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Outcome of Colpocleisis: A Ten year case series

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1 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

2 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.

3 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.

4 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.

5 Advantages A short operating time Few complications Speedy recovery
High success rate Low rate of regret Efficacy rate > 90%

6 Disadvantages Problems with self image
De novo or worsening urinary incontinence May delay the diagnosis of cervical and endometrial pathology in partial colpocleisis

7 Relative Contraindications (where the procedure might be difficult)
Previous colposuspension Previous sacrospinous fixation Previous proctocolectomy

8 Technique of colpocleisis

9 Video Le forts partial colpocleisis

10 Video Complete colpocleisis

11 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

12 Audit Total number of patients 85 Number deceased 10 Memory loss 2
Total questionnaires sent Responses received Percentage of responses received 70%

13 Data (n-85) Age: Median age 74.5 yrs Previous hysterectomy : 46

14 Data (n= 85) Current prolapse: 85 Procidentia 15 Vault 30 Cystocele 25
Rectocele 2nd degree cx descent 3

15 Data (n-85) Previous prolapse surgery 20 Procidentia 5
Posterior repair Anterior repair-5

16 Data (n-85) Bladder Symptoms: 44 Urgency,UI 24 SI 35 Freq, nocturia 8
Voiding problems 4

17 Data (n-85) Bowel symptoms: 4 Rectal prolapse IBS

18 Data (n-85) Additional procedures 45 TVT: TOT: TVTO: 28

19 Results (n-52) A) Any problems immediately following the operation:
Yes No Reasons: UTI Extreme incontinence 1 Discomfort

20 Longer term problems 1) Any bleeding from vagina after leaving the clinic: Yes No brownish loss which resolved spontaneously 2) Any bladder problems: Yes No Urgency,UI-15 ; SI-7; Nocturia-1; UTI-2

21 Longer term problems Any bowel problems: Yes 13 No 39 Reasons:
Constipation Diarrhea No control Constipation alternating with diarrhea 3

22 Results Any recurrence of prolapse: Yes 0 No 52 Any regrets: Yes 1
No response No

23 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.

24 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

25 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.

26 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.

27 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 prolapse recurrenced in ten (5%) other patients, only one of whom underwent reoperation.

28 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.

29 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.

30 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.

31 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

32 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.

33 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

34 Minor Complications UTI, vaginal hematomata, stress incontenance,
urge incontenance , posterior vaginal prolapse, cystotomy, fever.

35 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

36 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.

37 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.

38 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.

39 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.

40 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

41 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

42 References 1. US Government (2000) Federal Interagency Forum on Aging
Related Statistics, in Older Americans 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. Obstet Gynecol 89:501–506

43 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 Obstet Gynecol 29:222– 230 7. Wyatt J (1912) Le Fort’s operation for prolapse, with an account of eight cases. J Obstet Gynaecol 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


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