The Le Fort ColpocleisisThe Le Fort Colpocleisis

..

Learning ObjectivesLearning Objectives

• The participant should be able to describe the risks and benefits of colpocleisis .

• The participant should be able to list the indications for colpocleisis and discuss the advantages in selected patients.

• Participants will understand the indications and efficacy of incontinence procedures performed at the time of colpocleisis.

DefinitionsDefinitions

COLPOCLEISIS

* The surgical closure of the vaginal canal

Colpectomy (total colpocleisis)

* The surgical excision of the vagina

Obliterative Genital ProceduresObliterative Genital Procedures

• These procedures are often thought of as “destructive”, but can be extremely helpful, and should be in the armamentarium of every pelvic reconstructive surgeon.

Cespedes (Tech Urol 2001)

BackgroundBackground

• Millions of older women are prevented from living full active lives because of symptoms caused by pelvic organ prolapse.

• A significant percentage are poor candidates for definitive pelvic reconstructive procedures.

• There are over four million women in the U. S. greater than 85 years of age, and that number is expected to increase dramatically.

Reasons for Choosing ColpocleisisReasons for Choosing Colpocleisis

• Severe medical conditions

• Advanced age

• Fear of major surgery

• The need to provide care for a debilitated spouse

( Young. J. Pelvic Med.2004)

EuryphoneEuryphone

Al Al RaziRazi 864-930 CE 864-930 CE

Recent HistoryRecent History

• The idea was first proposed by Gerardin of Metz in 1823.

• The operation was first performed by Neugebauer of Warsaw in 1867.

• In 1876, Le Fort of Paris modified the Gerardin idea based on his observation that prolapse did not occur in cases of congenital septum of the vagina.

Colpocleisis ProceduresColpocleisis Procedures

Le Fort — a narrow strip of central vaginal epithelium removed

Neugebauer -- 6x3 cm strip, 3 cm proximal to the urethral meatus

Goodall-Power -- proximal third of the vagina (enabled coitus)

Cusier -- lateral excision— (enabled coitus) Extended Colpoperineorrhaphy--- Young (2004)

Colpectomy ProceduresColpectomy Procedures(Total Colpocleisis)(Total Colpocleisis)

* Harmanli ---- 2003

• DeLancey ---- 1997

IndicationsIndications

• Severe, symptomatic pelvic organ prolapse

• Failure of conservative measures (pessary)

• No desire for future vaginal coitus

• When a definitive procedure for POP with little risk of recurrence and minimal associated morbidity is desired

Pre Operative PrecautionsPre Operative Precautions

• Document normal cervix and endometrium (Pap, endometrial biopsy, sonogram)

• Cystometry with prolapse reduced (Veronikus 1997, found SUI in 83% and ISD in 56%)

• Consider IVP or Renal Sonography with severe prolapse (greater than stage III)

• Rectal prolapse?

AdvantagesAdvantages

• The advantage of this technique over sacrospinous ligament suspension and sacral colpopexy lies in the fact that damage to adjacent organs and major pelvic vessels and nerves is unlikely with colpocleisis. Because the plane of dissection is superficial, collateral organ damage is highly unlikely.

DeLancey-1997

Blood LossBlood Loss

• The blood loss incurred during colpocleisis is typically gradual and easily controlled, producing less stress on a weakened myocardium than the acute hemorrhage that can occur during reconstructive procedures such as sacral colpopexy or sacrospinous ligament fixatiion.

von Pechmann (2003)

Good, Fast, CheapGood, Fast, Cheap

Success Rates: (Good?)

Colpocleisis: good anatomic results --- 85-97%

relief of symptoms --- 86-93% recurrence of prolapse – 0-3%

Colpectomy: good anatomic results --- 89-100% relief of symptoms ------ 97-100% recurrence of prolapse -- 0-3%

Blood LossBlood Loss

• Miklos (1995) --- 153 cc

• Davila (2003) --- <100 cc

• Von Pechmann (2003)--- 396 cc

Fast and Cheap ?Fast and Cheap ?

0PERATING TIME• Miklos (1995) --- 55 minutes• Davila (2003 --- 36 minutes

HOSPITALIZATIONDavila ---- 36 hrsMiklos ---- 2.1days

EXPENSELocal anesthesia results in considerable expense reduction (Kaye, Clin Geriatric Med. 1990)

DisadvantagesDisadvantages

• Loss of coital ability:

* One third of women over the age of 78 remain sexually active ( Rogers,2003)

* 3% regretted loss of coital ability ( von Pechmann ) • Altered Body Image ? * QOL scores improved--- (Neimark,2003)

“The pleasure is momentary, the position ridiculous, and the expense damnable.”

Lord Chesterfield (1674-1773)

New Onset Urinary New Onset Urinary IncontinenceIncontinence

• Fitzgerald (2003) -- 16%• Goldman (1985) -- 10.2%• Harmanli (2003) -- 22% Reason ? Anatomic displacement (unkinking) of the urethrovesical

junction ?

• Von Pechmann performed some method of urethral support in 98% of those undergoing colpocleisis

Ureteral OcclusionUreteral Occlusion

• Colpocleisis with levator plication---1.8% had post operative ureteral occlusion

• Colpocleisis with levator plication and Vaginal Hysterectomy----- 8.1% had ureteral occlusion

(von Pechman)

Hydronephrosis with Stage III POPHydronephrosis with Stage III POP

• One site -- 10%

• Two sites -- 20.3%

• Three sites -- 34.6%

( Beverly, 1997)

Vaginal BleedingVaginal Bleeding(with the uterus left in place)(with the uterus left in place)

* Late vaginal bleeding occurred in 1.8 %

(Goldman,1985)

* Cervical and endometrial cancer are rare.

(less than one percent)

(Reddy, 1972)

Genital Malignancies in Women Genital Malignancies in Women greater than 70 years of agegreater than 70 years of age

Uterine cancer (all types)- 4.6 per 1,000

Cervical Cancer --- 0.6 per 1,000

Can Ques, (2005)

Concurrent ProceduresConcurrent Procedures

* Anti incontinence procedures

* Rectocele repair

* Enterocele repair

* Perineoplasty

Concurrent Incontinence SurgeryConcurrent Incontinence Surgery

Prevention of post operative stress incontinence must be balanced with the avoidance of disabling detrusor instability or urinary retention, as medical therapy may not improve symptoms, and urethrolysis after colpocleisis may be difficult. Additionally many patients will be unable to perform intermittent self catheterization.

Urinary Complications of Severe Urinary Complications of Severe CystoceleCystocele

Baden-Walker Grade 1-2 Grade 3-4

Bladder outlet 6% 70% Obstruction ( reduced 25%)

Detrusor 20% 54%Overactivity

ImpairedDetrusor Contractions 14% 13% Chaikin, 1998

Evaluation before Incontinence Evaluation before Incontinence ProceduresProcedures

• Because elderly patients with severe pelvic organ prolapse have a significant incidence of voiding dysfunction, including bladder outlet obstruction and inadequate detrusor contractions, multi channel urodynamic evaluations, including voiding studies, with the prolapse reduced, should be considered before choosing a surgical procedure.

The Colpocleisis Procedure is:The Colpocleisis Procedure is:

• Safe• Effective• Fast• Requires minimal anesthesia• Has rapid recovery

• Colpocleisis may be the ideal surgical procedure for the medically compromised patient with no present or future desire for coitus.

Suggested ReadingSuggested Reading

• Adair FL, DaSef L. The Le Fort Colpocleisis. Am J Obstet Gynecol 32:218-226,1936

• Cespedes RD. Colpocleisis for the treatment of vaginal vault prolapse. Tech Urol. 7:152-160,2001

• Grody T, Merchia V, Nyirjesy P. Total colpoclieisis: a prospective study. J Pelvic Surg.7: 72-78,2001.

• Moore RD, Miklos J. Colpocleisis and tension –free vaginal tape sling for severe uterine and vaginal prolapse and stress urinary incontinence under local anesthesia. J Am Assoc Gynecol laporosc. 10 (2):276-280,2003.