Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

7. Colpocleisis: Current Practice and Complications

Lior Lowenstein  and Shay Erisson1

(1)

Urogynecology Service, Department of Obstetrics and Gynecology, Technion-Israel Institute of Technology, Rambam Health Care Campus, Halya 8, Haifa, 31096, Israel

Lior Lowenstein

Email: lowensteinmd@gmail.com

Abstract

The term colpocleisis is derived from the ancient Greek term “kolpos,” which refers to a fold in the Greek tunic and “cleisis,” which stands for occlusion or closure. Colpocleisis is the obliterative alternative to reconstructive surgery, offered to women with stage II–IV Pelvic Organ Prolapse (POP) who are at high risk to surgery and no longer wish to preserve coital function per vagina.

Introduction

The term colpocleisis is derived from the ancient Greek term “kolpos,” which refers to a fold in the Greek tunic and “cleisis,” which stands for occlusion or closure. Colpocleisis is the obliterative alternative to reconstructive surgery, offered to women with stage II–IV Pelvic Organ Prolapse (POP) who are at high risk to surgery and no longer wish to preserve coital function per vagina.

Over the last decades the popularity of colpocleisis has declined from as high as 17,200 procedures in 1992 to around 900 procedures in 1997 [1]. Nevertheless, colpocleisis has an important role in the management of POP, especially with the aging of the population and the loss of coital function is offset by the positive impact in the daily activities.

Terminology

Colpocleisis is normally employed for treatment of posthysterectomy vaginal vault prolapse or advanced uterovaginal prolapse. Total colpocleisis usually refers to the removal of most or all of the vaginal epithelium from within the hymenal ring posteriorly to within 0.5–2.0 cm of the external urethral meatus, anteriorly [23].

During complete colpocleisis, the epithelial and lamina proprial layers are removed down to the fibromuscular layer. The operation attaches the anterior fibromuscular layer to the posterior fibromuscular layer, effectively closing the vaginal tube and replacing it back into the abdominal cavity. A partial colpocleisis refers for the most part to Le-Forte [4] and its modifications [5], i.e., removing two areas of vaginal mucosa anteriorly and posteriorly and subsequently creating a series of imbrication sutures to create a tissue platform. By preservation of the lateral vaginal epithelium one potentially permits drainage of serosanguinous fluid postoperatively as well as any postmenopausal bleeding remote from surgery [6]. Other terms used to describe these procedures include total or partial colpectomy, vaginal extirpation, complete procidentia, and total or subtotal vaginectomy [7].

Indications

There is no standardized guideline to choose colpocleisis over reconstructive surgery. While it is generally accepted that it may be utilized in Stage II–IV POP, the surgeon must consider the best surgical option in terms of duration of surgery, blood loss, recovery time, immediate and delayed postoperative complications, risk of foreign body, and comorbidities affecting surgical risk. Satisfaction and compatibility with the patient’s expectations are increasingly important factors that come into play; thus, the patient’s desire for future vaginal intercourse, postoperative expectations, body-image, and fear of prolapse recurrence are inherent to choice of procedure [8].

In general terms, the impetus to perform colpocleisis should follow the rationale that prolonged reconstructive surgery or general anesthesia is contraindicated for women with recurrent POP following previous surgical attempts to repair POP. The real question remaining is the desire to retain the potential for sexual intercourse per vagina. In a study that surveyed older adults on their sexuality and health, researchers found that the prevalence of sexual activity among women aged 57–64, 65–74, 75–85 years of age were 62%, 40%, and 17%, respectively [9]. However, these prevalence rates are overestimating sexual activity per vagina. Furthermore, the odds ratio for being sexually active among those who reported their health to be “poor” or “fair” as compared to “very good” or “excellent” was 0.36 for women. Put together with the epidemiologic data that those who reach the age of 85 years can expect to live on average about 7 more years [10], the frail segment of this population are good candidates for colpocleisis.

Preoperative Considerations and Evaluation

Typically, obliterative procedures are less invasive, require shorter operative times and have less surgical risks than traditional vaginal reconstructive procedures [11].

Assessing the elderly patient with urogenital prolapse requires a holistic approach, taking into account the operational anatomic plane, desired functional pelvic floor endpoints, concomitant urinary incontinence evaluation, and choice of complementary procedures. In addition, the patient’s physiology and potential perioperative complications need to be accounted and planned for in advance.

Considerations

·               Anatomic evaluation

·               Urinary symptoms

·               General comorbidity risk stratification

·               Choice of anesthesia

Anatomic Evaluation

Maximum extent of the prolapse should be assessed in the standing position unless the patient cannot support her own weight, in which case the prolapse assessment may be carried out with the patient supine or seated in a birthing chair. In both situations the surgeon performs a digital vaginal examination while the woman strains to push the vaginal bulge out. Prolapse should be measured in the anterior, posterior, and apical dimensions of the vaginal walls and recorded in the POP quantification system format [12].

Urinary Evaluation

Older women with advanced prolapse are at increased risk for urinary retention, which may be complicated by hydronephrosis and/or ureteral obstruction [13]. A study conducted by Fitzgerald et al. in 2002 showed that 89% of women with elevated postvoid residual volumes (>100 mL) will experience resolution of the urinary retention after their prolapse is surgically corrected [14]. All patients should undergo determination of postvoid residual volume by either straight catheter or bladder scanner. Urine dipstick analysis or urine analysis needs be performed to evaluate for urine infection and hematuria.

Historically, urinary incontinence (UI) occurs postoperatively in up to 27% of patients, representing the strongest deterrent against colpocleisis [15]. De novo stress incontinence is attributed to anatomic distortion with distal vaginal dissection and downward traction on the urethra; as a consequence, contemporary techniques avoid distal dissection and often utilize high ­perineorrhaphy. The other mechanism by which UI occurs postoperatively is due to unmasking of existent, occult stress urinary incontinence (SUI) due to “un-kinking” of the bladder neck with prolapse reduction. In this setting, selected patients undergo incontinence procedures to complement the obliterative procedure, with the risk of postoperative urinary retention considered against the morbidity of postoperative stress incontinence [1619].

Assessment of SUI in symptomatic women should include a cough stress test with the bladder filled to a standardized volume such as 300 mL, in a standing or supine position. A negative stress test should be repeated with the prolapse reduced. Cystometry is also warranted should the patient report symptoms of urinary retention or mixed incontinence. The role of complex urodynamics is debatable. Urodynamics has not been shown to be sensitive in differentiating severe prolapse from detrusor overactivity as a cause of poor bladder emptying. Of interest, a literature review by Roovers and Oelke [20] posits that there is little evidence suggesting that preoperative urodynamic investigation improves the outcome of treatment.

General Risk Stratification

Increasing age is associated with increased rates of complications and mortality especially in those beyond age 80, where mortality with urogynecologic surgery is 2.8 out of 1,000 [11].

However, in women 80 years and older, fewer complications occur with obliterative surgery than with reconstructive surgery (17.0% vs. 24.7%, P  <  0.01), making it an attractive surgical approach [21]. Still, preoperative risk stratification and minimization of postoperative complications are prudent and should be addressed through preventive measures and lab investigations.

It is noteworthy that cardiac output after age 60 is more dependent on diastolic filling and stroke volume. Furthermore, it responds poorly to sympathetic stimuli and has to compensate for a reduced secretion of water and sodium loads due to declining renal mass and filtration ability. Thus, perioperative fluid management is paramount [22] and antihypertensives should be given the day of surgery and restarted immediately after surgery. ADL (activities of daily living) status is another important parameter. Poor functional status is predictive of pulmonary complications and should prompt a rigorous assessment and postoperative preparedness with incentive spirometry.

Other factors that need to be taken into account are baseline dementia which increases the risk of acute postoperative delirium and nutritional status which influences recovery time and the durability of the repair.

Recommended preoperative laboratories and testing in the older woman (>65 years) include hematocrit, blood urea nitrogen, glucose, creatinine, and electrocardiogram.

Table 7.1

Summarizes the risks and advocates appropriate interventions

Issue

Background

Clinical recommendation

Deep venous thrombosis/thromboembolic events

Older patients have 20–40% risk of deep venousthrombosis because of advanced age (60 years) and length of surgery

Perioperative use of sequential pneumatic compression devices and selective use of heparin prophylaxis, early ambulation

Cardiovascular

Perioperative myocardial infarction associated with 50% mortality rate

Perioperative-blocker use in the high- and moderate-risk patient

Pulmonary

Increased perioperative morbidity and mortality rates with development of pneumonia

Pulmonary toilet with deep cough, incentive spirometry, early ambulation

Neuropathies

Neurologic injuries caused by nerve compression and ischemia as a result of patient positioning

Careful patient positioning with attention to peroneal, femoral, ulnar, and sciatic nerves with padd stir-ups, avoid hyperflexion of extension of the lower extremities

Hypothermia

Decreased immunologic response, prolonged wound healing, increased perioperative cardiac events

Intra-operative forced warm air blanket use, warmed intravenous fluids

Infectious disease

Clean contaminated procedures: mixed flora of the vagina

Perioperative dose of first-generation cephalosporin

Pharmacology

Decreased pharmacologic metabolic rates in older patients. Risk of oversedation and delirium

Avoidance of polypharmacy, sedatives, and anticholinergic medications

Delirium

Abrupt change in cognition of consciousness, postsurgical prevalence estimate 37%, at risk for long-term cognitive deficiencies and increased mortality, underdiagnosis

Avoid merperidine and anticholinergic agents including the promethazine, minimize hospital stay, allow a companion to stay at bedside, maintain circadian pattern

Urinary tract infection

Pelvic floor surgery postoperative rates up to 44%

Screen is new-onset bladder or voiding symptoms

Choice of Anesthesia

No benefit has been demonstrated favoring one type of anesthesia in the older patient undergoing surgery. General, regional, or local anesthesia technique should be tailored to the patient’s needs and desires and anesthesiologist and surgeon preference and training [23].

Obliterative Surgery Techniques: Le-Forte/Partial Colpocleisis, Complete Colpocleisis, Perineorrhaphy, Levator Myorrhaphy, Hysterectomy

In our institute we perform the colpocleisis according to Le Fort technique.

In case of uterovaginal prolapse, a cervical dilation and uterine curettage are performed to ensure there is no intrauterine pathology, and we begin the colpocleisis by marking rectangles on the anterior and posterior vaginal walls with a sterile marker; this facilitates maintaining orientation throughout the procedure. We begin with the posterior vaginal wall dissection to minimize obscuring the surgical field by blood. The vaginal epithelium is incised and removed from the underlying muscularis using Metzenbaum scissors with the surgeon’s nondominant finger underlying the epithelium for guidance and traction. The anterior vaginal wall flap of mucosa is removed in a similar fashion. Rectangular strips of vaginal mucosa of approximately equal size are removed from the anterior and posterior surfaces of the protruding vagina leaving a canal of approximately 3 cm on each side. Care is taken not to remove vaginal mucosa from the area beneath the urethra. Dissecting and placing sutures near the bladder neck places downward traction on the posterior urethra and may increase the risk postoperative SUI. In the case of vaginal vault prolapse, we still perform a partial colpocleisis and remove two rectangles of vaginal epithelium, leaving a small patch of mucosa at the apex marked to maintain orientation during the surgery. Once the mucosa is stripped off the underlying fascia, attention is paid to achieve hemostasis before the vaginal canal and the uterus are closed. The muscularis layers from the anterior and posterior vagina are brought together with imbricating interrupted 2-0 polyglactin 910 sutures (Vicryl®, Ethicon, Johnson and Johnson). With each row of imbricating sutures, an interrupted suture is placed on the lateral edge of the mucosa to approximate the anterior and posterior vaginal epithelium together to form a lateral tunnel. All women undergo cystoscopy to ensure that there is no cystotomy and that bilateral urine efflux from the ureteral offices is seen. To facilitate the visualization of ureteral efflux, we give 5 mL indigo carmine intravenously. Intravenous furosemide may be given if after 10–15 min no efflux is seen from either ureteral orifice.

Perineorrhaphy is done at the end of the procedure to reduce the size of the genital hiatus, Two Allis clamps are placed superiorly on the genital hiatus to demarcate where we ultimately want the inferior border of the introitus after the perineorrhaphy. After the perineorrhaphy, the genital hiatus should allow passage of one finger. A diamond-shaped flap of epithelium is marked and removed. The perineal body is reconstructed greatly reducing the size of the genital hiatus using a series of interrupted 2-0 polyglactin 910 sutures (Vicryl®, Ethicon, Johnson and Johnson). The skin is then closed with a running subcuticular suture of Vicryl 3-0 (Vicryl®, Ethicon, Johnson and Johnson).

Outcomes

There is no level I or II evidence concerning the efficacy of colpocleisis and published data is comprised primarily of case-series. Only a few case-series defined their outcomes in standardized terms of anatomy, function, and satisfaction. Nonetheless, both partial and complete colpocleisis emerge as highly effective and safe procedures for advanced POP with anatomic success rates ranging between 90 and 100%, symptomatic recurrence between 0 and 10% and satisfaction between 86 and 100% [24].

Perioperative Complications

Perioperative complications have been reported to occur in 0.2–26% of general gynecologic procedures [25]. In 2004, Giannice et al. found that to be an underestimate when observing women >70 undergoing gynecologic oncology surgery; according to their series, the perioperative complication rate is 38% [26]. In regards to the urogynecologic population, Lambrou et al. found the complication rate to be as high as 46%, regardless of age [25]. A report from the Cleveland Clinic on 267 patients >75 who underwent urogynecologic surgery between the years 1999 and 2003, noted a perioperative complication rate of 25.8% [27], most likely reflecting a “healthier” cohort of patients.

Data on perioperative complications with ­colpocleisis are scant and case-series-based. At best we could supply a scale and narrative to such complications and generalize individual case-series for the benefit of preoperative risk stratification and recommended adjunct surgical measures.

As generally practiced, we categorize colpocleisis-associated complications as intra and postoperative as well as major and minor in significance.

Complications of Colpocleisis

Intra-operative complications are rare with colpocleisis (Table 7.1). Numbers range from null [28] to a case of intra-operative ureteral occlusion in Von Pechmann’s series [29] and 5.2% in Kevin’s et al. review of all urogynecologic surgeries [27].

Major postoperative complications occur in about 4% [30], among which and most common overall is blood transfusion, reaching 22% in Von Pechman’s series [5].

Minor surgical complications, such as UTI, vaginal hematoma, cystotomy, fever, and thrombophlebitis, occur in approximately 15%. Consistent across studies is a 5% adverse event rate of cardiac, thromboembolic, pulmonary, and cerebrovascular morbidity. Infrequent complications include pyometra [31] and vaginal evisceration [32].

Mortality is approximately 1 in 400 cases [8] and through 2008, only three deaths were reported, one of which is multiorgan failure and may have been related to the procedure [415]. In comparison, Cleveland Clinic’s series 6 weeks mortality rate of 0.07% is just short of three times higher [27].

Complications in Cases with Concomitant Hysterectomy

Notably, concomitant hysterectomy done to avoid infrequent complications, such as pyometra, was not found to be more successful [21] and is currently not advocated unless uterine extirpation is medically justified. However, since colpocleisis alone denies access to the uterine cavity it mandates preoperative assessment of the ­endometrial lining for pathology as well as for possible postmenopausal bleeding. Importantly, concomitant hysterectomy is likely to increase adverse events due to an operative time increase from 90 to 120 min on average and up to 52 min longer [5], and a blood loss increase from 150 to 250 mL on average [11].

Postoperative Persistent or De Novo Stress Urinary Incontinence: Current Opinion

The postoperative report of urinary incontinence after colpectomy is common [3335], and as discussed previously, is a grievance that should be avoided. Fitzgerald et al. reported up to 27% de novo SUI in previously continent women as well as persistence of SUI in 28% of preoperatively symptomatic women [10].

Preoperative assessment of such patients is critical and challenging. Encouragingly, the long-term dilemma of employing prophylactic tension-free vaginal tape (TVT) in patients undergoing prolapse repair, including colpocleisis, is currently reviewed in the Outcomes Following Vaginal Prolapse Repair and Mid Urethral Sling (OPUS), randomized controlled trial run by the Pelvic Floor Disorders Network [36]. A hint at what their findings may be with regards to persistence of symptoms can be found in a recent study by Abbasy et al. in 2009 where mid-urethral slings were employed concomitantly with colpocleisis in women suffering from stage II–IV prolapse. In this cohort of 38 patients, 31 of which suffered from SUI symptoms, only four had persistent SUI postoperatively (∼13%) and there only was one case of de novo SUI.

It should be noted that the spectrum of urinary incontinence extends beyond SUI to urge incontinence, mixed incontinence, etc. It is beyond the scope of this text to delve into the intricacies of these different entities; however, in a recent study by Fitzgerald it was found that urge incontinence after colpocleisis decreased from 41 to 15%, 1 year after surgery.

Perioperative Management

Aside from careful preoperative assessment using ASA/CCI scoring and selecting the appropriate type of anesthesia, the following measures should be employed to decrease perioperative morbidity—this recommendation is based on our own experience.

Prior to incision—patients should receive a single dose of broad spectrum antibiotics.

Inpatient supervision—is recommended for at least 24 h; however, some healthy and active patients can be discharged the day of surgery. Follow up in the clinic is usually in 2 weeks time.

Cardiovascular/pulmonary risk management—patients with high cardiovascular risk should be prescribed alpha blockers and incentive spirometry.

Thromboembolism Prophylaxis

·  Moderate-risk patients with early ambulation prospects should use sequential compression devices.

·  High risk patients should be given low molecular weight heparin 1 day postoperatively when bleeding risk subsides.

Surgical pain: In the immediate postoperative period, pain can be managed with IV ketorolac and oral acetaminophen as well as hydrocodone as needed. Ibuprofen is routinely used after the first 24 h.

Surgical site pain can be managed via Ice-Packs and in situ bupivicaine around the perineorrhaphy wound.

Diet: A regular diet is started immediately after surgery.

Foley catheter removal: Before removal is carried out a voiding trial should be performed. If voiding is inadequate the Foley should be replaced. (*Once Foley is removed, a course of antibiotics Colmay be given as UTI prophylaxis.)

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