, 1 year after 5 • When colpocleisis is performed in a hys- colpocleisis. CONTINUED ON PAGE 28

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De novo or worsening urinary incon- Preoperative urodynamic studies to de- tinence is one of the drawbacks of colpo- tect urethral intrinsic defi ciency and detru- cleisis. However, the same risk is present in sor dysfunction are prudent, and detailed approximately 40% of women who undergo counseling of the patient about urinary con- surgical reconstructive procedures for POP trol is vital. We perform a midurethral sling without a continence operation.23 Because procedure in most of our colpocleisis cases, preoperative urinary retention is common and have had pleasing results. in women who have POP, the decision to add a potentially harmful continence procedure CASE 3 RESOLVED is complicated in colpocleisis candidates. A The patient decides to undergo partial colpo- small case series reported that the success cleisis using the LeFort procedure, along with rate ranged from 90% to 94% in women who placement of a midurethral sling, for a total underwent a midurethral tension-free sling operative time of 75 minutes. She is discharged procedure for the treatment of urinary in- 1 day later and reports substantial improve- continence at the time of colpocleisis.5 ment in urinary function and quality of life.

References

1. Luber KM, Boero S, Choe JY. Th e demographics of pelvic Long-term survival. Anesth Analg. 2003;96:583–589. fl oor disorders: current observations and future projections. Am J 13. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2001;184:1496–1503. ACOG Committee Opinion No. 426: Th e role of transvaginal 2. FitzGerald MP, Richter HE, Siddique S, Th ompson P, ultrasonography in the evaluation of postmenopausal bleeding. Zyczynski H, Weber A, for the Pelvic Floor Disorders Network. Obstet Gynecol. 2009;113(2 Pt 1):462–464. Colpocleisis: a review. Int Urogynecol J Pelvic Floor Dysfunct. 14. Moore RD, Miklos JR. Colpocleisis and tension-free vaginal 2006;17:261–271. tape sling for severe uterine and vaginal prolapse and stress 3. Wheeler TL Jr, Richter HE, Burgio KL, et al. Regret, urinary incontinence under local anesthesia. J Am Assoc Gynecol satisfaction, and symptom improvement: analysis of the impact Laparosc. 2003;10:276–280. of partial colpocleisis for the management of severe pelvic organ 15. Buchsbaum GM, Albushies DT, Schoenecker E, Duecy prolapse. Am J Obstet Gynecol. 2005;193:2067–2070. EE, Glantz JC. Local anesthesia with sedation for vaginal 4. Hullfi sh KL, Bovbjerg VE, Steers WD. Colpocleisis for pelvic reconstructive surgery. Int Urogynecol J Pelvic Floor Dysfunct. organ prolapse: patient goals, quality of life, and satisfaction. 2006;17:211–214. Obstet Gynecol. 2007;110(2 Pt 1):341–345. 16. Gustilo-Ashby AM, Jelovsek JE, Barber MD, Yoo EH, Paraiso 5. FitzGerald MP, Richter HE, Bradley CS, et al, for the Pelvic MF, Walters MD. Th e incidence of ureteral obstruction and the Floor Disorders Network. Pelvic support, pelvic symptoms, and value of intraoperative cystoscopy during vaginal surgery for patient satisfaction after colpocleisis. Int Urogynecol J Pelvic Floor pelvic organ prolapse. Am J Obstet Gynecol. 2006;194:1478–1485. Dysfunct. 2008;19:1603–1609. 17. Goodall JR, Power RMH. A modifi cation of the Le Fort 6. Patel D, Gillespie B, Foxman B. Sexual behavior of older operation for increasing its scope. Am J Obstet Gynecol. women: results of a random-digit-dialing survey of 2,000 women 1937;34:968–976. in the . Sex Transm Dis. 2003;30:216–220. 18. Harmanli OH, Dandolu V, Chatwani AJ, Grody MT. Total 7. Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, colpocleisis for severe pelvic organ prolapse. J Reprod Med. Steegers-Th eunissen RP, Burger CW, Vierhout ME. Symptomatic 2003;48:703–706. pelvic organ prolapse and possible risk factors in a general 19. DeLancey JOL, Morley GW. Total colpocleisis for vaginal population. Am J Obstet Gynecol. 2009;200:184.e1–184.e7. eversion. Am J Obstet Gynecol. 1997;176:1228–1232. 8. Berlin F. Th ree cases of complete prolapsus uteri operated 20. Goldman J, Ovadia J, Feldberg D. Th e Neugebauer–Le Fort upon according to the method of Leon LeFort. Am J Obstet operation: a review of 118 partial colpocleises. Eur J Obstet Gynecol. 1881;14:866–868. Gynecol Reprod Biol. 1981;12:31–35. 9. Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA. A 21. Ubachs JM, van Sante TJ, Schellekens LA. Partial colpocleisis survey of pessary use by members of the American Urogynecologic by a modifi cation of Le Fort’s operation. Obstet Gynecol. Society. Obstet Gynecol. 2000;95(6 Pt 1):931–935. 1973;42:415–420. 10. Esin S, Harmanli OH. Large vesicovaginal fi stula in women 22. Von Pechmann WS, Mutone MD, Fyff e J, Hale DS. Total with pelvic organ prolapse: the role of colpocleisis revisited. Int colpocleisis with high levator plication for the treatment Urogynecol J Pelvic Floor Dysfunct. 2008;19:1711–1713. of advanced pelvic organ prolapse. Am J Obstet Gynecol. 11. Gerten KA, Markland AD, Lloyd LK, Richter HE. Prolapse 2003;189:121–126. and incontinence surgery in older women. J Urol. 2008;179:2111– 23. Albo ME, Richter HE, Brubaker L, et al, for Urinary 2118. Incontinence Treatment Network. Burch colposuspension versus 12. Manku K, Bacchetti P, Leung JM. Prognostic signifi cance of fascial sling to reduce urinary . N Engl J Med. postoperative in-hospital complications in elderly patients. I. 2007;356:2143–2155.

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