Transcript Outcome of Colpoleisis - Mr Glyn Constantine FRCOG, MRCP

Dr Satya Duvvur (S T6)
Dr Sangeeta Jha (ST5)
Dr Hima Vemulapalli (SPR)
Mr G. Constantine Consultant O& G
Good Hope Hospital
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.
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.
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.
Advantages
 A short operating time
 Few complications
 Speedy recovery
 High success rate
 Low rate of regret
 Efficacy rate > 90%
Disadvantages
 Problems with self image
 De novo or worsening urinary incontinence
 May delay the diagnosis of cervical and endometrial
pathology in partial colpocleisis
Relative Contraindications (where the
procedure might be difficult)
 Previous colposuspension
 Previous sacrospinous fixation
 Previous proctocolectomy
Technique of colpocleisis
Video
 Le forts partial colpocleisis
Video
 Complete colpocleisis
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
Audit
 Total number of patients
85
 Number deceased
10
 Memory loss
2
 Total questionnaires sent
75
 Responses received
52
 Percentage of responses received 70%
Data (n-85)
 Age: Median age 74.5 yrs
 Previous hysterectomy : 46
Data (n= 85)
 Current prolapse:
85
Procidentia
15
Vault
30
Cystocele
25
Rectocele
13
2nd degree cx descent 3
Data (n-85)
 Previous prolapse surgery 20
 Procidentia
 Posterior repair
 Anterior repair-5
5
10
Data (n-85)
 Bladder Symptoms: 44
 Urgency,UI
24
 SI
35
 Freq, nocturia
8
 Voiding problems 4
Data (n-85)
 Bowel symptoms:
 Rectal prolapse
 IBS
4
2
2
Data (n-85)
 Additional procedures 45
 TVT:
5
 TOT:
12
 TVTO: 28
Results (n-52)
A)
Any problems immediately following the
operation:
Yes
No
8
44
Reasons:
UTI
6
Extreme incontinence 1
Discomfort
1
Longer term problems
 1)
Any bleeding from vagina after leaving the clinic:
Yes
1
No
51
brownish loss which resolved spontaneously
 2)
Any bladder problems:
Yes
26
No
26
Urgency,UI-15 ; SI-7; Nocturia-1; UTI-2
Longer term problems
 Any bowel problems:
Yes
13
No
39
Reasons:
 Constipation5
 Diarrhea
3
 No control
2
 Constipation alternating with diarrhea 3
Results
 Any recurrence of prolapse:
Yes
No
0
52
 Any regrets:
Yes
No response
No
1
1
50
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.
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
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.
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.
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.
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.
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.
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.
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
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.
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
Minor Complications
 UTI,
 vaginal hematomata,
 stress incontenance,
 urge incontenance ,
 posterior vaginal prolapse,
 cystotomy,
 fever.
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
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.
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.
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.
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.
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
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
References
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1. US Government (2000) Federal Interagency Forum on Aging
Related Statistics, in Older Americans 2000. 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
References
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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