1 / 44

Outcome of Colpocleisis : A Ten year case series

Outcome of Colpocleisis : A Ten year case series. 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

Audrey
Download Presentation

Outcome of Colpocleisis : A Ten year case series

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Outcome of Colpocleisis: A Ten year case series Dr Satya Duvvur (S T6) Dr Sangeeta Jha (ST5) Dr Hima Vemulapalli (SPR) Mr G. Constantine Consultant O& G Good Hope Hospital

  2. 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.

  3. 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.

  4. 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.

  5. Advantages • A short operating time • Few complications • Speedy recovery • High success rate • Low rate of regret • Efficacy rate > 90%

  6. Disadvantages • Problems with self image • De novo or worsening urinary incontinence • May delay the diagnosis of cervical and endometrial pathology in partial colpocleisis

  7. Relative Contraindications (where the procedure might be difficult) • Previous colposuspension • Previous sacrospinous fixation • Previous proctocolectomy

  8. Technique of colpocleisis

  9. Video • Le forts partial colpocleisis

  10. Video • Complete colpocleisis

  11. 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

  12. Audit • Total number of patients 85 • Number deceased 10 • Memory loss 2 • Total questionnaires sent 75 • Responses received 52 • Percentage of responses received 70%

  13. Data (n-85) • Age: Median age 74.5 yrs • Previous hysterectomy : 46

  14. Data (n= 85) • Current prolapse: 85 Procidentia 15 Vault 30 Cystocele 25 Rectocele 13 2nd degree cx descent 3

  15. Data (n-85) • Previous prolapse surgery 20 • Procidentia 5 • Posterior repair 10 • Anterior repair-5

  16. Data (n-85) • Bladder Symptoms: 44 • Urgency,UI 24 • SI 35 • Freq, nocturia 8 • Voiding problems 4

  17. Data (n-85) • Bowel symptoms: 4 • Rectal prolapse 2 • IBS 2

  18. Data (n-85) • Additional procedures 45 • TVT: 5 • TOT: 12 • TVTO: 28

  19. Results (n-52) A) Any problems immediately following the operation: Yes 8 No 44 Reasons: UTI 6 Extreme incontinence 1 Discomfort 1

  20. 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

  21. Longer term problems • Any bowel problems: Yes 13 No 39 Reasons: • Constipation- 5 • Diarrhea 3 • No control 2 • Constipation alternating with diarrhea 3

  22. Results • Any recurrence of prolapse: Yes 0 No 52 • Any regrets: Yes 1 No response 1 No 50

  23. 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.

  24. 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

  25. 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.

  26. 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.

  27. 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 prolapserecurrenced in ten (5%) other patients, only one of whom underwent reoperation.

  28. 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.

  29. 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.

  30. 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.

  31. 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

  32. 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.

  33. 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

  34. Minor Complications • UTI, • vaginal hematomata, • stress incontenance, • urge incontenance , • posterior vaginal prolapse, • cystotomy, • fever.

  35. 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

  36. 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.

  37. 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.

  38. 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.

  39. 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.

  40. 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

  41. 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

  42. References • 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. ObstetGynecol 89:501–506

  43. References • 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 ObstetGynecol 29:222– • 230 • 7. Wyatt J (1912) Le Fort’s operation for prolapse, with an • account of eight cases. J ObstetGynaecol 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

More Related