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Advances in Urogynecology

Obliterative Vaginal Surgery for the Treatment of Advanced Pelvic Organ Prolapse

Sandra R. Valaitis, MD

The development of symptomatic pelvic organ prolapse (POP) is a common problem. An estimated 11% of women will undergo surgery for symptomatic POP or urinary incontinence in their lifetime.¹ Moreover, a recent study of a large managed-care population found that 29% of women undergoing surgery for prolapse will require reoperation.¹ Therefore, surgical reconstruction of a functional vagina has limitations in terms of a successful outcome. Prolapse is more often seen in an aging population, many of whom have other significant underlying medical problems, often making them poor surgical candidates. Also, some women become less sexually active with age due to loss of sexual partners or to personal or partnersÍ medical disorders. It is this population of patients who are not sexually active, and who have no desire to be active in the future, that are the best candidates for closure or obliteration of the vagina. Given the aging of the US population, obliterative surgical techniques may be utilized more frequently by pelvic surgeons to manage this frustrating problem.

The only nonsurgical option for the management of POP consists of fitting the patient with a vaginal pessary. Pessaries come in a variety of shapes and sizes (Figure 1). The most common types of pessaries include the ring, donut, and Gellhorn pessaries. Pessary types used with more severe degrees of POP include the InflatoBall and cube pessaries. Although pessaries can successfully reduce prolapse and provide a means of nonsurgical management, once removed, the prolapse will recur. Therefore, pessaries are frequently used as a preoperative management tool, or as a long-term option for patients who do not desire or who are not good candidates for surgery. High perineorrhaphy (ie, modified Martius-Labhardt vulvoplasty), with or without concomitant pessary use, has also been described.²

Figure not available online

FIGURE 1. Technique for Le Fort/partial colpocleisis. The technique of Le Fort or partial colpocleisis involves removal of segments of the anterior (1) and posterior (2) vagina. The raw edges closest to the cervix are then sutured together (3). Edge A is sewn to edge a) to leave a channel for uterine and cervical secretions to exit. Imbricating stitches then complete closure of the raw surfaces (4).

Patients who are poor surgical candidates or otherwise unable to retain a pessary due to a very wide genital hiatus generally undergo outpatient perineorrhaphy, which greatly reduces the diameter of the genital hiatus, enabling the patient to better retain a pessary without incurring the risk of a more involved surgical intervention. Reported drawbacks of this technique include closure of the introitus, precluding the patient from vaginal intercourse, and a 40% chance of patients in the series still requiring a pessary because of persistent symptomatic POP.²

There are many options for the surgical management of symptomatic POP. More definitive surgical options include reconstructive surgical techniques, which attempt to restore a functional vagina. These surgeries can be approached abdominally, laparoscopically (eg, sacrocolpopexy, paravaginal repair), or vaginally (eg, sacrospinous suspension, uterosacral ligament suspension, colporrhaphy), depending on the technique chosen and the surgeonÍs skill and experience. A discussion of these techniques is beyond the scope of this article, but regardless of the approach or method used, a reoperation rate of 29% has been cited.¹

Obliteration of the vagina via complete or partial colpocleisis is an option for the surgical management of advanced symptomatic POP in women who are not engaging in vaginal intercourse. Although patients undergoing partial or complete colpocleisis no longer have a functional vagina, they may still be able to experience sexual function postoperatively without vaginal intercourse. Given the high rate of failure with reconstructive surgery for POP, some patients may also be willing to compromise vaginal function in exchange for a more definitive surgical correction of their problem.

Partial colpocleisis was first performed by Neugebauer in 1867, who later published his experience in 1881.³ Le Fort also published his results for partial colpocleisis in 1877.⁴ Since that time, various other modifications have also been proposed for closure of the vagina.

This paper addresses some of the more common techniques used for closure of the vagina, with or without leaving the uterus in situ. The potential complications associated with these procedures and the reported success rates for the techniques are also described.

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EVALUATION

In evaluating patients for obliterative surgical treatment of POP, the physician must assess the patientÍs overall general fitness and desire for sexual activity. It is important to ascertain why a patient might not be sexually active. Although aging can contribute to a decline in sexual activity due to vaginal atrophy or other comorbid medical conditions, a decrease in frequency of sexual activity may also be due to decreased partner availability or limitations in the partnerÍs sexual function.⁵ It is therefore important to ascertain whether a patientÍs potential and desire for sexual activity would change if there were a foreseeable change in the availability or sexual function of her partner. Validated sexual-function questionnaires are available to address specific sexual issues in women with POP.⁶

In addition, the physical examination should assess the extent of prolapse in the anterior, apical, and posterior vaginal compartments. An assessment of continence—either in the form of urodynamics or a cough stress test with a full bladder—should be performed with reduction of the prolapse. After the patient has voided, a postvoid residual measurement should also be obtained. If a uterus is present and a partial colpocleisis is proposed, an endometrial biopsy is advised to help rule out any intrauterine pathology that may contraindicate leaving the uterus in situ.⁷ Any ulcerations in the vaginal mucosa should be treated with topical estrogen and healed prior to surgery.

Bladder Function

Once POP has protruded beyond the hymen, it is not unusual for patients to develop difficulties with obstructed voiding, leading to urinary retention and recurrent urinary tract infections as a result. The pathophysiologic mechanism by which this may occur is likely due to obstruction or ñkinkingî of the urethra as the prolapsing organs and bladder descend in the pelvis and beyond the introitus. Long-standing voiding difficulties may lead to detrusor underactivity or overactivity, so preoperative urodynamic testing—preferably with reduction of the prolapse during evaluation—is important to establish preoperative bladder function, and may help to predict postoperative bladder emptying and symptomatology.

Although the patient with POP advanced beyond the hymen may not complain of urinary incontinence symptoms before treatment, once the prolapse is effectively reduced, leakage may ensue. Rosenzweig et al⁸ performed urodynamic testing on women with severe POP, and found that while none of the subjects complained of incontinence more often than once a week, 59% were found to have occult urinary incontinence when the POP was reduced by a vaginal ring pessary, and 41% were found to have unstable detrusor contractions demonstrated during urodynamic testing. Therefore, preoperative assessment of bladder function in patients with severe POP is important not only to evaluate preoperative bladder function, but also to assist in counseling the patient with regard to expectations for postoperative bladder function, because detrusor overactivity/underactivity or stress incontinence may persist or become more symptomatic postoperatively.

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SURGICAL OPTIONS

Partial Colpocleisis

The most common method for performing partial colpocleisis is the technique described by Le Fort⁴ or its variations. This procedure is performed by leaving the uterus and cervix in situ while removing segments of the anterior and posterior vaginal mucosa. The segments removed may be rectangular or triangular in shape.^3,4,9 The uterus and cervix are then pushed cephalad with the placement of a series of imbricating absorbable sutures, leaving a horizontal space through which uterine and cervical secretions can drain. (Figure 1)

Complete Colpocleisis

Complete colpectomy or colpocleisis may be performed with a vaginal hysterectomy or on the vaginal vault in a patient who has already undergone hysterectomy. DeLancey and Morley¹⁰ have described a circumscribing incision through the vaginal mucosa at the base of the prolapse, followed by placement of a series of purse-string absorbable sutures to reduce the prolapse cephalad (Figure 2). The vaginal mucosa is closed by suturing the anterior and posterior vaginal mucosa together utilizing interrupted absorbable sutures. Other authors have modified this technique to include plication of the levator ani muscles with interrupted absorbable sutures to create a ñshelfî from the rectum to the bladder neck.^11,12

Figure not available online

FIGURE 2. Technique for complete colpocleisis. Complete colpocleisis with purse-string reduction of prolapse.10 Adapted with permission from Am J Obstet Gynecol. 1997;176(6):1228-1235.

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SURGICAL OPTIONS

Partial (Le Fort-type) or complete colpocleisis may be performed under any type of anesthesia, including local anesthesia with sedation and pudendal nerve block. Denehy et al⁷ reported using local anesthesia in 24% of patients undergoing Le Fort colpocleisis in their series. Miklos et al¹³ reported a series of 20 patients undergoing vaginal correction of POP under local anesthesia and sedation, four of whom underwent Le Fort colpocleisis. In DeLancey and MorleyÍs¹⁰ series of 33 cases of complete colpocleisis, 19 patients underwent regional anesthesia, 13 general anesthesia, and one local anesthesia. The selection of appropriate anesthesia should be based on the anticipated length of surgery and the patientÍs history.

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COMPLICATIONS

De novo or persistent stress incontinence has been well described after vaginal obliteration. For this reason, many authors have advocated suburethral plication of the pubocervical fascia to further support the bladder neck in patients who have no occult or overt stress incontinence. A specific procedure to treat stress incontinence—eg, suburethral sling—may be performed at the same time if stress incontinence has been identified with preoperative evaluation. However, even when attempts are made to detect stress incontinence preoperatively and correct it at the time of partial or complete colpocleisis, incontinence may still persist or occur de novo postoperatively. In FitzGerald and BrubakerÍs review,¹⁴ stress incontinence persisted in 28% of preoperatively symptomatic women and occurred de novo in 27% of preoperatively continent women.

Other potential complications of colpocleisis have been described. von Pechmann et al¹² described reversible ureteral occlusion in almost 10% of cases, and advocate intraoperative cystoscopy to confirm ureteral patency at the time of surgery. Moore and Miklos¹⁵ reported a case of vaginal evisceration 6 months after colpocleisis, and performed surgical closure of the defect utilizing allogenic graft material due to a lack of adequate adjacent vaginal tissues. This latter complication attests to the need for continued postoperative follow-up of patients to ensure a lasting repair.

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COMPLICATIONS

Complete or partial colpocleisis has been shown to take significantly less operative time than traditional vaginal hysterectomy with colporrhaphy. In the series by Denehy et al,⁷ the average operative time for the Le Fort group was 75 minutes, versus 150 minutes in the vaginal hysterectomy/colporrhaphy group (P < .001). In DeLancey and MorleyÍs¹⁰ series of 33 cases of complete colpocleisis, the average operating time was 104 minutes (range of 10 to 205 minutes). In the study by von Pechmann et al,¹² total operating time was estimated to be an average of 52 minutes longer if hysterectomy was performed at the time of complete colpocleisis. Operative time may vary widely due to factors such as the surgeonÍs experience and performance of concomitant procedures (eg, suburethral sling, bladder neck suspension) at the time of colpocleisis. Concomitant procedures may also affect intraoperative morbidity, adding to blood loss and prolonged anesthesia.

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OUTCOMES

Postoperative regret of loss of coital function in patients undergoing partial or complete colpocleisis is reported infrequently in the literature. Ubachs et al¹⁶ reported on 141 patients who underwent a modified Le Fort procedure, nine of whom expressed regret postoperatively. Appropriate, thorough preoperative screening of patients should minimize the risk of such regret in most cases. Success and length of follow-up are summarized in the Table.^{7,10-12,14,16-18}

Table not available online

TABLE. Outcomes for Partial or Complete Colpocleisis

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OUTCOMES

Obliterative surgical techniques to close the vaginal vault for the treatment of severe symptomatic POP are an excellent and successful option for women who no longer desire vaginal intercourse. In women who have been adequately screened, counseled, and evaluated, these procedures promise correction of a problem that can substantially improve quality of life, minimizing the risk of recurrence.

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References

1. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501-506.
2. Young SB. Extended perineorrhaphy video (abstract). 2004 Joint Scientific Meeting of the American Urogynecologic Society and the Society of Gynecologic Surgeons. San Diego, Calif, July 29-31.
3. Neugebauer JA. Eurigre worte uber die mediane vagmalnaht als mitten zur besestigung des gavar mutler vor falls. Zentralbl Gynako. 1881;5:25.
4. Le Fort L. Nouveau precede pour la guerison du prolapsus uterin. Bull Gen Therap. 1877;92:337-346.
5. Bachmann GA. Influence of menopause on sexuality. Int J Fertil Menopausal Stud. 1995;40(Suppl 1):16-22.
6. Rogers RG, Kammerer-Doak D, Villarreal A, Coates K, Qualls C. A new instrument to measure sexual function in women with urinary incontinence or pelvic organ prolapse. Am J Obstet Gynecol. 2001;184(4): 552-558.
7. Denehy TR, Choe JY, Gregori CA, Breen JL. Modified Le Fort partial colpocleisis with Kelly urethral plication and posterior colpoperineoplasty in the medically compromised elderly: a comparison with vaginal hysterectomy, anterior colporrhaphy, and posterior colpoperineoplasty. Am J Obstet Gynecol. 1995;173(6):1697-1702.
8. Rosenzweig BA, Pushkin S, Blumenfeld D, Bhatia NN. Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse. Obstet Gynecol. 1992;79(4): 539-542.
9. Goodall J, Power R. A modification of the LeFort operation for increasing its scope. Am J Obstet Gynecol. 1937; 34:968-976.
10. DeLancey JO, Morley GW. Total colpocleisis for vaginal eversion. Am J Obstet Gynecol. 1997;176(6):1228-1235.
11. Langmade CF, Oliver JA. Partial colpocleisis. Am J Obstet Gynecol. 1986;154(6):1200-1205.
12. Von Pechmann WS, Mutone M, Fyffe J, Hale DS. Total colpocleisis with high levator plication for the treatment of advanced pelvic organ prolapse. Am J Obstet Gynecol. 2003;189(1):121-126.
13. Miklos JR, Sze EH, Karram MM. Vaginal correction of pelvic organ relaxation using local anesthesia. Obstet Gynecol. 1995;86(6):922-924.
14. FitzGerald MP, Brubaker L. Colpocleisis and urinary incontinence. Am J Obstet Gynecol. 2003;189(5):1241-1244.
15. Moore RD, Miklos JR. Repair of a vaginal evisceration following colpocleisis utilizing an allogenic dermal graft. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(3):215-217.
16. Ubachs JM, van Sante TJ, Schellekens LA. Partial colpocleisis by a modification of LeFortÍs operation. Obstet Gynecol. 1973;42(3):415-420.
17. Falk HC, Kaufman SA. Partial colpocleisis: the LeFort procedure; analysis of 100 cases. Obstet Gynecol. 1955;5(5):617-627.
18. Hanson GE, Keettel WC. The Neugebauer-LeFort operation. A review of 288 colpocleises. Obstet Gynecol. 1969;34(3): 352-357.

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