1. The Le Fort Colpocleisis.

2. Learning 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.

3. Definitions * The surgical closure of the vaginal canal Colpectomy
COLPOCLEISIS
* The surgical closure of the vaginal canal
Colpectomy
(total colpocleisis)
* The surgical excision of the vagina

4. Obliterative 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)

5. Background
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.

6. Reasons 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)

7. Euryphone

8. Al Razi CE

9. Recent 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.

10. Colpocleisis Procedures
Le Fort — a narrow strip of central vaginal epithelium
removed
Neugebauer x3 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)

11. Colpectomy Procedures (Total Colpocleisis)
* Harmanli
DeLancey

12. Indications 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

13. Pre 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?

14. Advantages
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

15. Blood 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)

16. Good, Fast, Cheap Success Rates: (Good?)
Colpocleisis: good anatomic results %
relief of symptoms %
recurrence of prolapse – %
Colpectomy:
good anatomic results %
relief of symptoms %
recurrence of prolapse %

17. Blood Loss Miklos (1995) --- 153 cc Davila (2003) --- <100 cc
Von Pechmann (2003) cc

18. Fast and Cheap ? 0PERATING TIME Miklos (1995) --- 55 minutes
Davila ( minutes
HOSPITALIZATION
Davila hrs
Miklos days
EXPENSE
Local anesthesia results in considerable expense reduction
(Kaye, Clin Geriatric Med. 1990)

19. Disadvantages 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)

20. “The pleasure is momentary, the position ridiculous, and the expense damnable.”
Lord Chesterfield
( )

21. New Onset Urinary Incontinence
Fitzgerald (2003) %
Goldman (1985) %
Harmanli (2003) %
Reason ?
Anatomic displacement (unkinking) of the urethrovesical junction ?
Von Pechmann performed some method of urethral support in 98% of those undergoing colpocleisis

22. Ureteral Occlusion
Colpocleisis with levator plication---1.8% had post operative ureteral occlusion
Colpocleisis with levator plication and Vaginal Hysterectomy % had ureteral occlusion
(von Pechman)

23. Hydronephrosis with Stage III POP
One site %
Two sites %
Three sites %
( Beverly, 1997)

25. Vaginal Bleeding (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)

26. Genital Malignancies in Women greater than 70 years of age
Uterine cancer (all types)- 4.6 per 1,000
Cervical Cancer per 1,000
Can Ques, (2005)

27. Concurrent Procedures
* Anti incontinence procedures
* Rectocele repair
* Enterocele repair
* Perineoplasty

28. Concurrent 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.

29. Urinary Complications of Severe Cystocele
Baden-Walker Grade Grade 3-4
Bladder outlet % %
Obstruction ( reduced 25%)
Detrusor % %
Overactivity
Impaired
Detrusor Contractions % %
Chaikin, 1998

31. Evaluation before Incontinence Procedures
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.

54. 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.

55. Suggested Reading
Adair FL, DaSef L. The Le Fort Colpocleisis. Am J Obstet Gynecol 32: ,1936
Cespedes RD. Colpocleisis for the treatment of vaginal vault prolapse. Tech Urol. 7: ,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): ,2003.