Pelvic organ prolapse is a common condition, the incidence of which increases with age.¹ By the age of 80 years, 12.6% of women from the United States undergo surgery for pelvic floor disorders²; 61% of these surgeries include correction for pelvic organ prolapse.³ As the elderly population continues to increase, the number of patients seeking treatment for pelvic organ prolapse will also increase, including those who do not wish to maintain the ability to have vaginal intercourse. Female pelvic medicine and reconstructive surgeons should therefore be comfortable discussing obliterative procedures such as a LeFort colpocleisis or colpocleisis with hysterectomy.

Throughout history, women have endured advanced pelvic organ prolapse. Early attempts at treatment included vaginal packing, crude pessaries, and instillation of caustic materials. Hippocrates describes a process called succussion, a technique to reduce prolapse by hanging the patient upside down to invert the prolapse back into the pelvis (Fig. 49.1).⁴ Initial methods of surgical management involved amputation of the prolapsing segments or closure of the vaginal introitus⁵ with morbid results.

The idea to surgically obliterate severe prolapse is credited to Gerardin,⁶ who suggested suturing surgically denuded anterior and posterior vaginal walls together. Although he described the technique in 1823, he never attempted the procedure. Subsequently, the first known procedure was performed in 1867 by Neugebauer,⁷ who waited until 1881 to publish his technique. Neugebauer⁷ obliterated the vagina by denuding 6 × 3 cm anterior and posterior areas proximal to the introitus and suturing them together. The French surgeon Léon Clément LeFort⁸ published his technique first in 1877 (Fig. 49.2). LeFort modifications differed in that longer and narrower areas of denudation were performed and that a colpoperineoplasty was performed 8 days after the colpocleisis to address the widened genital hiatus. In general, an obliterative procedure in which the lateral vaginal epithelium remains in situ forming bilateral drainage tunnels is referred to as a partial, or LeFort colpocleisis, but a less common eponym is the Neugebauer-LeFort procedure. Edebohls,⁹,¹⁰ in 1901, was the first to report performing a total colpocleisis with levator myorrhaphy following hysterectomy (i.e., panhysterocolpectomy). His report was followed by several case series that had comparable results to the partial colpocleisis-type procedures.¹¹ Although adoption of colpocleisis procedures was slow in the United States, in 1880, Berlin¹² reported a series of three cases (one of which failed) in the New England Hospital. The failure was blamed on lack of a concurrent perineorrhaphy.

To make colpocleisis a more accepted treatment option, early modifications were directed at reducing the recurrence risk and the incidence of postoperative urinary incontinence, which was as high as 25%.¹³ Urinary incontinence was attributed to scarring from the distal dissection and distortion of the bladder neck. Other authors addressed postoperative urinary incontinence by sparing the distal vagina near the urethra or by supporting the bladder neck.⁵,¹⁴,¹⁵,¹⁶,¹⁷,¹⁸ Goodall and Power¹⁹ in 1937 tried to preserve sexual function by creating a triangular recess higher in the vagina that would allow for intercourse and potentially minimize stress urinary incontinence.

As a result of the many modifications to the colpocleisis, the American Urogynecologic Society and the International Urogynecological Association created standardized terminology for obliterative procedures. The term colpectomy has been used synonymously with colpocleisis for posthysterectomy vaginal vault prolapse. It specifically refers to the complete removal of the vaginal epithelium. Per the new standardized terminology, the terms colpocleisis without hysterectomy, colpocleisis of vaginal vault, and colpocleisis with hysterectomy is used throughout the remainder of this chapter. A LeFort
colpocleisis is a term used to describe a colpocleisis without hysterectomy. It requires the obliteration of the vaginal canal by removal of panels of vaginal epithelium on the anterior and posterior vaginal walls and suturing together the fibromuscular layers of the anterior and posterior vagina with creation of bilateral tunnels from the cervix to the introitus.²⁰ When patients have a concurrent or history of a hysterectomy, a colpocleisis with hysterectomy or colpocleisis of the vaginal vault is performed.

Colpocleisis is an effective treatment for those who no longer desire vaginal intercourse. In a multicenter study by Crisp et al.,²¹ colpocleisis positively impacted bowel, bladder, and prolapse symptoms, with high satisfaction and low levels of regret. Outcome assessments repeatedly report 90% to 100% success for treatment of symptomatic pelvic organ prolapse.²² In one retrospective cohort study of women who underwent LeFort colpocleisis, 94.3% were satisfied with the outcome. After a median follow-up of 5 years, none of the women in the cohort had prolapse recurrence.²³ In 2017, a retrospective study was conducted to evaluate the impact of LeFort colpocleisis on body image, regret, and pelvic floor symptoms long term after surgery. At a median follow-up of 3 years, 97% of the patients were satisfied with their surgery and none regretted their decision to proceed with colpocleisis.²⁴ Body image was assessed using the modified Body Image Scale (BIS), a tool validated for subjects with pelvic organ prolapse.²⁵ The mean and total body image scores improved significantly postoperatively (P < .001).²⁴

Traditionally, colpocleisis has been reserved for older patient populations with multiple comorbidities. However, it may be an ideal surgery for anyone who no longer desires vaginal penetrative intercourse and/or has significant medical comorbidities and does not tolerate or desire a pessary. The preoperative assessment of patients includes informed consent, a discussion of patient goals, history, physical exam, and evaluation of urinary dysfunction such as incontinence or retention. The actual procedure may be conducted under local, general, or regional anesthesia after an assessment of the patient’s anesthesia risk. Enhanced Recovery after Surgery (ERAS) pathways are encouraged because elderly patients are particularly sensitive to fluid imbalances, falls, and opioid side effects. Such pathways include preoperative counseling, no bowel preparation, an opioid-sparing multimodal approach to pain management, goal-directed fluid management, and early mobilization and feeding.²⁶