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Obliterative Lefort Colpocleisis in a Large Group of Elderly Women

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Obliterative Lefort Colpocleisis in a Large Group of Elderly Women Obliterative LeFort Colpocleisis in a Large Group of Elderly Women Salomon Zebede, MD, Aimee L. Smith, MD, Leon N. Plowright, MD, Aparna Hegde, MD, Vivian C. Aguilar, MD, and G. Willy Davila, MD OBJECTIVE: To report on anatomical and functional satisfaction. Associated morbidity and mortality related outcomes, patient satisfaction, and associated morbidity to the procedure are low. Colpocleisis remains an and mortality in patients undergoing LeFort colpocleisis. excellent surgical option for the elderly patient with METHODS: This was a retrospective case series of advanced pelvic organ prolapse. LeFort colpocleisis performed from January 2000 to (Obstet Gynecol 2013;121:279–84) October 2011. Data obtained from a urogynecologic DOI: http://10.1097/AOG.0b013e31827d8fdb database included demographics, comorbidities, medi- LEVEL OF EVIDENCE: III cations, and urinary and bowel symptoms. Prolapse was quantified using the pelvic organ prolapse quantification y 2050, the elderly will represent the largest section (POP-Q) examination. Operative characteristics were Bof the population and pelvic floor dysfunction is recorded. All patients underwent pelvic examination projected to affect 58.2 million women in the United and POP-Q assessment at follow-up visits. Patients also States. We thus can expect to see a increase in the were asked about urinary and bowel symptoms as well as demand for urogynecologic services in this popula- overall satisfaction. All intraoperative and postoperative tion.1,2 Most women older than age 65 years are surgical complications were recorded. afflicted with at least one chronic medical condition, RESULTS: Three hundred twenty-five patients under- and, with the rate of comorbid conditions increasing went LeFort colpocleisis. Fifteen patients were excluded from the analysis because of incomplete data. The mean with age, surgery to treat pelvic floor dysfunction in age was 81.365.3 years. Comorbidities were common, the elderly can present a challenge for the pelvic recon- 3 with 74.1% of the patients having at least one concomi- structive surgeon. In fact, women older than age 80 tant medical condition. The procedure was performed years undergoing urogynecologic procedures have under spinal anesthesia in 67%. Additional procedures a 13.6 times increased risk of death after the procedure at the time of colpocleisis included incontinence proce- compared with their younger counterparts.4 Factors dures (79%) and dilation and curettage (46%). Mean fol- increasing surgical morbidity include long operative low-up was 45 (range 2–392) weeks. Anatomical success time, significant blood loss, and anesthesia-related com- rate was 98.1% and patients were highly satisfied, with plications. Colpocleisis, a vaginal obliterative proce- 92.9% reported being “cured” or “greatly improved.” dure, can be a viable option for elderly women with Complication and mortality rates were 15.2% and 1.3%, pelvic organ prolapse because of its simplicity, reported respectively. good anatomical outcomes, minimal anesthesia require- CONCLUSION: Colpocleisis is an effective and low-risk ments, short operative times, and less blood loss com- procedure with high anatomical success rates and patient pared with reconstructive procedures.5 Previous published studies include several From the Section of Urogynecology and Reconstructive Pelvic Surgery, Depart- descriptive case series reviewing anatomical outcomes ment of Gynecology, Cleveland Clinic Florida, Weston, Florida. as their primary focus. However, many of these series Corresponding author: G. Willy Davila, MD, 2950 Cleveland Clinic Blvd. are small and lack a comprehensive characterization Weston, FL 33331; e-mail: [email protected]. of preoperative symptomatology, patient comorbid- Financial Disclosure ities, and comprehensive postoperative outcomes, The authors did not report any potential conflicts of interest. including anatomical and functional aspects. In addi- © 2013 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. tion, most published reports have only historical ISSN: 0029-7844/13 value, being at least 30 years old, and likely do not VOL. 121, NO. 2, PART 1, FEBRUARY 2013 OBSTETRICS & GYNECOLOGY 279 apply to the current elderly population and current raphy was performed in all cases and concomitant practice of medicine.6 incontinence procedures were performed as indicated. The objective of this descriptive retrospective Demographic information collected included age, review was to report on the LeFort colpocleisis pro- body mass index (calculated as weight (kg)/[height cedure not only as it relates to anatomical outcomes but (m)]2), parity, smoking status, history of prolapse sur- also as it relates to resolution of patient symptoms, gery or hysterectomy, and degree of prolapse on exam- surgical satisfaction, and associated morbidity and ination. Comorbid conditions of interest included mortality. hypertension, heart disease, diabetes, depression, pul- monary disease, neurologic disease, history of cerebro- MATERIALS AND METHODS vascular disease accident, and thyroid disease. The age- This single-center chart review was approved by the adjusted Charlson comorbidity index was calculated Cleveland Clinic Florida Institutional Review Board. All for all individuals. Patients with a Charlson comorbid- – patients who underwent a LeFort colpocleisis between ity index of 0 2 points were considered to be at low – January 2000 and October 2011 were included in the risk, 3 5 points indicated moderate risk, and 6 or more 9,10 review. Patient information was obtained from the points indicated high risk. Patient symptomatology institution’s urogynecologic database and patients with also was recorded, including the presence of pelvic incomplete data were excluded. The LeFort colpocleisis pain, any urinary and bowel symptoms, or both. Uri- is our preferred obliterative technique regardless of the nary symptoms included stress and urge incontinence, presence of a uterus, and thus no colpectomies were voiding dysfunction, and urinary retention. Bowel performed. The procedure is offered to elderly women symptoms were categorized as constipation, obstruc- older than 65 years with advanced vaginal prolapse who tive defecation, and fecal incontinence. do not have and do not express a desire for future sexual Urodynamic testing was performed for all patients intercourse. During the study period, all procedures to assess any bladder symptoms and to identify “ ” were performed by two fellowship-trained female pelvic occult stress incontinence. All urodynamic tests per- reconstructive surgeons with the assistance of fellows in formed at our institution include multichannel cystom- training. Our standard protocol includes preoperative etry, pressure uroflowmetry, and urethral pressure medical clearance, one dose of preoperative intravenous profilometry. Concomitant sling placement when indi- antibiotic, prophylaxis for deep vein thrombosis, and cated and choice of sling were based on urodynamic 11 recommendation for regional anesthesia.7 The LeFort parameters previously published at our institution. procedure was performed using a standard technique Additionally, when performing an obliterative proce- previously described in detail (Video 1, available online dure, it is our standard of practice to evaluate the endo- at http://links.lww.com/AOG/A343).8 Essentially, rect- metrium and uterus before surgery by recommending angular portions of the anterior and posterior vaginal pelvic ultrasonography. Concomitant dilatation and walls are demarcated with a sterile marker and the epi- curettage is then performed in those patients with thelium is removed with sharp dissection. The denuded abnormal or inconclusive ultrasound results. areas are then sewn together front-to-back in progressive The operative report was reviewed to confirm type rows of 2-0 vicryl interrupted suture. A high perineor- of anesthesia, estimated blood loss, and any operative complications. Complications were categorized as intraoperative or postoperative, with postoperative complications further divided into early or late com- plications. Early complications were defined as those occurring within the first postoperative week, whereas late complications were defined as those occurring after the first postoperative week until 3 months after the surgery. To ensure that we obtained complete infor- mation on any and all complications, all operative reports, discharge summaries, outpatient notes, any emergency room visits, and all documented telephone calls were reviewed. Perioperative complications were separated into systems that included urogenital, pul- Video 1. LeFort colpocleisis for advanced vaginal prolapse. monary, gastrointestinal, skin, cardiovascular, neuro- Zebede. LeFort Colpocleisis in Elderly Women. Obstet Gynecol logic, and renal and death. These included urinary tract 2013. infections, pulmonary embolism, bowel perforations, 280 Zebede et al LeFort Colpocleisis in Elderly Women OBSTETRICS & GYNECOLOGY hematomas, abscess, congestive heart failure, arrhyth- Table 2. Comorbid Conditions (N5310) mia, and deep vein thrombosis. 95% CI for Patients returned to our clinic for postoperative n (%) Proportion visits typically at 2 weeks, 6 weeks, 6 months, and then yearly. At every postoperative visit, all patients Hypertension 180 (58) 0.525–0.634 were questioned regarding any medical problems, Heart disease 97 (31.3) 0.263–0.367 Diabetes 47 (15.1) 0.116–0.196 pelvic floor symptoms, and
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