Presentation on theme: "Outcome of Colpocleisis: A Ten year case series"— Presentation transcript:
1Outcome 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& GGood Hope Hospital
2Total colpocleisisThe removal of the majority of the vaginal epitheliumfrom within the hymenal ring posteriorly, and to within 0.5  – 2.0  cm of the external urethral meatus anteriorly.
3Partial colpocleisistechnique of leaving some portion of the vaginal epithelium in place, providing drainage tracts for cervical or other upper genital dischargeOther terms used to describe these procedures include total or partial colpectomy.
4BackgroundFrail 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 colpocleisisOn the matter of self image, colpocleisis eliminates prolapse, reduces genital hiatus and may improve the appearance of the external genital area.
5Advantages A short operating time Few complications Speedy recovery High success rateLow rate of regretEfficacy rate > 90%
6Disadvantages Problems with self image De novo or worsening urinary incontinenceMay delay the diagnosis of cervical and endometrial pathology in partial colpocleisis
7Relative Contraindications (where the procedure might be difficult) Previous colposuspensionPrevious sacrospinous fixationPrevious proctocolectomy
19Results (n-52) A) Any problems immediately following the operation: YesNoReasons:UTIExtreme incontinence 1Discomfort
20Longer term problems1) Any bleeding from vagina after leaving the clinic:YesNobrownish loss which resolved spontaneously2) Any bladder problems:YesNoUrgency,UI-15 ; SI-7; Nocturia-1; UTI-2
21Longer term problems Any bowel problems: Yes 13 No 39 Reasons: ConstipationDiarrheaNo controlConstipation alternating with diarrhea 3
22Results Any recurrence of prolapse: Yes 0 No 52 Any regrets: Yes 1 No responseNo
23Discussion All early reports of colpocleisis emanate from Europe. The earliest report of colpocleisis is probably that of Geradin, who in 1823  suggested denuding portionsof the anterior and posterior vagina at the introitus and suturing them.However, he did not perform this technique himself.
24DiscussionIn 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 1881The first report of colpocleisis in the USA was byBerlin  who reported three cases in 1881
25DiscussionThe evolution of the current modern techniques began with LeFort’s publication of colpocleisis technique in 1877 .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.
26DiscussionSubsequent case reportof the LeFort technique included modifications such asmaking the lateral channels smaller to allow greaterapposition of the anterior and posterior vagina and to prevent recurrent prolapse ,use of different suture material , plication of the levator ani muscle and fascia in the midline along with perineorrhaphy ,cervical amputation , and attention to vaginal dissection toward the external urethral meatus.
27DiscussionHanson  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 prolapse recurrenced in ten (5%) other patients, only one of whom underwent reoperation.
28DiscussionOverall, 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.
29DiscussionIn 1981, Goldman  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.
30DiscussionDeLancey and Morley  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.
31DiscussionVon Pechmann  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
32DiscussionFitzGerald  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 completerecurrence of her Stage 4 prolapse 15 months aftersurgery.
33Major ComplicationsMainly 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
35ComplicationsUrinary incontinence has been reported as a common complication after colpectomyHoffman 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  reported new incontinence or worsening of pre-existing incontinence in 22 of 288 (7%) patients
36ComplicationsVery 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.
37Bowel function after colpocleisis No studies report the effect of colpocleisis on bowel function. Von Pechmann  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 aftersurgery, or were truly of new onset after surgery.
38Regret after colpocleisis There are some reports of regret after colpocleisis, although few studies address this topic.In Urbach’s  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.
39DiscussionRecent 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.
40Conclusions Very effective and safe procedure Efficacy rates nearly 100% with no evidence of recurrenceNo long term major complicationsImprovement in bladder symptomsRegret rate is very low
41Recommendations Easy procedure to learn Careful documented pre-op counselling is mandatoryMore emphasis on trainingImportant to understand and learn this procedure as persistently increase in elderly population requiring colpocleisis.To include the procedure for competency in the Urogynaecology ATSM
42References 1. US Government (2000) Federal Interagency Forum on Aging Related Statistics, in Older Americans Key indicators ofwell being2. US Department of Commerce (1998) Statistical abstract of theUnited States, in The National Data Book3. Boyles SH, Weber AM, Meyn L (2003) Procedures for pelvicorgan prolapse in the United States, 1979–1997. Am J ObstetGynecol 188:108–1154. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL(1997) Epidemiology of surgically managed pelvic organ prolapseand urinary incontinence. Obstet Gynecol 89:501–506
43References5. Thompson HG, Murphy CJ Jr, Picot H (1961) Hysterocolpectomyfor the treatment of uterine procidentia. Am J ObstetGynecol 82:748–7516. Rubovits W, Litt S (1935) Colpocleisis in the treatment ofuterine and vaginal prolapse. Am J Obstet Gynecol 29:222–2307. Wyatt J (1912) Le Fort’s operation for prolapse, with anaccount of eight cases. J Obstet Gynaecol Br Emp 22:266–2698. Ubachs JM, van Sante TJ, Schellekens LA (1973) Partial colpocleisisby a modification of LeFort’s operation. ObstetGynecol 42:415–4209. Bradbury WC (1963) Subtotal vaginectomy. Am J Obstet