Introduction
As our population ages, pelvic floor disorders are becoming more prevalent and increasingly important health and social issues. Approximately 63 million women will be 45 years old or older by 2030, and 33% of the population will be postmenopausal by 2050. In the United States, the largest segment of the population growthwise is the woman above 60 years of age. Population data show 11% of women will undergo surgery at some point for pelvic organ prolapse or incontinence, with some studies quoting a reoperation rate for failures of up to 30%, the majority of which occur in the anterior compartment.
As more women enter the eighth and ninth decades of life, many develop symptomatic primary or recurrent pelvic organ prolapse, often after unsuccessful attempts at pessary therapy or surgery, due to inherent longevity of repairs and many other factors. In addition, elderly women frequently have concomitant medical issues and are not sexually active, making extensive surgery less than ideal. Procedures have been described to alleviate the symptoms of pelvic organ prolapse by obliterating the vaginal canal. Both the Le Fort partial colpocleisis, which is uterine sparing, and a partial or complete colpectomy and colpocleisis performed post-hysterectomy are viable options for vaginal obliteration. This chapter discusses the indications and techniques for these procedures.
Historical Perspectives
Prior to the advent of surgical procedures for severe prolapse, women were treated with obstructing foreign bodies such as vaginal packing or pessaries, being hung upside down to invert the prolapse, or with caustic substances that were introduced into the vaginal canal to promote scarring. Early surgical procedures then arose that described the reapproximation of denuded vaginal mucosa to obliterate the vaginal canal (Gerardin of Metz, 1823). Gerardin never performed the procedure himself, but it served as a basic concept for several other techniques. This hypothesized procedure was further elaborated by Neugebauer in 1867, who removed a 3 × 6-cm area of vaginal epithelium anteriorly and posteriorly and sutured the area together. Neugebauer published this technique in 1881 after Leon Le Fort described a similar practice. Some descriptions also incorporate partial closure of the labia with suture. In 1877, Leon Le Fort described what we now term the Le Fort partial colpocleisis, whereby a narrower rectangle of the anterior and posterior walls is denuded and then sutured to replace the prolapse and leave channels for cervical drainage at the lateral fornices. He then coupled this procedure with a delayed colpoperineorrhaphy to narrow the genital hiatus. ultimately described a Le Fort partial colpocleisis in conjunction with a levator muscle plication and perineorrhaphy to further narrow the introitus and build up the perineum.
Early literature of the 20th century further modified these descriptions and, by the 1920s, a series of outcomes data began arising. In 1928, Baer and Reis reported a series of 14 women who underwent the Le Fort procedure with 100% success. published a series of 38 women of whom one had a recurrent prolapse through the Le Fort drainage channel and two others had recurrent cystocele. In 1948, Mazer and Isral showed a 97% success rate in 38 women using the Le Fort technique. In a larger series of 288 patients, described excellent results with only 1% of patients experiencing complete recurrence within the first year and 5% of patients some degree of recurrence. Overall, 92% of these patients believed that they had good or excellent support as a result of their colpocleisis.
Total colpectomy and colpocleisis with levator plication at the time of hysterectomy or post-hysterectomy was first described by . described excellent success in a case series of 23 patients who underwent complete vaginectomy with purse-string closure and levator plication. also described success with no recorded recurrences in a series of 60 patients undergoing vaginal hysterectomy and vaginectomy with levator plication.
Preoperative Evaluation
As with most urogynecologic complaints, choice of imaging and testing prior to treatment options is contingent on a thorough history and physical examination. Pelvic floor complaints may vary widely between patients and are associated with a variety of both anatomic and functional derangements that must be elucidated to determine whether ancillary testing will assist in determining the best treatment options.
Urodynamic testing prior to obliterative procedures is widely performed, but there is a lack of evidence regarding its necessity in an elderly population with medical comorbidities. Since occult incontinence may be masked in cases of obstructive prolapse in which the urethra may kink due to anatomic distortion, use of simple office cystometrics is often helpful. This is performed by asking a patient to perform a Valsalva maneuver with her prolapse reduced; this will reveal stress incontinence without the need to perform formal urodynamics. illustrated the high prevalence of occult stress urinary incontinence (SUI) in advanced prolapse. In this study, 75 of 92 subjects underwent urodynamic testing, 48% had stress incontinence, 17% had detrusor instability, and 21.3% had mixed incontinence. Another study in 2003 by Fitzgerald and Brubaker showed a 27% de novo stress incontinence rate after surgery. Although some argue that placement of a midurethral sling at the time of colpocleisis increases the rate of voiding dysfunction at a higher rate in elderly individuals, evaluated a series of 38 elderly women with SUI diagnosed preoperatively who underwent concomitant midurethral sling with colpocleisis. They found low rates of urinary retention and voiding dysfunction postoperatively, regardless of preoperative postvoid residual volumes.
Radiologic imaging may be helpful in revealing hydronephrosis or hydroureter as a result of obstruction from severe pelvic organ prolapse. showed that the presence of hydronephrosis increases with increasing prolapse and that knowledge of poor function may be helpful in evaluating changes in renal status postoperatively. Radiologic evidence of hydronephrosis, however, does not generally change the surgical management plan.
Voiding diaries, although recommended in some populations, may be difficult in extremely elderly patients due to both cognitive disability and compliance as well as the potential for mobility and dexterity issues. Proper methods for performing a voiding diary can be found in Chapter 9 .
Le Fort Partial Colpocleisis
A Le Fort partial colpocleisis is an option if the patient has her uterus and is no longer sexually active. Because the uterus is retained, evaluating any future uterine bleeding or cervical pathology is difficult. Therefore transvaginal ultrasound or endometrial biopsy, and Papanicolaou (Pap) smear must be performed before surgery to prevent delayed diagnosis of endometrial and cervical cancers, even though the incidence is rare ( ). The ideal candidate for a Le Fort partial colpocleisis is the patient who has uterine procidentia with symmetric eversion of the anterior and posterior vaginal walls ( Fig. 27.1 ).
Surgical Technique and Outcomes
- 1.
The procedure is begun by placing the cervix on traction to evert the vagina. A Foley catheter with a 5 to 10-mL balloon is placed in the bladder to aide in identification of the bladder neck.
- 2.
The rectangular areas to be denuded are marked anteriorly and posteriorly. The area should extend from approximately 2 cm from the tip of the cervix to 4 to 5 cm below the external urethral meatus. A mirror image on the posterior aspect of the cervix and vagina are also identified. The vaginal mucosa is injected with 0.025% bupivacaine or 2% lidocaine with 1:200,000 epinephrine just below the vaginal epithelium.
- 3.
The previously outlined areas are removed by sharp dissection ( Fig. 27.1 A and B ). The surgeon should leave the maximum amount of muscularis behind on the bladder and rectum. Hemostasis is an absolute must. While removing the posterior vaginal flap, one should not attempt to enter the peritoneum. If the peritoneum is inadvertently entered, the defect should be closed with an interrupted delayed absorbable suture.
- 4.
The cut edges of the anterior and posterior vaginal walls are sewn together with interrupted delayed absorbable sutures ( Fig. 27.1 C ). The knots are turned into the epithelium-lined tunnels, which have been created bilaterally ( Fig. 27.1 C ). After the uterus and vagina have been inverted, superior and inferior margins of the rectangle can be sutured together ( Fig. 27.1 D ).
- 5.
In the author’s opinion, plication of the bladder neck ( Fig. 27.1 A ) or a synthetic midurethral sling should be routinely performed because of the high incidence of postoperative stress incontinence. In addition, an aggressive perineorrhaphy with a distal levator plication should be performed to decrease the caliber of the genital hiatus and to build up the perineum. For the technique of levatorplasty, the reader is referred to a discussion described later in this chapter ( Fig. 27.3 ).
FIGURE 27.2
Colpectomy and complete colpocleisis. A and B. The vagina is circumscribed by an incision at the site of the hymen and is marked into quadrants. Each quadrant is removed by sharp dissection. C. Purse string delayed absorbable sutures are placed. The leading edge of the soft tissue is inverted by the tip of the forceps. Purse string sutures are tied 1 before 2 and 2 before 3, with progressive invision of the soft tissue before tying of each suture. D. The final relationship is shown in a cross section. A perineorraphy is also usually performed.
According to the literature, 90% to 95% of patients achieve good anatomic results, with relief of many of their symptoms. Partial recurrence or breakdown of the repair is seen in 2% to 5% and is thought to be due to poor hemostasis with hematoma formation or infectious morbidity. In a series of 118 patients and following a modified Le Fort procedure by , 91% of patients exhibited good anatomic outcomes, 85% had resolution of prolapse symptoms, and 2.5% developed recurrent prolapse, mostly due to wound breakdown or hematoma. In addition, 10.2% developed de novo or worsening of incontinence.
Several studies have looked at complication rates after partial colpocleisis, which is generally quoted at 5% significant complications and 15% for minor complications. These are mostly due to multiple comorbidities and the frailty of the population being considered. , in a population-based study, showed that although complications increase in subjects >80 years of age, obliterative procedures had fewer major adverse events than reconstructive procedures. reported few complications in a series of 25 Le Fort colpocleises and 17 total colpectomies.
Total Colpectomy and Colpocleisis
In patients with post-hysterectomy prolapse with near complete vaginal eversion and who are not interested in further sexual function, a total colpectomy and colpocleisis provides a minimally invasive durable option to correct their prolapse. However, if there is significant prolapse of just one segment of the pelvic floor, for example the anterior vaginal wall, then an aggressive repair of the compartment with a narrowing of the genital hiatus will accomplish the same result without requiring complete removal of all vaginal epithelium. Total colpectomy may also be performed at the same time as vaginal hysterectomy if desired, although the total blood loss tends to be greater with the addition of this procedure ( ). The rationale for performing a hysterectomy at the time of colpocleisis is to eliminate the risk of endometrial or cervical malignancy. It also eliminates the risk of development of pyometra, a rare but serious complication that can occur if the lateral canals become obstructed after a Le Fort procedure.
Surgical Technique and Outcomes
- 1.
The most prominent portion of the prolapse is grasped with two Allis clamps. The vaginal epithelium is injected with a 1% or 2% lidocaine with epinephrine solution as previously mentioned for the Le Fort partial colpocleisis.
- 2.
The vagina is circumscribed by an incision several centimeters from the hymen at the base of the prolapse. A marking pencil is then used to mark rectangular portions of the vagina that will be removed sharply. The vaginal epithelium is completely removed. An effort is made to avoid entering the peritoneal cavity ( Fig. 27.2 A and B ).
