Female Pelvic Surgery

6. Obliterative Vaginal Procedures

Karen Soules Ryan M. Krlin  and Jack Winters 

(1)

Department of Urology, Louisiana State University Health Sciences Center, New Orleans, LA, USA

Karen Soules

Email: karensoules@gmail.com

Ryan M. Krlin

Email: Rkrli1@lsuhsc.edu

Jack Winters (Corresponding author)

Email: cwinte@lsuhsc.edu

Background

Pelvic organ prolapse (POP) is a common condition among women, and its prevalence increases with age [13]. Approximately 4.1 % of women age 80 years or older have symptomatic POP [3], and an estimated 11.1 % of women will undergo at least one surgery for POP repair or stress urinary incontinence by 80 years of age [4].

As the population of older women expands, there will be increasing numbers of patients suffering from and seeking care for POP. U.S. Census Bureau estimates indicate that starting in 2056, the population, age 65 and over, will outnumber the population under age 18 [5]. Additionally, Census calculations project that the population age 65 and older will double between 2012 and 2060, from 43.1 million to 92.0 million [5]. Using population projections and age-specific prevalence of POP, Wu et al. [6] estimated that between 2010 and 2050 the number of women with POP will increase 46 % from 3.3 to 4.9 million. In a second study, Wu et al. predict that between 2010 and 2050 there will be a 47 % increase in women undergoing procedures for POP (166,000 in 2010 and 245,970 in 2050) [7].

Surgical repair of POP is challenging and has been fraught with a high reoperation rate of up to 29 % [4]. Pelvic tissues that are either weakened or damaged are thought to predispose some women to failure. The mean time to first reoperation for recurrent prolapse after primary surgical correction has been reported to be between 3 and 4 years [89]. Each additional repair appears to be less successful, with the time between surgeries decreasing with each successive repair [4]. Johnson et al. looked at patient reported outcomes and found a high rate of early recurrence with 35.4 % of patients experiencing recurrent prolapse within 3 months of a primary surgical repair. Furthermore, they found a much higher overall recurrence rate of 64.6 %, with 30 % of patients not reporting recurrences to their primary surgeon [10]. This low reporting rate could account for an underestimation of failure rates in any given physician’s practice.

Colpocleisis is simply a closure of the vagina with reduction of the prolapse back into the pelvis. Replacement of the pelvic organs into their anatomic position allows for the relief of the symptoms caused by POP. Closure of the vagina is permanent and it precludes future vaginal intercourse, a point which should be stressed to the patient. Obliteration may be performed in the setting of a prior hysterectomy or with the uterus left intact. The LeFort modification of the procedure is utilized when leaving the uterus in situ. Additionally, hysterectomy may be performed concurrently with colpocleisis in those patients that require removal of the uterus and/or cervix. Removal of the vaginal epithelium followed by apposition of the anterior and posterior fibromuscularis layers achieves obliteration of the vaginal space.

Colpocleisis is an effective and durable procedure for the treatment of POP. Anatomical success rates range from 97 to 100 % in most series [1118]. Patients with symptomatic POP commonly experience other pelvic floor symptoms including lower urinary tract symptoms, incomplete bladder emptying, and various bowel complaints. Significant improvements have been seen in these additional domains in several studies.

Hullfish et al. looked at symptom relief via postsurgical attainment of patient goals that were set preoperatively. In this format, 91 % of patients reported improvement of urinary urgency and frequency following colpocleisis [19]. In a series of 324 women who underwent colpocleisis, Zebede et al. reported preoperative urgency symptoms in 54 % of patients. Following surgical repair, there was a statistically significant reduction in these urgency symptoms by 50 % (p < 0.001) [18].

Again, looking at postoperative attainment of patient goals, Hullfish et al. found a 76.4 % subjective improvement in bladder emptying following colpocleisis [19]. In a cohort of women with POP and a postvoid residual (PVR) greater than 100 cm3, Fitzgerald et al. reported 89 % resolution of incomplete bladder emptying after surgical prolapse repair [20]. Similarly, in a series of 64 women who underwent colpocleisis, 36 % had an elevated preoperative PVR volumes all of which normalized postoperatively [15].

The resolution of bowel symptoms is equally encouraging. In a prospective study by Gutman et al, bothersome bowel symptoms resolved in the majority of patients after colpocleisis. Specifically, all obstructive symptoms (digital assistance, straining, incomplete emptying) and the majority of incontinence symptoms [anal (fecal) incontinence with stress and urge, anal incontinence of flatus and liquid stool] were significantly decreased 1 year after surgery [21]. Likewise, in their large case series, Zebede et al. found a significant resolution of bowel symptoms including: constipation, obstructed defecation, and fecal incontinence [18].

Patients report a high rate of satisfaction after colpocleisis ranging from 90.3 to 100 % [121417182224]. Barber et al. reported that patients had significant improvements in multiple quality of life measures including: bodily pain, vitality, social functioning, and mental health measures [22]. Also, in this study of women 65 or older with stage 3 or 4 prolapse, there were no differences found between the reconstructive and obliterative groups as both demonstrated significant improvements in health-related quality of life [22]. Correspondingly, Murphy et al. also found that quality of life and patient satisfaction was similar between groups of women who had reconstructive versus obliterative prolapse repairs [25].

Rates of regret following colpocleisis are low typically ranging from 3 to 9 % [192627]. In a series by von Pechmann et al. a higher rate of regret (12.9 %) was reported; however, half of those patients also stated that they would have the surgery again. There are concerns that closure of the vagina may negatively affect a patient’s body image, but most patients report improved body image following surgery [171928]. In their series of 40 patients with self-created goals, Hullfish et al. found a 96.9 % improvement in self-image after surgery [19]. Utilizing questions regarding body image and perception, Koski et al. found that 50 % of patients felt their body looked better after colpocleisis and 82 % reported their body felt better after the procedure [17].

In the carefully selected patient, these results demonstrate that an obliterative procedure remains a particularly good option following a thorough informed discussion.

Evaluation/Work-Up

Preoperative evaluation for colpocleisis should include a thorough history of the prolapse complaint including prior reconstructive procedures and associated pelvic floor symptoms. Details should be obtained regarding pain and pressure symptoms, urinary incontinence, voiding dysfunction, fecal incontinence, and defecatory dysfunction. A detailed vaginal exam, both bimanual and speculum, is required with evaluation of all compartments. A quantitative scoring of the prolapse, assessment of uterine size when applicable, measurement of postvoid residual, and assessment of urine for infection and hematuria should be included. Colpocleisis is most easily completed in patients with Stage 3 or greater prolapse (Fig. 6.1). In patients with less severe support defects the dissection required may be more challenging.

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Fig. 6.1

Stage 4 vaginal vault prolapse

Some type of preoperative evaluation for stress urinary incontinence (SUI), even in patients that report continence, is recommended due to the high rate of occult SUI in women with POP. The rate of occult stress urinary incontinence in the setting of Stage 2 prolapse or greater ranges from 33.5 to 67.9 % [182932]. A simple cough stress test with a full bladder and the prolapse reduced is often sufficient in patients with uncomplicated, demonstrable SUI. Patients with voiding dysfunction, mixed incontinence, incomplete bladder emptying, or prior urologic surgery should undergo a more thorough investigation with urodynamics.

The data is varied and the true predictive value of preoperative urodynamics remains unclear. Reena et al. studied women both before and after they underwent prolapse repairs without anti-incontinence procedures and found that 64.2 % of patients with documented occult SUI also demonstrated SUI postop [30]. In a small series of patients, Chaikin et al. reported that no patients with negative preoperative testing developed postoperative SUI [29]. Similarly, Hafidh et al. found a very low rate of postoperative SUI (4 %) in patients with no SUI demonstrated on preoperative urodynamics [33]. In contrast, studies by Wei and Al-Mandeel found a high incidence of postoperative SUI, 38 % and 42 % respectively, in patients with preoperative testing that was negative for SUI [3234]. What is clear, however, is that it is reasonable to place a midurethral sling at the time of prolapse repair in women with clinical SUI or documented occult SUI. In a 100 women with occult SUI who underwent TVT, Croutz et al. report a 83 % success rate for absence of postoperative SUI and only 2 % of patients with persistent SUI were symptomatic [35]. Meschia et al. also reported high rates of postoperative continence (objective 92 %, subjective 96 %) in patients who underwent TVT placement for occult SUI [36].

It remains controversial whether to place a sling in patients without clinical SUI or documented occult stress incontinence. The large, randomized CARE trial looked at women who were stress continent preoperatively and found decreased rates of postoperative SUI in women who underwent prophylactic Burch procedure at the time of sacrocolpopexy versus those who did not (32 % versus 45.2 %) [37]. However, midurethral slings are the most common anti-incontinence procedures performed, and it is unclear if this data can be extrapolated to colpocleisis and midurethral slings. In another large, randomized trial Wei et al. also looked at stress continent women undergoing prolapse repair and randomized patients to sling versus no sling. They also found a significantly lower rate of urinary incontinence in the sling patients (27.3 % versus 43 %), but at the expense of increased adverse advents including bladder perforation, urinary tract infection, major bleeding complications, and incomplete bladder emptying [32]. Another argument for prophylactic sling placement at the time of colpocleisis is the issue of access to the suburethral area. Successful colpocleisis is dependent on aggressive closure of the genital hiatus with levator placation [43]. Depending on the degree of closure, this can make it very challenging to access the midurethra for future placement of a sling.

Management of the Uterus

In women with a uterus it is prudent to confirm that there is no cervical or endometrial pathology which would be a contraindication to leaving the uterus in situ. Closure of the vagina will severely limit the ability to perform future surveillance via the traditional routes (pap smear, endometrial biopsy). A complete history should be taken regarding any history of abnormal pap smears as well as any episodes of postmenopausal bleeding. Benign cervical cytology should be documented in a patient with a history of any abnormal pap smears or a previous treatment for cervical intraepithelial neoplasia (CIN). The most recent guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommend that women with a history of CIN2, CIN3, or adenocarcinoma in situ should have 20 years of negative screening following treatment prior to discontinuation of cervical cancer screening [38]. Therefore, it is recommended that any woman who would need continued surveillance based on her history should have a hysterectomy at the time of colpocleisis.

Women with a history of endometrial hyperplasia or any episodes of postmenopausal bleeding should have a preoperative assessment of the endometrium. This can be accomplished with endometrial sampling via endometrial biopsy or dilation and curettage of the uterus. Alternatively, the least invasive approach is to evaluate the endometrial thickness via transvaginal ultrasound. In women with postmenopausal bleeding, endometrial sampling is not required if an endometrial thickness of less than or equal to 4 mm is found on transvaginal ultrasound [39]. The decision to screen asymptomatic women with transvaginal ultrasound for assessment of the endometrial thickness may be left to the discretion of the surgeon. As reported by ACOG, the significance of an endometrial thickness greater than 4 mm in a postmenopausal woman without bleeding has not been established and does not routinely need evaluation in the absence of risk factors [39]. Concurrent hysterectomy is recommended for women with the finding of endometrial hyperplasia. Patients with the diagnosis of atypical endometrial hyperplasia should be referred to a gynecologic oncologist for surgical management due to the high rate (42.6 % [40]) of concurrent carcinoma.

It is important to note that hysterectomy with concurrent colpocleisis does not improve success rates over colpocleisis alone [1441], and the combination of procedures may significantly increased blood loss and patient transfusion requirements [14]. Due to this increased morbidity, exceptions to the above recommendations may be reasonable in patients who are of advanced age or debilitated and should be a joint decision between the patient and the surgeon.

Because colpocleisis eliminates the possibility of future vaginal intercourse, preoperative counseling is extremely important and patient selection is key. There is no identified minimum age requirement for consideration of the procedure. With colpocleisis, as in all cases of prolapse repair and reconstruction, the treatment plan must be individualized for each patient. Preoperative counseling should be specific and thorough including information on potential pessary management, alternative options for repair, possibility of postoperative urinary incontinence, and recurrence risk.

The option for concurrent midurethral sling placement should also be discussed with patients. Specifically, in the situation of demonstrated SUI in the setting of incomplete bladder emptying as well as patients with no preoperative urinary incontinence. The addition of a midurethral sling does not appear to cause a high risk of urinary retention and preoperative incomplete bladder emptying seems to resolve in most patients [3142]. In a series of 38 women who underwent colpocleisis and midurethral sling placement, Abbasy et al. reported a 2 % rate of elevated PVR postoperatively. Additionally, they saw a 90 % postoperative resolution of preoperative incomplete bladder emptying (defined as PVR greater than 100 ml) [42]. In a much larger series of 210 women, Smith et al. found a de novo voiding dysfunction rate of 1.9 % in women who underwent colpocleisis and midurethral sling. Similarly, they found a 91 % resolution of preoperative incomplete emptying [31]. An alternative, nonpermanent approach is to offer periurethral bulking injections to patients for whom the risk of retention is thought to be particularly high.

The decision whether to offer a midurethral sling to continent patients at the time of colpocleisis remains controversial. As detailed previously, the risk for de novo SUI may be quite significant; however, midurethral slings are not without complications or sequela. A large randomized controlled trial by Wei et al. specifically addressed this question by randomizing women without SUI who were undergoing vaginal prolapse repair to either have a midurethral sling or sham sling incisions. The sling group had significantly decreased rates of urinary incontinence at both 3 [23.6 % versus 49.4 % (p < 0.001)] and 12 months [27.3 % versus 43.0 % (p = 0.002)] [32]. However, the sling group did have significantly higher rates of complications including: bladder perforation, urinary tract infection, major bleeding complications, and incomplete bladder emptying for up to 6 weeks following surgery. Also of note, 5 % of patients in the sham group had a sling placement within the first year after surgery, but only 2.4 % of patients in the sling group required sling revision for voiding dysfunction. A detailed discussion of all the possible risks and benefits should be carried out with patients when making the determination of whether to place a sling in this population.

Surgical Procedures

All patients receive a preoperative prophylactic broad-spectrum antibiotic. Additionally, all patients have DVT prophylaxis; our standard is to use compression stockings and sequential compression devices on the lower extremities. Table 6.1

Table 6.1

Risk classification for venous thromboembolism

Level of risk

Definition

Prevention strategies

Low

Surgery less than 30 min in patients younger than 40 years with no additional risk factors

No specific prophylaxis, early mobilization

Moderate

Surgery lasting less than 30 min in patients with additional risk factors

Low-dose unfractionated heparin: (5,000 units every 12 h)

OR

Low molecular weight heparin: (2,500 units dalteparin or 40 mg enoxaparin daily)

OR

Graduated compression stockings

OR

Intermittent pneumatic compression device

Surgery lasting less than 30 min in patients aged 40–60 years with no additional risk factors

Major surgery in patients younger than 40 years with no additional risk factors

High

Surgery lasting less than 30 min in patients older than 60 years or with additional risk factors

Low-dose unfractionated heparin: (5,000 units every 8 h)

OR

Low molecular weight heparin: (5,000 units dalteparin or 40 mg enoxaparin daily)

OR

Intermittent pneumatic compression device

Major surgery in patients older than 40 years or with additional risk factors

Highest

Major surgery in patients older than 60 years plus prior venous thromboembolism, cancer, or molecular hypercoagulable state

Low-dose unfractionated heparin: (5,000 units every 8 h)

OR

Low molecular weight heparin: (5,000 units dalteparin or 40 mg enoxaparin daily)

OR

Intermittent pneumatic compression device/graduated compression stockings + low-dose unfractionated heparin or low molecular weight heparin

Consider continuing prophylaxis for 2–4 weeks postop

Data from: American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin Number 84: Prevention of Deep Vein Thrombosis and Pulmonary Embolism. Obstet Gynecol. 2007 Aug;110(2Pt1):429–40; and from Geerts WH, Pineo GR, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(suppl):338 s–400 s

For a patient in whom the uterus is to remain in situ, a LeFort colpocleisis is performed (Fig. 6.2a–e). To begin, outward traction is placed on the cervix using a tenaculum or Allis clamp. Two rectangles (anterior and posterior) are outlined with a surgical marker starting approximately 2 cm distal to the cervix and extending to the bladder neck anteriorally and mirroring this posteriorly. This will aid in maintaining orientation during removal of the vaginal epithelium. Laterally, there should be at least 2 cm of epithelium separating anterior from posterior rectangles in order to allow adequate tissue for creation of the drainage channels. Starting with the posterior wall 1 % lidocaine with a 1:200,000 dilution of epinephrine is infiltrated in to the subepithelial space to aid in hemostasis and hydrodissection. The demarcated areas are circumscribed with knife and sharp dissection is performed to start the removal of the vaginal epithelium from the underlying fibromuscularis layer. We use a number 10 blade to make the initial incisions. Dissection is initiated with tenotomy scissors for precision in finding the appropriate plane and then is completed with curved mayo scissors which are safer for combined blunt and sharp dissection. It can be helpful to refrain from making all incisions initially but rather to proceed in a systematic fashion (posterior to anterior) in order to decrease blood loss and improve visualization during dissection. Typically, a combination of sharp and blunt finger dissection with a sponge can be employed to facilitate removal of the epithelium once the appropriate plane is achieved. Hemostasis is maintained with meticulous use of monopolar cautery throughout the dissection. With the LeFort procedure only the areas of anterior and posterior rectangles are denuded.

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Fig. 6.2

LeFort colpocleisis. (a) Removal of the anterior rectangle of vaginal epithelium. (b) After removal of the posterior rectangle at least 2 cm of epithelium should remain laterally separating the denuded anterior and posterior rectangles. (c) Creation of the drainage channels: an interrupted or running stitch is used to tubularize the remaining, lateral strips of epithelium. (d) Anterior to posterior imbricating sutures to reduce the epithelialized cervix. (e) Further reduction of the uterus with continued anterior to posterior imbrications

To continue the LeFort procedure, channels are created after the removal of the epithelium and prior to starting closure of the vagina. Absorbable suture is used to tubularize the lateral strips of epithelium by suturing the epithelial edges together, superior to inferior. This may be done with an interrupted or running stitch. Our preference is to use 2-0 polyglycolic acid suture on a CT2 needle and run this closure towards the cervix, thus allowing the surgeon to sew towards him/herself. These channels will allow the drainage of cervical and uterine secretions. Care should be taken to continue to identify the location of the channels throughout the rest of the procedure in order to avoid inadvertently suturing them closed.

Following creation of the channels, imbricating sutures using 2-0 polyglycolic acid on CT-2 needle are placed in the fibromuscularis to begin reduction of the prolapse. Successive anterior to posterior imbricating sutures (Fig. 6.3a, b) in either an interrupted or figure-of-eight fashion are the most effective when reducing the epithelialized cervix. Once the cervix has been fully reduced, it is usually most straightforward to continue with anterior to posterior imbrication until the prolapse has been reduced to the level of the levator plate. Cystoscopy is then carried out following administration of Indigo Carmine to ensure ureteral efflux. From this point onward the procedure is completed with a levator plication and perineorrhaphy, using 2-0 and 3-0 polyglycolic acid, respectively, in the same fashion as a complete colpocleisis is performed without the uterus in situ.

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Fig. 6.3

(a) Placement of stitch for anterior to posterior imbrications. (b) Reduction of the prolapse after performing several anterior to posterior imbricating sutures

As addressed already, concomitant hysterectomy should be performed for patients with a contraindication to retention of the uterus. This combined procedure can have increased morbidity due to inherent risk of entry into the peritoneal cavity, increased operative time, and increased blood loss. Following vaginal hysterectomy, the cuff should be closed to protect the intraperitoneal structures at which point removal of the epithelium is then started.

In the patient with a prior hysterectomy, a complete colpocleisis requires removal of the entire vaginal epithelium. A surgical marker is used to outline the lateral borders of dissection along the perineum, vaginal sidewalls, and anterior vaginal wall proximal to the urethra. This may be further demarcated into quadrants in order to aid in maintaining orientation, which can be easily lost, during dissection with severe POP (Figs. 6.4 and 6.5). Injection of 1 % lidocaine with a 1:200,000 dilution of epinephrine into the subepithelial space may be utilized to aid in hemostasis and hydrodissection. The demarcated areas are circumscribed with a knife and sharp dissection is used to initiate removal of the vaginal epithelium from the underlying fibromuscularis. Similar to the Lefort, it is best to proceed in a systematic fashion in order to maintain orientation, decrease blood loss, and preserve visualization. The authors would recommend posterior to anterior (Fig. 6.6). Again, once the appropriate plane is entered, a combination of sharp and blunt dissection can be used to separate the epithelium from the fibromuscularis layer (Fig. 6.7a–c). Attention should be given to maintaining hemostasis throughout the dissection with judicious use of the monopolar cautery. Significant blood loss can be encountered when performing extensive dissection on severe POP, so all efforts towards hemostasis will help to decrease the need for transfusion.

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Fig. 6.4

Demarcated quadrants for dissection

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Fig. 6.5

Boundaries of perineal dissection

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Fig. 6.6

Posterior dissection of vaginal epithelium from fibromuscularis

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Fig. 6.7

(ac) Dissection and removal of vaginal epithelium

It is not uncommon to encounter an enterocele during removal of the vaginal epithelium. An attempt should be made to avoid entering the enterocele. However, these dissections can be challenging and with some severe defects there may be peritoneum directly abutting vaginal epithelium. If an enterocele is entered, the sac should be meticulously mobilized circumferentially from the surrounding tissue with special care taken to avoid small bowel injury. The enterocele sac should then be tied off using 3-0 polyglycolic acid on a SH needle and a circular purse-string stitch. For large defects in the peritoneum, 2–3 full purse-string sutures are required to ensure adequate closure. If there is an excessive amount of redundant, prolapsing enterocele sac, the peritoneum can be trimmed circumferentially for a more proximal and effective closure.

Following removal of the vaginal epithelium, reduction of the prolapse can be performed with one of two techniques or a combination of both. One option is to use successive anterior to posterior imbricating sutures in either an interrupted or figure-of-eight fashion. Alternatively, sequential, circular purse-string stitches are an effective technique for reduction of the prolapse (Fig. 6.8). The authors favor using 2-0 polyglycolic acid suture on a CT2.

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Fig. 6.8

Purse-string reduction of the prolapse

Several centimeters of vaginal epithelium should be retained on the distal, anterior vaginal wall underneath the urethra. This is recommended for all patients whether they are having a concomitant sling placement or not. Maintenance of this distal epithelium prevents excessive traction on the urethra, which can predispose the patient to postoperative incontinence and leaves room for immediate or future sling placement. Placement of a midurethral sling is most easily achieved after the prolapse has been reduced to or above the levator plate and before levator plication.

Cystoscopy with IV indigo carmine administration is performed at this point to rule out bladder injury and ureteral obstruction. If ureteral obstruction is diagnosed on cystoscopy, a prudent first step is to remove the anterolateral sutures as this is often the location where the ureters are encountered. Cystoscopy is then repeated.

Next a levator plication is performed close to the genital hiatus and buttress the repair. Using 2-0 polyglycolic acid suture on a CT 2, interrupted or figure-of-eight sutures are performed pulling the muscles together in the midline (Fig. 6.9). Initially, excessively lateral bites of tissue can cause undue tension and may make it difficult to achieve approximation in the midline. Following levator plication, the perineorrhaphy should include reapproximation of the transverse perineal and bulbocavernosus muscles at the introitus. This is also most easily achieved using 2-0 polyglycolic acid on CT-2 needle so that large, secure bites can be taken. Finally, the vaginal epithelium is reapproximated with 3-0 polyglycolic acid on a SH needle in 1–2 layers with a subcutaneous and a subcuticular stitch or a running through-and-through stitch (Fig. 6.10).

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Fig. 6.9

Completed levator placation

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Fig. 6.10

Completion of perineorrhaphy

Summary

Colpocleisis is a successful operation with few complications and little regret for patients postoperatively [43]. SUI should be evaluated preoperatively, but may warrant postoperative reassessment based on patient symptoms. Urgency urinary incontinence after these surgeries can be problematic and may require additional medical treatment. Overall, the procedure is a very attractive option in the properly selected patient.

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