Obliterative procedures for pelvic organ prolapse





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 fastest growing segment in the population is women above 60 years of age. Approximately 11% of women will undergo surgery at some point for pelvic organ prolapse (POP) or incontinence, with some studies quoting a reoperation rate for failures of up to 30%, the majority of which occur in the anterior compartment.


Obliterative surgery or colpocleisis is undertaken in approximately 5% of women in the United States undergoing surgery for POP. The surgery is usually undertaken in the elderly or medically compromised who are happy to sacrifice vaginal intercourse and is an effective procedure with quick recovery and low morbidity. As more women enter the eighth and ninth decades of life, many develop symptomatic primary or recurrent POP, often after unsuccessful attempts at pessary therapy or surgery, owing to the inherent limits on the longevity of repairs, as well as many other factors. In addition, elderly women frequently have concomitant medical issues and are not sexually active, making extensive surgery less than ideal. Both the Le Fort partial colpocleisis, which is uterine sparing, and a partial or complete colpectomy and colpocleisis performed posthysterectomy are viable options for vaginal obliteration. This chapter discusses the indications and techniques for these procedures.


Historical perspectives


Before 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 never performed the procedure himself, but it served as a basic concept for several other techniques. This hypothesized procedure was further elaborated by in 1867 by Neugebauer, who removed a 3 × 6 cm area of vaginal epithelium anteriorly and posteriorly and sutured the edges of the removed area together. Neugebauer published this technique in 1881 after Leon Le Fort described a similar procedure. Some descriptions also incorporate partial closure of the labia with suture. In 1877, Le Fort described what we now term the Le Fort partial colpocleisis, whereby a narrow 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 from the twentieth century further modified these descriptions and, by the 1920s, a series of outcomes data began to arise. 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 experiencing 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 posthysterectomy 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


The most important first step when considering obliterative prolapse surgery is proper patient selection. In-depth discussion of a patient’s current and future sexual desires is essential, as is an understanding of the patient’s comorbidities and perioperative risk. The risks and benefits of and alternatives to obliterative versus reconstructive procedures and pessary should be included as part of a shared decision-making process. As with most urogynecologic complaints, choice of imaging and testing before 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. In addition, thorough counseling regarding sexual function and desire to preserve a functional vagina should guide selection of surgical intervention, regardless of age and baseline functional status.


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 stress urinary incontinence (SUI) may be masked in cases of obstructive prolapse in which the urethra may kink because of anatomic distortion, use of a simple office cough stress test 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 SUI in patients with 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. However, in a randomized controlled trial of 91 women who underwent vaginal POP surgery with occult SUI, only 48% of patients who did not receive a concomitant midurethral sling (MUS) experienced SUI postoperatively, and only 13% of those patients subsequently underwent a secondary antiincontinence procedure for SUI ( ). Whereas some argue that placement of an MUS 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 MUS with colpocleisis and found low rates of urinary retention and voiding dysfunction postoperatively, regardless of preoperative postvoid residual (PVR) volumes.


Radiologic imaging may be helpful in revealing hydronephrosis or hydroureter as a result of obstruction from severe POP. 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.


An additional preoperative consideration for Le Fort partial colpocleisis includes endometrial and cervical assessment, especially in patients with symptoms of abnormal uterine bleeding or a history of abnormal Pap smears. Because the uterus is retained, evaluating any future uterine bleeding or cervical pathology is difficult. A study by based on an anonymous web-based survey of 322 physicians reported that the preferred first-line endometrial evaluation is a transvaginal ultrasound (81%), whereas a minority of physicians (14%) perform dilatation and curettage with or without hysteroscopy. Although it is commonly performed, there is a lack of consensus regarding the optimal workup modality or the clinical utility of preoperative endometrial evaluation to rule out uterine cancer before obliterative POP surgeries in asymptomatic patients. Endometrial evaluation may be of limited clinical value because of the low prevalence (0.5% of 786 patients) of occult uterine malignancy in asymptomatic, low-risk patients who undergo POP surgeries ( ; ). In contrast, a study by reported pathologic endometrial findings in 3.17% (2 of 63) patients who underwent morcellation during benign robotic-assisted supracervical hysterectomy and cervicosacropexy. Similarly, a retrospective evaluation of 644 women undergoing surgery for uterovaginal prolapse by found that the rate of unanticipated uterine pathology was 2.6%. In postmenopausal women without bleeding, the risk of unanticipated uterine pathology is 2.6%. Importantly, in women with a history of postmenopausal bleeding who had negative endometrial evaluation, the risk of unanticipated endometrial hyperplasia or cancer was 13%. As such, these authors do not recommend uterine preservation at the time of prolapse surgery, including Le Fort colpocleisis, in women with postmenopausal bleeding, even in the face of a negative endometrial evaluation.


Le fort partial colpocleisis


A Le Fort partial colpocleisis is an option if the patient with prolapse has her uterus, is no longer sexually active, and does not have postmenopausal bleeding (see earlier). This procedure can be performed under local anesthesia or with a pudendal block ( ), but is typically performed using regional or general anesthesia, depending upon the patient’s comorbidities. 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 who no longer desires sexual activity ( Fig. 23.1 ).




Fig. 23.1


Le Fort partial colpocleisis. A , A rectangular piece of anterior vaginal wall has been removed. Note in the inset that the dissection has been extended laterally at the level of the proximal urethra to perform a Kelly–Kennedy plication in the hope of providing preferential support to the bladder neck and thus preventing any occult or potential stress incontinence. B , A similar rectangular piece of posterior vaginal wall is removed. A portion of the posterior vaginal wall will usually lie over an enterocele, and the surgeon should attempt to avoid entering the peritoneal cavity if at all possible. C , The cut edge of the anterior incision at the level of the cervix is sewn to the distal cut edge of the posterior incision with interrupted No. 2-0 delayed absorbable sutures. ( inset ) Once the cervix is inverted, the interrupted sutures are taken through the cut edges of the lateral portions of the incision. D , Once the entire vagina has been inverted, the superior and inferior margins over the rectangle can be sutured horizontally, thus completely obliterating the midportion of the vagina. Note: draining channels are left in the lateral portions of the vagina to facilitate drainage of any cervical discharge. A levatoroplasty is commonly performed to increase posterior pelvic muscle support and narrow the introitus. (See Fig. 23.3 for technique of levatoroplasty.)








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 is also identified. The vaginal epithelium 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. 23.1 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. 23.1 C). The knots are turned into the epithelium-lined tunnels, which have been created bilaterally (see Fig. 23.1 C). After the uterus and vagina have been inverted, the superior and inferior margins of the rectangle can be sutured together ( Fig. 23.1 D).


  • 5.

    In the authors’ opinion, plication of the bladder neck (see Fig. 23.1 A) or a synthetic MUS procedure should be routinely performed in the hope of avoiding 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. 23.3 ). (See : LeFort Partial Colpocleisis.)




    Fig. 23.3


    Distal levatoroplasty and perineorrhaphy. A , Widened genital hiatus with levator muscle shown in a lateral position. B , Perineal and midline vaginal incision is used to expose medial edge of levator muscle. ( inset ) Distal portions of levator muscle are plicated across the midline. C , Plication sutures are placed and tied, and perineorrhaphy is performed.





According to the literature, 90% to 95% of patients achieve good anatomic results, with relief of many of their symptoms and low risk of regret ( ). Recent long-term follow-up studies reported satisfaction rates at 75% with a mean follow-up of 6.4 years and 94.3% with a median follow-up of 5 years ( ; ). 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 retrospective cohort study of 107 patients who underwent colpocleisis for stage 3 or 4 POP, a longer duration from prolapse occurrence to surgery (24.6 ± 22.8 years vs. 8.0 ± 12.9 years, P = .021) was associated with recurrence ( ).


Several studies have looked at complication rates after partial colpocleisis, which is generally quoted at 5% for significant complications and 15% for minor complications. These are mostly due to multiple comorbidities and the frailty of the population being considered. Quantified frailty using the National Surgical Quality Improvement Program – Frailty Index (NSQIP-FI) shows that age is strongly correlated with an increased risk of complication (NSQIP-FI 0.18 vs. 0.0, odds ratio 2.8, 95% confidence interval 1.8–3.0) in a retrospective cohort study by Suskind et al. comparing obliterative and reconstructive POP surgery (2017). , in a population-based study, showed that, although complications increase in subjects over 80 years of age, obliterative procedures had fewer major adverse events than reconstructive procedures. In contrast, reported more postoperative complications (5%) in patients who undergo vaginal obliterative surgery in comparison to other vaginal or abdominal procedures (3.0% vs. 3.0%; P = .71). The trends noted in this NSQIP database analysis of 33,416 patients are likely the result of increased age and morbidity in patients who undergo obliterative procedures.


Total colpectomy and colpocleisis


In patients with posthysterectomy 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 ( ). A study by reported higher preoperative and postoperative risks in patients who underwent colpocleisis with concomitant vaginal hysterectomy. The retrospective chart review used Current Procedural Terminology codes to categorize patients into three groups: partial or complete vaginectomy/colpectomy, vaginal hysterectomy with total or partial colpectomy, and Le Fort colpocleisis. Concomitant vaginal hysterectomy was associated with longer mean operating times (144 vs. 108 vs. 111 minutes, P = .0001) and higher estimated blood loss (253 vs. 135 vs. 146 mL, P = .0001), independent of age, body mass index, or comorbidities.


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



Nov 27, 2021 | Posted by in GYNECOLOGY | Comments Off on Obliterative procedures for pelvic organ prolapse
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