By Chiara Ghetti, MD

Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis

Dr. Ghetti reports no financial relationships relevant to this field of study.

SYNOPSIS: Colpocleisis is an effective surgical treatment for pelvic organ prolapse. Women report high satisfaction and low regret.

SOURCE: Crisp CC, Book NM, Cunkelman JA, et al; Society of Gynecologic Surgeons’ Fellows’ Pelvic Research Network. Body image, regret, and satisfaction 24 weeks after colpocleisis: A multicenter study. Female Pelvic Med Reconstr Surg 2016;22:132-135.

The objective of this study was to determine the effect of colpocleisis on body image, regret, and pelvic floor symptoms 24 weeks after surgery. This was a multicenter prospective cohort study of 88 women choosing to undergo colpocleisis for surgical management of prolapse. The primary outcomes were body image, measured by the modified Body Image Scale; pelvic floor symptoms, measured by the Pelvic Floor Impact Questionnaire and the Pelvic Floor Disorders Inventory; satisfaction, measured by the modified Satisfaction with Decision Scale and a Visual Analog Scale that measured satisfaction with surgical outcome; and regret, measured using the Decision Regret Scale. Six-week outcomes were reported in a prior study. Outcomes for this study were measured 24 weeks after surgery. Women with dementia or mental status changes impeding completion of study questionnaires were excluded, as were subjects who did not ultimately undergo a colpocleisis.

Eighty-eight women underwent colpocleisis. Seven subjects were deceased at the time of 24-week follow up. Body image and pelvic floor symptoms bother scores were significantly improved at 24 weeks compared to preoperative scores. Subjects reported high satisfaction and low regret. Of the six subjects who expressed regret, three reported regret due to urinary complaints, one due to prolapse, one due to a perioperative complication, and one reported regret due to loss of the ability to have vaginal intercourse.

COMMENTARY

For patients and physicians, choices surrounding surgical management of pelvic organ prolapse are influenced by numerous factors. These factors are unique to each patient and include pelvic floor symptoms, anatomic extent of prolapse, medical comorbidities, and the patient’s desire to restore vaginal anatomy to maintain vaginal function (penetrative sex).1 For older patients who do not desire vaginal patency, a colpocleisis is a viable option with excellent anatomic outcome. This obliterative procedure can be used both in the treatment of post-hysterectomy apical prolapse or uterovaginal prolapse. In a woman with a uterus, a total colpocleisis can be performed after vaginal hysterectomy. A total colpocleisis involves a total colpectomy (removal of the majority of the vaginal epithelium) and imbrication of the fibromuscular layer, and ideally is followed by restriction of the genital hiatus with a concurrent levator myorrhaphy. The resulting vaginal length is usually approximately 3 cm. In women retaining their uterus, a partial, or Le Fort, colpocleisis can be performed. During a Le Fort colpocleisis, rectangles of anterior and posterior vaginal epithelium are excised and the underlying fibromusclar layer is sutured together. As the prolapsing uterus and vagina are progressively reduced, drainage tunnels are created from the cervix to the introitus bilaterally. These tunnels allow passage of vaginal discharge and uterine bleeding. Compared to reconstructive approaches, the possible benefits of a colpocleisis include decreased operative time, decreased blood loss, decreased operative adverse events, and decreased recovery time.2,3

In this study of patients undergoing colpocleisis, subjects demonstrated significant improvements in pelvic floor symptoms and body image 24 weeks after surgery. Subjects also reported high satisfaction and low regret. Similar findings were reported in this cohort at six weeks. This study provides the long-term follow-up of the initial short-term postoperative findings.

There is a paucity of literature addressing the indication of additional procedures at time of colpocleisis. Specifically, there is very little to guide the decision of whether to perform a hysterectomy at time of obliterative procedure in women with uterovaginal prolapse. Concomitant hysterectomy has been shown to lead to increased operative time and blood loss.3 Some surgeons routinely perform a hysterectomy due to concerns about possible future endometrial cancer; others choose to perform a Le Fort and to evaluate the endometrium via endometrial biopsy or ultrasound prior to the procedure, and/or dilatation and curettage at time of Le Fort’s colpocleisis. Long-term prospective data are lacking to establish a standard of care. A recent decision analysis suggests that a Le Fort colpocleisis should be the preferred option in a patient with uterovaginal prolapse undergoing an obliterative procedure.4 However, many individual factors affect this decision, and a Le Fort is never appropriate in a patient with postmenopausal bleeding.

In our practice, the preferred obliterative procedure is a vaginal hysterectomy with total colpectomy, colpocleisis, and levator myorrhaphy. We believe the most critical part of the procedure is the levator myorrhaphy, which significantly reduces genital hiatus size. In colpocleisis failures referred to us, a levator myorrhaphy was not performed.

Despite several limitations, including absent description of standardized surgical methodology, use of a non-condition specific body image scale, and lack of anatomic outcomes, this study adds to existing literature supporting colpocleisis in appropriate patients. Colpocleisis is a reliable option for elderly women with pelvic organ prolapse who are not and do not plan to be sexually active and should be included in surgical counseling of patients.

REFERENCES

  1. Fitzgerald MP, Richter HE, Siddique S, et al. Colpocleisis: A review. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:261-271. Epub 2005 Jun 28.
  2. Fitzgerald MP, Richter HE, Bradley CS, et al. Pelvic support, pelvic symptoms, and patient satisfaction after colpocleisis. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1603-1609.
  3. Hill AJ, Walters MD, Unger CA. Perioperative adverse events associated with colpocleisis for uterovaginal and posthysterectomy vaginal vault prolapse. Am J Obstet Gynecol 2016;214:501.e1-6.
  4. Jones KA, Zhuo Y, Solak S, et al. Hysterectomy at the time of colpocleisis: A decision analysis. Int Urogynecol J 2016;27:805-810.