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Lefort Colpocleisis: a Step-By-Step Simulation Video for Female Pelvic Surgeons

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Lefort Colpocleisis: a Step-By-Step Simulation Video for Female Pelvic Surgeons LeFort colpocleisis: a step-by-step simulation video for Female Pelvic Surgeons Andrey Petrikovets, Theresa Fisher, Christina Krudy, David Sheyn, Jeffrey Mangel & Sangeeta T. Mahajan International Urogynecology Journal Including Pelvic Floor Dysfunction ISSN 0937-3462 Int Urogynecol J DOI 10.1007/s00192-017-3543-9 1 23 Your article is protected by copyright and all rights are held exclusively by The International Urogynecological Association. This e-offprint is for personal use only and shall not be self- archived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy International Urogynecology Journal https://doi.org/10.1007/s00192-017-3543-9 IUJ VIDEO LeFort colpocleisis: a step-by-step simulation video for Female Pelvic Surgeons Andrey Petrikovets1,2 & Theresa Fisher1 & Christina Krudy2 & David Sheyn1,2 & Jeffrey Mangel2 & Sangeeta T. Mahajan1 Received: 25 August 2017 /Accepted: 10 December 2017 # The International Urogynecological Association 2017 Abstract Introduction and hypothesis LeFort colpocleisis is a minimally invasive surgical option for patients with pelvic organ prolapse who no longer desire sexual activity. Pelvic surgeons have limited exposure to this procedure during their training, and are therefore less likely to offer this procedure to their patients. Methods We use a split screen live action surgery, side by side with a low cost 3D model of a prolapse to describe a LeFort colpocleisis step by step. Results This video is an easily reproducible guide to the steps and surgical techniques necessary to successfully perform a LeFort colpocleisis. The simulation model can be used to educate and train those performing female pelvic surgery. Conclusion Pelvic surgeons should be able to offer LeFort colpocleisis to their patients. This video may be used to facilitate the understanding and reproducibility of the procedure. Keywords LeFort colpocleisis . Educational model . Pelvic organ prolapse . Surgical video Introduction Surgery is the definitive treatment for POP in symptom- atic patients. Obliterative procedures for POP are minimal- Pelvic organ prolapse (POP), an increasingly prevalent condition, ly invasive surgical options for appropriately counseled is diagnosed in over 40% of women older than 50 years [1]. As patients who do not desire future vaginal intercourse. the population of women over 65 years is expected to double by Typically, obliterative surgery is the procedure of choice 2050, it is predicted that the number of women experiencing for older, fragile patients with multiple comorbidities and POP will increase over the course of the coming decades [2, advanced prolapse that is not amenable to conservative 3]. Up to 10% of women will have POP surgery before the age management. Obliterative procedures can generally be per- of 80 years and approximately 220,000 surgical procedures are formed under local anesthesia and in a shorter time than performed annually for this condition in the US [4]. more invasive surgical options such as uterosacral ligament suspension and sacrocolpopexy. The two common types of obliterative procedures for POP Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00192-017-3543-9) contains supplementary are LeFort colpocleisis for patients with a uterus, and com- material. This video is also available to watch on http://link.springer. plete colpectomy with colpocleisis for patients with a previous com/. Please search for this article by the article title or DOI number, and hysterectomy. LeFort colpocleisis has an extremely high de- ‘ ’ on the article page click on Supplementary Material . gree of success for treating POP, with 91–100% reported suc- cess rates [5]. In the case of LeFort colpocleisis, given that the * Andrey Petrikovets [email protected] uterus is retained inside, an associated limitation is difficulty in the evaluation of postmenopausal bleeding or cervical pa- 1 thology in the future. Overall, obliterative procedures have a Department of Female Pelvic Medicine & Reconstructive Surgery, positive impact on postoperative quality of life with 85–95% Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA patient satisfaction 1 year after surgery [6, 7]. In a prospective study of 79 patients who underwent obliterative surgery, 90% 2 Department of Urogynecology and Pelvic Reconstructive Surgery, MetroHealth Medical Center, 2500 MetroHealth Drive, of patients said they would have the surgery again when sur- Cleveland, OH 44109, USA veyed 12 months after surgery [8]. Author's personal copy Int Urogynecol J Residents who graduated from residency less than 10 years used throughout the entire surgery. We begin with ago are less likely to offer obliterative procedures to their imbrication of a tunnel on either side, followed by patients than providers who graduated more than 10 years imbrication of the cervix, and ending with imbri- ago [9, 10]. In the authors’ training institution, residents grad- cation of a tunnel on the opposite side. With the uate with one to three obliterative procedures as surgeon. cervix reduced, the surgery continues with imbri- Therefore, the purpose of this video is to demonstrate a cation of a tunnel, the formation of two box sutures LeFort colpocleisis simulation model side-by-side with a live to reduce the middle aspect of the prolapse, follow- procedure to serve as an educational tool for female pelvic ed by imbrication of a tunnel on the opposite side. reconstructive surgeons of all levels. In our practice, box sutures are used to reinforce and reduce the prolapse. Use of box sutures is an optional step as the prolapse can be manually re- Materials and methods duced, allowing the raw surfaces to adhere to one another. These steps are performed as needed until This video demonstrates a LeFort colpocleisis using an easily the entire prolapse is reduced. constructed and reproducible low-cost 3D model of a stage IV Step 6 Approximation of vaginal epithelium: Once the prolapse side-by-side with surgical footage of the same pro- prolapse is reduced, the vaginal epithelium is ap- cedure. First, we describe the construction of the POP model proximated in an interrupted or running fashion to practice LeFort colpocleisis. Model assembly is simple, with a delayed absorbable suture. using easily accessible items such as cotton balls, pantyhose, Step 7 Cystoscopic evaluation: Cystoscopy is performed socks, and glue. The total cost of the model is less than five with an agent of choice (i.e. Pyridium, sodium dollars and assembly takes only a few minutes. To perform the fluorescein) to evaluate for a possible bladder or simulation, surgical tools and suture are also required, along ureteral injury. with the addition of an optional pelvic model. Step 8 Perineorrhaphy: Finally, a perineorrhaphy is per- The footage in this video emphasizes these following key formed to reduce the length of the genital hiatus, to steps to successfully perform the procedure: increase the length of the perineal body, and to prevent recurrence of the prolapse. A rectal exam- Step 1 Landmarks and hydrodissection: The apex of the ination should be performed to exclude the pres- prolapse is grasped with Allis clamps and two rect- ence of any sutures in the rectum. angular sections of vaginal mucosa, one anteriorly and one posteriorly, are outlined for dissection. The outlines of the anterior and posterior rectangles cre- ate two lateral epithelial strips, which serve as drain- Conclusion age tunnels. Care must be taken to ensure that enough vaginal mucosa is spared at the edges to LeFort colpocleisis is an effective and well-tolerated option make a patent tunnel; a tunnel that is too narrow for the surgical treatment of POP in patients who no longer may be blocked with thick cervical secretions post- desire vaginal intercourse. This video may be used to facilitate operatively. The rectangular sections are marked the understanding and reproducibility of this procedure for from their distal aspects near the cervix to the hy- surgeons taking care of patients with pelvic floor disorders. menal ring posteriorly and to the level of the urethrovesical junction anteriorly. The rectangles Compliance with ethical standards are marked in a similar fashion regardless of whether or not a concomitant sling is performed. More ex- Conflicts of interest A.P., T.F., C.K., D.S., J.M. do not have any disclosures. tensive dissection past the level of the urethrovesical S.T.M. acts as a consultant and lecturer for Allergan and Astellas. junction may lead to de novo stress urinary inconti- nence. The planes are then hydrodissected using li- Consent Written informed consent was obtained from the patient for docaine with epinephrine or dilute vasopressin. publication of this case report and any accompanying images. Step 2 Denude vaginal epithelium: Sharp dissection is used to denude the outlined vaginal epithelial rectangles References from the underlying fibromuscular
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