Total colpectomy and colpocleisis: Key step by key step
In a patient who has post-hysterectomy prolapse and is not interested in continued sexual function, total colpectomy and colpocleisis provide a highly minimally invasive, durable option to correct her prolapse.
If there is complete eversion of the vagina then, truly, total colpectomy and colpocleisis is the procedure of choice. If there is significant prolapse of only one segment of the pelvic floor, however—for example, the anterior vaginal wall (FIGURE 1)—then aggressive repair of this variant with a narrowing down of the genital hiatus accomplishes the same result without requiring complete removal of what appears to be fairly well supported vaginal mucosa.
Here are key steps for performing partial or complete colpectomy and colpocleisis.
Completely remove the vaginal epithelium (FIGURES 3A and 3B); your goal is to leave most of the muscularis of the vaginal wall on the prolapse.
Avoid the peritoneal cavity if at all possible; when the main portion of the prolapse is secondary to an enterocele and the vaginal epithelium is very thin, however, formal excision of the enterocele sac, with closing of the defect, may be required.
If at all possible, avoid the peritoneum and the wall of the viscera, whether bladder or bowel. Invert the apex of the soft tissue, using the tip of forceps, as each purse-string suture is tied.
There is a variation of this procedure: Perform a separate anterior and posterior colporrhaphy, with two purse-string sutures used to approximate the anterior and posterior segments, thus obliterating any dead space.
See Video #2 and Video #3 for a demonstration of how to perform a complete colpectomy and colpocleisis. FIGURE 3D shows the completed colpocleisis.
FIGURE 3 Steps: Total colpectomy and colpocleisis
Denude the anterior vaginal epithelium (A) and then the posterior epithelium (B). C. Place sequential purse-string sutures. D. The completed colpocleisis, in cross-section.
Distal levatoroplasty with high perineorrhaphy: Key step by key step
FIGURE 4 Steps: Distal levatoroplasty with high perineorrhaphy
A. Lateral dissection to the levator ani muscles. Inset: levator ani plicated with sequential sutures. B. Place three sutures to plicate the levator ani. C. Secure the plication sutures. Inset C, and D: Completed levatoroplasty.
Our experience
We are often asked questions about the procedures that we’ve just described, including patients’ satisfaction with the outcome, complications, and the risk that prolapse will recur. In the accompanying box, “Questions we’re asked (and answers we give) about obliterative surgery,” opposite, we give our responses to eight common inquiries.
about obliterative surgery
Q1 How satisfied are women with the outcome of these procedures—do many regret having their vaginal canal obliterated?
A Overall, studies indicate that 85% to 100% of patients are “satisfied” or “very satisfied” with the outcomes of obliterative procedures.1 There are rare reports of regret after colpocleisis over loss of coital ability; in one study of a series of procedures,2 5% of subjects expressed regret postoperatively.
Q2 Why is levatoroplasty and perineorrhaphy such an important part of both the LeFort partial colpocleisis and colpectomy and colpocleisis?
A The aim of both these procedures is to reduce prolapsed tissue. The true durability of repair comes from significantly decreasing the caliber of the genital hiatus, with the hope of closing off the bulk of the distal vaginal canal. This can really only be accomplished by utilizing an aggressive levatoroplasty and perineorrhaphy, described in the text.
Q3 How often do patients develop de novo stress incontinence or significant voiding dysfunction, or both, after an obliterative procedure?
A The risk of developing urinary incontinence after an obliterative procedure is difficult to ascertain. In general, patients who had retention or a high postvoid residual volume preoperatively have a good outcome in regard to correcting their voiding dysfunction. This is because, in most cases, the voiding dysfunction is directly related to the anatomic distortion created by the prolapse.
Q4 What is the rate of prolapse recurrence after these procedures, and how is a recurrence managed?
A Multiple studies have documented an excellent anatomic outcome after these procedures, with a prolapse recurrence rate of only 1% to 8%.3 Very little has been written about how to best manage recurrent prolapse after an obliterative procedure. Most surgeons would, most likely, recommend repeat colpocleisis or aggressive levatoroplasty and perineorrhaphy. (Note: The patient whose colpectomy and colpocleisis is shown in Video #3 failed two previous colpectomy and colpocleisis procedures.)
Q5 Can these procedures be performed under local anesthesia, with some intravenous sedation, or under regional anesthesia—thereby avoiding intubation?
A Yes. We have utilized IV sedation and bilateral block successfully to perform these procedures. (Note: Video #3 of LeFort partial colpocleisis shows the procedure performed under local anesthesia.)
Q6 What does the literature say about common complications after these procedures?
A Postoperative morbidity and mortality in the elderly surgical population is a considerable concern. Significant postoperative complications occur in approximately 5% of patients in modern series4—often attributed to the effects of age and to the frail condition of patients who are commonly selected for colpocleisis.
Specifically, approximately 5% of patients experience a postoperative cardiac, thromboembolic, pulmonary, or cerebrovascular event. Transfusion is the most commonly reported major complication related to the procedure itself. Other complications include:
- fever and its associated morbidity
- pneumonia
- ongoing vaginal bleeding
- pyelonephritis
- hematoma
- cystotomy
- ureteral occlusion.
Minor surgical complications occur at a rate of approximately 15%. Surgical mortality is about 1 in 400 cases.
Q7 Do you routinely undertake urodynamic study of patients who are scheduled to undergo an obliterative procedure?
A At minimum, a lower urinary tract evaluation should include a postvoid residual volume study and, we believe, some kind of a filling study and stress test, with reduction of the prolapse. Beyond that, we recommend that you conduct more detailed urodynamic tests on a patient-by-patient basis, when you think that the findings will add to the clinical picture.
Q8 Would you ever perform a vaginal hysterectomy and then proceed with a colpectomy and colpocleisis?
A The principal rationale for performing hysterectomy at the time of colpocleisis is to eliminate the risk of endometrial or cervical carcinoma. Hysterectomy also eliminates the risk of pyometra, a rare but serious complication that can occur when the lateral canals become obstructed after a LeFort procedure.
A recent study5 looked at 1) concomitant hysterectomy in conjunction with colpectomy and colpocleisis and 2) traditional LeFort partial colpocleisis. In this retrospective review, objective and subjective success rates were high, but patients who underwent hysterectomy had a statistically significantly greater decline in postoperative hematocrit and a significant increase in the need for transfusion, compared with patients who did not undergo hysterectomy (35% vs. 13%).
References
1. Fitzgerald MP, Richter HE, Bradley CS, et al. Pelvic support, pelvic symptoms and patient satisfaction after colpocleisis. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(12):1603-1609.
2. Hullfish K, Bobbjerg B, Steers W. Colpocleisis for pelvic organ prolapse Patient Goals Quality of life and Satisfaction. Obstet Gynecol. 2007;110(2 Pt 1):341-345.
3. Fitzgerald MP, Brubaker L. Colpocleisis and urinary incontinence. Am J Obstet Gynecol. 2003;189(5):1241-1244.
4. von Pechmann WS, Muton M, Fyffe J, Hale DS. Total colpocleisis with high levator placation for the treatment of advanced organ prolapse. Am J Obstet Gynecol. 2003;189(1):121-126.
5. Kohli NE, Sze E, Karram M. Pyometra following LeFort colpocleisis. Int Urogyn J. 1996;7(5):264-266.