Review Colpocleisis revisited

Transcription

1 The Obstetrician & Gynaecologist /toag Colpocleisis revisited Authors Pallavi M Latthe / Kamakshi Karri / AS Arunkalaivanan Key content: Colpocleisis is used to treat advanced pelvic organ prolapse in older women who are too frail for conventional surgery and who are no longer sexually active. It is quick, easy, effective and associated with low recurrence rates and high patient satisfaction. Other procedures can be performed concomitantly for stress urinary incontinence and deficient perineum. Learning objectives: To understand the indications, alternatives, advantages and procedure of colpocleisis. To review the available data on effectiveness and complications. Ethical issues: Is colpocleisis an appropriate choice in sexually inactive women under 70 years in whom other corrective procedures have failed? Keywords colpectomy / colpocleisis / vault prolapse Please cite this article as: Latthe PM, Karri K, Arunkalaivanan AS. Colpocleisis revisited. The Obstetrician & Gynaecologist. Author details Pallavi M Latthe MD MRCOG Subspecialty Trainee in Urogynaecology Birmingham Women s Hospital, Metchley Park Road, Edgbaston, Birmingham B15 2TG, UK Kamakshi Karri MRCOG Specialist Registrar in Obstetrics and Gynaecology Birmingham Women s Hospital, Metchley Park Road, Edgbaston, Birmingham B15 2TG, UK Angamuthu S Arunkalaivanan MD MRCOG Honorary Senior Lecturer (University of Birmingham) and Consultant Urogynaecologist and Obstetrician City Hospital, Dudley Road, Birmingham B18 7QH, UK anga.arunkalaivanan@swbh.nhs.uk (corresponding author) 133

2 The Obstetrician & Gynaecologist Figure 1 Complete procidentia Introduction Genital prolapse occurs in 37% of women over the age of 80 years. 1 The primary underlying causes are weakness in the supporting connective tissue of the pelvic structures aggravated by age, menopause, multiparity, obstetric trauma and prior surgery and chronically increased abdominal pressure associated with obesity, chronic cough or heavy lifting. 1 Vaginal vault prolapse occurs in % of women who have had hysterectomy. 2 Prolapse encompasses a range of disorders, from asymptomatic altered vaginal anatomy to complete vaginal eversion associated with severe urinary, defaecatory and sexual dysfunction. 3 The main presenting symptom is significant discomfort caused by the associated large mass protruding through the introitus. In very old women, genital prolapse can lead to significant morbidity because of problems with hygiene and increased social isolation. There is a lack of standardisation and routine application of tools to assess pre- and postoperative anatomical and functional outcomes. Patient satisfaction is a major endpoint for surgical success; thus, all aspects of the prolapse pathology and the woman s lifestyle should be considered. The surgeon needs to be well versed and flexible in order to choose the most appropriate operative approach to achieve optimal results for each individual woman. 4 Pelvic organ prolapse, including vault prolapse, can be treated conservatively with a variety of pessaries but they can be associated with ulceration, encrustation or impaction. Depending on the woman s age, sexual activity and comorbidities and the surgeon s expertise, the alternative procedures for vault prolapse available are: abdominal, laparoscopic or robotic sacrocolpopexy uterosacral suspension sacrospinous fixation combined abdominovaginal procedures. Recently, the use of surgical mesh in pelvic floor surgery, including the intravaginal sling, 5 has become increasingly popular because of the high incidence of recurrence with primary repairs without the insertion of surrogate material. However, these are associated with higher morbidity, longer hospital stays and slower recovery rates. An operation for complete procidentia (Figure 1), performed by denuding a portion of the anterior and posterior vaginal walls and suturing them, was first suggested by Gerardin in First performed by Neugebauer in 1867 and published by Le Fort in 1877, colpectomy and colpocleisis had been considered obsolete. However, in recent years these operations have been re-evaluated; they are again being performed by gynaecological surgeons for genital prolapse in elderly women where prolonged reconstructive surgery or general anaesthesia may be contraindicated or when everything else has failed. Types of colpocleisis Total If ulcers and atrophy are present, our personal practice is to administer topical estrogen to heal the epithelium prior to surgery. If healing does not occur, colpocleisis is carried out after infection in the ulcerated area has been cleared: these areas are excised during the operation. Intraoperative antibiotic prophylaxis to reduce the risk of postoperative infection is advised, as with any vaginal surgery. The surgical procedure (Figures 2 6) consists of stripping the vaginal epithelium from the underlying fascia and suturing the vaginal cavity to close it. A superficial circumscribing incision is made through the vaginal epithelium at the base of the prolapse at a level adjacent to the hymenal ring. The entire vaginal epithelium up to 2 cm from the urethral meatus is mobilised by sharp dissection except for 1 2 cm strips near the vault. The prolapse is serially reduced with absorbable sutures placed into the vaginal muscularis, beginning at the leading edge of the prolapse and continuing sequentially in interrupted purse-string fashion, or with interrupted sutures placed in an anteroposterior direction, until the prolapsed tissues are superior to the level of the levator plate. Colpocleisis will close the potential space into 134

3 TOG10_3_ qxd 6/30/08 7:30 PM Page 135 The Obstetrician & Gynaecologist which the enterocele might protrude, so the enterocele does not need to be opened or repaired. Once the majority of the prolapse is reduced, the support of the vesical neck can be improved where necessary. In the caudal portion of the vagina, just above the hymenal ring, the dense connective tissue attached to the levator ani muscles and perineal membrane is closed with the lowest suture to lend firm closure of the pelvic floor. The procedure is completed by closing the anterior vaginal epithelium to the posterior epithelium with interrupted sutures at the level of the introitus. When a perineorrhaphy is performed, it is done just before the epithelium is closed off. Figure 2 A rectangular strip of vagina is removed anteriorly Partial This procedure is performed in women with an intact uterus and prolapse, to allow expulsion of discharge from the uterus. Rectangular strips of vaginal epithelium of approximately equal size are removed from the anterior and posterior surfaces of the protruding vagina, leaving a canal of approximately 3 cm at each side. Care is taken not to remove vaginal epithelium from the area beneath the urethra. The anterior and posterior surfaces are approximated to each other with rows of interrupted stitches, resulting in a lateral tunnel on each side, which communicate at the vault across the front of the cervix. Figure 3 A rectangular strip of the vaginal epithelium is removed posteriorly Anaesthesia and operating time General anaesthesia can be administered when concomitant procedures are carried out.6 Colpocleisis can also be performed under local7,8 as well as regional anaesthesia. The mean hospital stay is reported to be 1 5 days.7,8 The mean operative time is longer if additional operations (for example, perineorrhaphy, paravaginal repair, insertion of tension-free vaginal tape or hysterectomy) are performed. Literature review of effectiveness In October 2006 a literature search of Medline and EMBASE was conducted using the terms colpocleisis, colpectomy, pelvic organ prolapse, and vaginal vault prolapse and surgery. No controlled studies were identified. The overall quality of reported studies was poor, with no formal assessment of quality-of-life measures. Reports from the first half of the 20th century were primarily descriptions of technique, with little emphasis on outcomes. The first report was of four cases of panhysterokolpectomy in which vaginal hysterectomy, vaginectomy and purse-string reduction of the remaining viscera were performed.9 In the first half of the 20th century there were reports of modification of the technique Although no recurrences were reported in these early series, outcomes were typically described as satisfactory. In 1972, Pratt13 reviewed 41 out of 58 cases of colpocleisis and identified no instances of recurrence. In a series of 33 women with post-hysterectomy prolapse who underwent vaginectomy and levator plication, there was one case of recurrence identified after a mean objective follow-up time of 7.7 months and mean subjective follow-up of 34.6 months.14 In a 24-month follow-up15 of 38 women who 135

4 TOG10_3_ qxd 6/30/08 7:30 PM Page 136 The Obstetrician & Gynaecologist very satisfied on telephone interview, with a 97.8% subjective cure at 24-month follow-up. Some series have reported satisfaction rates as low as 83%.17 Of the 30 women who underwent colpocleisis with pubovaginal sling for stress urinary incontinence, 94% were cured of their incontinence and 3 subsequently underwent further surgery for minor prolapse.8 In a case series of 41 women, all of whom had perineorrhaphy and colpocleisis along with concomitant vaginal hysterectomy (n 12) and modified paravaginalcystourethropexy (n 31) no recurrence was observed; there was a very low complication rate at a mean follow-up interval of 28.7 months.6 In a series of 188 women18 with complete procidentia, reported in 1981, good anatomical results were obtained in 90.7% of them. Figure 4 Cervical sutures are made for the lateral tunnel for the drainage of discharge In 102 cases,19 no recurrence was found and no women had de novo incontinence. To avoid de novo stress incontinence, partial colpocleisis was performed, in which the posterior repair was performed in such a way as to form a pencil-sized vagina. On comparison of Le Fort colpocleisis with Kelly s plication versus vaginal hysterectomy, anterior colporrhaphy and posterior colpoperineoplasty, women in whom colpocleisis was performed were older, their operation time was halved and urological symptoms were ameliorated. Concomitant elective hysterectomy was associated with an increase in blood loss and length of hospital stay, without improvement in outcomes Figure 5 Anteroposterior suturing with PDS I (polydioxanone) (Ethicon, Livingston, UK) to reduce the prolapse Total colpocleisis combined with site-specific reconstructive surgery or so-called multicompartment colpocleisis is an effective and safe treatment. 6,15 There have been reports in the literature of procedures such as the Latzko operation performed concomitantly for vesicovaginal fistula repair along with colpocleisis for stage III pelvic organ prolapse as above.23 It has also been used with good results in women with previous failed vault surgery.14,24 Complications underwent total colpocleisis, there were no reported complications or recurrence and none had regrets about their loss of sexual function. In a retrospective analysis16 of 92 women who had total colpocleisis with high levator plication, 37 of whom also had concomitant hysterectomy, it was observed that concurrent hysterectomy was associated with an increase in changes in hematocrit and transfusion requirement. Women were satisfied or 136 No intraoperative complications have been reported in the literature. Only one woman had a myocardial infarction in the postoperative period and one death was reported from multisystem organ failure unrelated to the colpocleisis.25 Vaginal discharge, postoperative infection and postoperative bleeding requiring resuturing are recognised complications of the Le Fort colpocleisis. As mentioned earlier, de novo symptoms of stress urinary incontinence can appear in up to 27% of previously continent women25 and some advocate that this can be avoided by concomitant use of tension-free vaginal tape.8 Vaginal evisceration is a rare event,26 as are recurrence18 and enterocele. There have been

5 The Obstetrician & Gynaecologist reports of congestive cardiac failure and pulmonary embolism but these complications are not exclusive to colpocleisis. 17 Pyometra or pelvic abscess can sometimes occur in spite of the creation of lateral channels. 27,28 The main disadvantage when postmenopausal bleeding occurs is inaccessibility of the uterus. Occasionally, a woman does regret the loss of vaginal sexual function postoperatively. Figure 6 Completion of colpocleisis Conclusion Elderly women with advanced pelvic organ prolapse, who no longer desire sexual intercourse or are medically unstable, can be treated effectively with colpocleisis. The procedure is simple, short and can be performed under local anaesthesia. It is arguable that urodynamics should be performed prior to surgery to identify occult or evident stress incontinence and concomitant procedures can be carried for incontinence, if necessary. 29 The advantage of total colpocleisis over sacrospinous ligament suspension and sacrocolpopexy is that damage to adjacent organs and major pelvic vessels or nerves is much less likely with this technique. The surgical approach ultimately undertaken depends largely on the wishes of the fully informed patient. The woman s goals and preferences may be more important than standardised objective outcome measures. Whilst there is a clear need to study preand postoperative bowel and urinary function as well as the postoperative quality of life for these women, it must be remembered that most are elderly and participation in such in-depth analysis may simply be too difficult. Whilst the creation of lateral channels affords a natural exit for cervical or uterine secretions, dilatation and curettage and a cervical smear should be performed either at the time of the procedure or in the evaluation of the woman prior to surgery, along with ultrasound imaging of the endometrium to exclude concurrent pathologies. In the minimal surgical intervention associated with colpocleisis, symptomatically optimal results can be obtained with low surgical morbidity and low recurrence. The evidence thus far is mainly from retrospective studies. Randomised clinical trials are required to compare it to other vaginal procedures such as sacrospinous and uterosacral ligament suspension. 30 References 1 Morley GW. Treatment of uterine and vaginal prolapse. Clin Obstet Gynecol 1996;39: doi: / Toozs-Hobson P, Boos K, Cardozo L. Management of vaginal vault prolapse. BrJ Obstet Gynaecol 1998;105: Weber AM, Richter HE. Pelvic organ prolapse. Obstet Gynecol 2005;106: Arbel R, Lavy Y. Vaginal vault prolapse: choice of operation. Best Pract Res Clin Obstet Gynaecol 2005;19: doi: /j.bpobgyn Kim DY, Choi S. Efficacy of posterior IVS for the patients with vaginal vault and uterine prolapse. Korean J Urol 2006;47: Harmanli OH, Dandolu V, Chatwani AJ, Grody MT. Total colpocleisis for severe pelvic organ prolapse. J Reprod Med 2003;48: Ardekany MS, Rafee R. A new modification of colpocleisis for treatment of total procidentia in old age. Int J Gynaecol Obstet 1978;15: Moore RD, Miklos JR. Colpocleisis and tension-free vaginal tape sling for severe uterine and vaginal prolapse and stress urinary incontinence under local anesthesia. J Am Assoc Gynecol Laparosc 2003;10: doi: /s (05) Edebohls GM. Panhysterokolpectomy: a new prolapsus operation. Med Rec NY 1901;60: PhaneufTE. The place of colpectomy in the treatment of uterine and vaginal prolapse. Am J Obstet Gynecol 1935;30: Masson JC, Knepper PA. Vaginectomy. Am J Obstet Gynecol 1938;36: Williams J. Vaginal hysterectomy and colpectomy for prolapse of the uterus and bladder. Am J Obstet Gynecol 1950;59: Ridley JH. Evaluation of the colpocleisis operation: a report of fifty-eight cases. Am J Obstet Gynecol 1972;113: DeLancey JO, Morley GW. Total colpocleisis for vaginal eversion. Am J Obstet Gynecol 1997;176: doi: /s (97) Cespedes RD, Winters JC, Ferguson KH. Colpocleisis for the treatment of vaginal vault prolapse. Tech Urol 2001;7: von Pechmann WS, Mutone M, Fyffe J, Hale DS. Total colpocleisis with high levator plication for the treatment of advanced pelvic organ prolapse. Am J Obstet Gynecol 2003;189: doi: /mob Deval B. Hysterocolpectomy with colpocleisis for massive genital prolapse in women aged over 70 years. EurJ Obstet Gynecol Reprod Biol 2005;123: doi: /j.ejogrb Goldman J, Ovadia J, Feldberg D. The Neugebauer-Le Fort operation: a review of 118 partial colpocleises. EurJ Obstet Gynecol Reprod Biol 1981;12:31 5. doi: / (81) Langmade CF, Oliver JA, Jr. Partial colpocleisis. 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6 The Obstetrician & Gynaecologist 25 FitzGerald MP, Brubaker L. Colpocleisis and urinary incontinence. Am J Obstet Gynecol 2003;189: doi: /s (03) Moore RD, Miklos JR. Repair of a vaginal evisceration following colpocleisis utilizing an allogenic dermal graft. Int Urogynecol J Pelvic FloorDysfunct 2001;12: doi: /pl Roth TM. Pyometra and recurrent prolapse after Le Fort colpocleisis. Int Urogynecol J Pelvic Floor Dysfunct 2007;18: doi: /s z 28 Shobeiri SA. Management of pelvic abscess after Le Fort colpocleisis. Int Urogynecol J Pelvic FloorDysfunct 2006;17: doi: /s z 29 Bergman A, Koonings PP, Ballard CA. Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. Am J Obstet Gynecol 1988;158: Lovatsis D, Drutz P. Vaginal surgical approach to vaginal vault prolapse: considerations of anatomic correction and safety. Curr Opin Obstet Gynecol 2003;15: doi: /