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Outcome of Colpocleisis : A Ten year case series. Dr Satya Duvvur (S T6) Dr Sangeeta Jha (ST5) Dr Hima Vemulapalli (SPR) Mr G. Constantine Consultant O& G Good Hope Hospital. Total colpocleisis. The removal of the majority of the vaginal epithelium

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outcome of colpocleisis a ten year case series

Outcome of Colpocleisis: A Ten year case series

Dr Satya Duvvur (S T6)

Dr Sangeeta Jha (ST5)

Dr Hima Vemulapalli (SPR)

Mr G. Constantine Consultant O& G

Good Hope Hospital

total colpocleisis
Total colpocleisis
  • The removal of the majority of the vaginal epithelium

from within the hymenal ring posteriorly, and to within 0.5 [5] – 2.0 [6] cm of the external urethral meatus anteriorly.

partial colpocleisis
Partial colpocleisis
  • technique of leaving some portion of the vaginal epithelium in place, providing drainage tracts for cervical or other upper genital discharge
  • Other terms used to describe these procedures include total or partial colpectomy.
background
Background
  • Frail women with stage 3 or 4 pelvic organ prolapse, recurrent prolapse, medically complex patients who don’t wish to preserve coital ability are candidates for colpocleisis
  • On the matter of self image, colpocleisis eliminates prolapse, reduces genital hiatus and may improve the appearance of the external genital area.
advantages
Advantages
  • A short operating time
  • Few complications
  • Speedy recovery
  • High success rate
  • Low rate of regret
  • Efficacy rate > 90%
disadvantages
Disadvantages
  • Problems with self image
  • De novo or worsening urinary incontinence
  • May delay the diagnosis of cervical and endometrial pathology in partial colpocleisis
relative contraindications where the procedure might be difficult
Relative Contraindications (where the procedure might be difficult)
  • Previous colposuspension
  • Previous sacrospinous fixation
  • Previous proctocolectomy
video
Video
  • Le forts partial colpocleisis
video10
Video
  • Complete colpocleisis
audit
Audit
  • Retrospective audit
  • 10 years (Jan 2000 to Dec 2010)
  • Retrospective review of case notes
  • Patient data obtained from i care
  • Questionnaires posted to patients
  • Data analysed by spreadsheet
audit12
Audit
  • Total number of patients 85
  • Number deceased 10
  • Memory loss 2
  • Total questionnaires sent 75
  • Responses received 52
  • Percentage of responses received 70%
data n 85
Data (n-85)
  • Age: Median age 74.5 yrs
  • Previous hysterectomy : 46
data n 8514
Data (n= 85)
  • Current prolapse: 85

Procidentia 15

Vault 30

Cystocele 25

Rectocele 13

2nd degree cx descent 3

data n 8515
Data (n-85)
  • Previous prolapse surgery 20
  • Procidentia 5
  • Posterior repair 10
  • Anterior repair-5
data n 8516
Data (n-85)
  • Bladder Symptoms: 44
  • Urgency,UI 24
  • SI 35
  • Freq, nocturia 8
  • Voiding problems 4
data n 8517
Data (n-85)
  • Bowel symptoms: 4
  • Rectal prolapse 2
  • IBS 2
data n 8518
Data (n-85)
  • Additional procedures 45
  • TVT: 5
  • TOT: 12
  • TVTO: 28
results n 52
Results (n-52)

A) Any problems immediately following the operation:

Yes 8

No 44

Reasons:

UTI 6

Extreme incontinence 1

Discomfort 1

longer term problems
Longer term problems
  • 1) Any bleeding from vagina after leaving the clinic:

Yes 1

No 51

brownish loss which resolved spontaneously

  • 2) Any bladder problems:

Yes 26

No 26

Urgency,UI-15 ; SI-7; Nocturia-1; UTI-2

longer term problems21
Longer term problems
  • Any bowel problems:

Yes 13

No 39

Reasons:

  • Constipation- 5
  • Diarrhea 3
  • No control 2
  • Constipation alternating with diarrhea 3
results
Results
  • Any recurrence of prolapse:

Yes 0

No 52

  • Any regrets:

Yes 1

No response 1

No 50

discussion
Discussion
  • All early reports of colpocleisis emanate from Europe.
  • The earliest report of colpocleisis is probably that of Geradin, who in 1823 [11] suggested denuding portions

of the anterior and posterior vagina at the introitus and suturing them.

  • However, he did not perform this technique himself.
discussion24
Discussion
  • In 1867, Neugebauer denuded an area approximately 3·6 cm on the anterior and posterior vagina near the introitus and sutured them together at a higher level in the vagina, but did not publish this technique until 1881
  • The first report of colpocleisis in the USA was by

Berlin [14] who reported three cases in 1881

discussion25
Discussion
  • The evolution of the current modern techniques began with LeFort’s publication of colpocleisis technique in 1877 [13].
  • He hypothesized that if it were possible to hold the vaginal walls in apposition, it would be possible to prevent uterine prolapse.
  • Therefore, his first operation was done in two stages, with a perineorrhaphy performed 8 days after the colpocleisis.
discussion26
Discussion
  • Subsequent case reportof the LeFort technique included modifications such as
  • making the lateral channels smaller to allow greater

apposition of the anterior and posterior vagina and to prevent recurrent prolapse [10],

  • use of different suture material [7], plication of the levator ani muscle and fascia in the midline along with perineorrhaphy [6],
  • cervical amputation [15], and attention to vaginal dissection toward the external urethral meatus.
discussion27
Discussion
  • Hanson [30] has published the largest colpocleisis series to date, describing their cohort in 288 patients who underwent partial colpocleisis between 1932 and 1956.
  • Of the 216(75%) with follow-up available, ‘‘the majority’’ was followed at least 5 years after their operation.
  • In three (1%) patients, complete recurrence of prolapse occurred 2 weeks – 5 months after surgery and was treated with repeat LeFort procedures.
  • Lesser degrees of prolapserecurrenced in ten (5%) other patients, only one of whom underwent reoperation.
discussion28
Discussion
  • Overall, 92% of patients judged themselves as having had ‘‘good or excellent’’.
  • long-term results, while 7% judged themselves to be only slightly improved or no better.
  • One patient developed endometrial cancer 3 years after colpocleisis and was treated with intracavitary radium.
discussion29
Discussion
  • In 1981, Goldman [31] described outcomes in 118 women undergoing LeFort colpocleisis. Mean hospital stay was 8 days, and postoperatively ‘‘good anatomic results’’ were found in 91% of patients.
  • Complete recurrence of prolapse was reported in one (1%) patient and partial recurrence in two patients.
discussion30
Discussion
  • DeLancey and Morley [32] reported results of their technique of total colpocleisis in 33 women who were on an average of 34 months from their surgery.
  • All women were initially cured (not defined), although recurrent eversion developed in one woman (3%) 1 year after surgery.
discussion31
Discussion
  • Von Pechmann [24] described results in 92 patients, who underwent total colpocleisis with high levator plication between 1988 and 2000.
  • objective cure defined as lack of prolapse to the hymen, 90 (98%) patients were cured, 0–64 months (median 12 months)
  • after surgery with just one patient requiring reoperation.
  • They noted new rectal prolapse in two (2%) patientswithin 6 months of colpocleisis
discussion32
Discussion
  • FitzGerald [33] reviewed outcomes in 64 women, who underwent partial colpocleisis (technique similar to LeFort’s) with perineorrhaphy between 2000 and 2002.
  • When evaluated 2–56 (median 12) weeks later, two

(3%) patients had some recurrence of their prolapse beyond the hymen, one patient experiencing complete

recurrence of her Stage 4 prolapse 15 months after

surgery.

major complications
Major Complications
  • Mainly related to age cardiac, pulmonary, and cerebrovascular complications occur at a rate of approximately 2%.
  • Major complications due to the surgical procedure itself (including transfusion and pyelonephritis) occur at a rate of approximately 4% and are related to concomitant hysterectomy
minor complications
Minor Complications
  • UTI,
  • vaginal hematomata,
  • stress incontenance,
  • urge incontenance ,
  • posterior vaginal prolapse,
  • cystotomy,
  • fever.
complications
Complications
  • Urinary incontinence has been reported as a common complication after colpectomy
  • Hoffman reported that mixed incontinence was a new symptom in three of 27 (11%) patients, who had either no urinary symptoms or urinary retention before colpocleisis.
  • Hanson [30] reported new incontinence or worsening of pre-existing incontinence in 22 of 288 (7%) patients
complications36
Complications
  • Very little has been written on the topic of management of recurrent prolapse after prior colpocleisis.
  • Those series that do mention it, report that the patient was cured of her prolapse by repeating the colpocleisis procedure [30, 32] or by performing perineorrhaphy.
bowel function after colpocleisis
Bowel function after colpocleisis
  • No studies report the effect of colpocleisis on bowel function. Von Pechmann [24] reports a new onset of rectal prolapse soon after colpocleisis in two patients.
  • No further information is provided to help us interpret whether those rectal prolapse cases were undiagnosed preoperatively and became newly symptomatic after

surgery, or were truly of new onset after surgery.

regret after colpocleisis
Regret after colpocleisis
  • There are some reports of regret after colpocleisis, although few studies address this topic.
  • In Urbach’s [8] series of 141 colpocleisis patients, there were two women requesting ‘‘restoration of cohabitation’’, one of whom achieved this using vaginal dilation. Four others who had agreed to colpocleisis stated their husbands regretted consenting to the procedure.
  • There was no relationship between age and later regret.
discussion39
Discussion
  • Recent statistics highlight the aging of the population in general particularly in western world.
  • In 1900, just 3.1 million Americans were aged over 65 years, with 0.1 million aged over 85 years.
  • By 1950,there were 12.3 million Americans over 65 and 0.6 million over 85 years.
  • Currently approximately 40 million Americans are over 65 years of age and 6 million are over 85 years age.
conclusions
Conclusions
  • Very effective and safe procedure
  • Efficacy rates nearly 100% with no evidence of recurrence
  • No long term major complications
  • Improvement in bladder symptoms
  • Regret rate is very low
recommendations
Recommendations
  • Easy procedure to learn
  • Careful documented pre-op counselling is mandatory
  • More emphasis on training
  • Important to understand and learn this procedure as persistently increase in elderly population requiring colpocleisis.
  • To include the procedure for competency in the Urogynaecology ATSM
references
References
  • 1. US Government (2000) Federal Interagency Forum on Aging
  • Related Statistics, in Older Americans 2000. Key indicators of
  • well being
  • 2. US Department of Commerce (1998) Statistical abstract of the
  • United States, in The National Data Book
  • 3. Boyles SH, Weber AM, Meyn L (2003) Procedures for pelvic
  • organ prolapse in the United States, 1979–1997. Am J Obstet
  • Gynecol 188:108–115
  • 4. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL
  • (1997) Epidemiology of surgically managed pelvic organ prolapse
  • and urinary incontinence. ObstetGynecol 89:501–506
references43
References
  • 5. Thompson HG, Murphy CJ Jr, Picot H (1961) Hysterocolpectomy
  • for the treatment of uterine procidentia. Am J Obstet
  • Gynecol 82:748–751
  • 6. Rubovits W, Litt S (1935) Colpocleisis in the treatment of
  • uterine and vaginal prolapse. Am J ObstetGynecol 29:222–
  • 230
  • 7. Wyatt J (1912) Le Fort’s operation for prolapse, with an
  • account of eight cases. J ObstetGynaecol Br Emp 22:266–
  • 269
  • 8. Ubachs JM, van Sante TJ, Schellekens LA (1973) Partial colpocleisis
  • by a modification of LeFort’s operation. Obstet
  • Gynecol 42:415–420
  • 9. Bradbury WC (1963) Subtotal vaginectomy. Am J Obstet