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The Le Fort Colpocleisis

The Le Fort Colpocleisis. Learning Objectives. The participant should be able to describe the risks and benefits of colpocleisis . The participant should be able to list the indications for colpocleisis and discuss the advantages in selected patients.

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The Le Fort Colpocleisis

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  1. The Le Fort Colpocleisis .

  2. Learning Objectives • The participant should be able to describe the risks and benefits of colpocleisis . • The participant should be able to list the indications for colpocleisis and discuss the advantages in selected patients. • Participants will understand the indications and efficacy of incontinence procedures performed at the time of colpocleisis.

  3. Definitions COLPOCLEISIS * The surgical closure of the vaginal canal Colpectomy (total colpocleisis) * The surgical excision of the vagina

  4. Obliterative Genital Procedures • These procedures are often thought of as “destructive”, but can be extremely helpful, and should be in the armamentarium of every pelvic reconstructive surgeon. Cespedes (Tech Urol 2001)

  5. Background • Millions of older women are prevented from living full active lives because of symptoms caused by pelvic organ prolapse. • A significant percentage are poor candidates for definitive pelvic reconstructive procedures. • There are over four million women in the U. S. greater than 85 years of age, and that number is expected to increase dramatically.

  6. Reasons for Choosing Colpocleisis • Severe medical conditions • Advanced age • Fear of major surgery • The need to provide care for a debilitated spouse ( Young. J. Pelvic Med.2004)

  7. Euryphone

  8. Al Razi 864-930 CE

  9. Recent History • The idea was first proposed by Gerardin of Metz in 1823. • The operation was first performed by Neugebauer of Warsaw in 1867. • In 1876, Le Fort of Paris modified the Gerardin idea based on his observation that prolapse did not occur in cases of congenital septum of the vagina.

  10. Colpocleisis Procedures Le Fort — a narrow strip of central vaginal epithelium removed Neugebauer -- 6x3 cm strip, 3 cm proximal to the urethral meatus Goodall-Power -- proximal third of the vagina (enabled coitus) Cusier -- lateral excision— (enabled coitus) Extended Colpoperineorrhaphy--- Young (2004)

  11. Colpectomy Procedures(Total Colpocleisis) * Harmanli ---- 2003 • DeLancey ---- 1997

  12. Indications • Severe, symptomatic pelvic organ prolapse • Failure of conservative measures (pessary) • No desire for future vaginal coitus • When a definitive procedure for POP with little risk of recurrence and minimal associated morbidity is desired

  13. Pre Operative Precautions • Document normal cervix and endometrium (Pap, endometrial biopsy, sonogram) • Cystometry with prolapse reduced (Veronikus 1997, found SUI in 83% and ISD in 56%) • Consider IVP or Renal Sonography with severe prolapse (greater than stage III) • Rectal prolapse?

  14. Advantages • The advantage of this technique over sacrospinous ligament suspension and sacral colpopexy lies in the fact that damage to adjacent organs and major pelvic vessels and nerves is unlikely with colpocleisis. Because the plane of dissection is superficial, collateral organ damage is highly unlikely. DeLancey-1997

  15. Blood Loss • The blood loss incurred during colpocleisis is typically gradual and easily controlled, producing less stress on a weakened myocardium than the acute hemorrhage that can occur during reconstructive procedures such as sacral colpopexy or sacrospinous ligament fixatiion. von Pechmann (2003)

  16. Good, Fast, Cheap Success Rates: (Good?) Colpocleisis: good anatomic results --- 85-97% relief of symptoms --- 86-93% recurrence of prolapse – 0-3% Colpectomy: good anatomic results --- 89-100% relief of symptoms ------ 97-100% recurrence of prolapse -- 0-3%

  17. Blood Loss • Miklos (1995) --- 153 cc • Davila (2003) --- <100 cc • Von Pechmann (2003)--- 396 cc

  18. Fast and Cheap ? 0PERATING TIME • Miklos (1995) --- 55 minutes • Davila (2003 --- 36 minutes HOSPITALIZATION Davila ---- 36 hrs Miklos ---- 2.1days EXPENSE Local anesthesia results in considerable expense reduction (Kaye, Clin Geriatric Med. 1990)

  19. Disadvantages • Loss of coital ability: * One third of women over the age of 78 remain sexually active ( Rogers,2003) * 3% regretted loss of coital ability ( von Pechmann ) • Altered Body Image ? * QOL scores improved--- (Neimark,2003)

  20. “The pleasure is momentary, the position ridiculous, and the expense damnable.” Lord Chesterfield (1674-1773)

  21. New Onset Urinary Incontinence • Fitzgerald (2003) -- 16% • Goldman (1985) -- 10.2% • Harmanli (2003) -- 22% Reason ? Anatomic displacement (unkinking) of the urethrovesical junction ? • Von Pechmann performed some method of urethral support in 98% of those undergoing colpocleisis

  22. Ureteral Occlusion • Colpocleisis with levator plication---1.8% had post operative ureteral occlusion • Colpocleisis with levator plication and Vaginal Hysterectomy----- 8.1% had ureteral occlusion (von Pechman)

  23. Hydronephrosis with Stage III POP • One site -- 10% • Two sites -- 20.3% • Three sites -- 34.6% ( Beverly, 1997)

  24. Vaginal Bleeding(with the uterus left in place) * Late vaginal bleeding occurred in 1.8 % (Goldman,1985) * Cervical and endometrial cancer are rare. (less than one percent) (Reddy, 1972)

  25. Genital Malignancies in Women greater than 70 years of age Uterine cancer (all types)- 4.6 per 1,000 Cervical Cancer --- 0.6 per 1,000 Can Ques, (2005)

  26. Concurrent Procedures * Anti incontinence procedures * Rectocele repair * Enterocele repair * Perineoplasty

  27. Concurrent Incontinence Surgery Prevention of post operative stress incontinence must be balanced with the avoidance of disabling detrusor instability or urinary retention, as medical therapy may not improve symptoms, and urethrolysis after colpocleisis may be difficult. Additionally many patients will be unable to perform intermittent self catheterization.

  28. Urinary Complications of Severe Cystocele Baden-Walker Grade 1-2 Grade 3-4 Bladder outlet 6% 70% Obstruction ( reduced 25%) Detrusor 20% 54% Overactivity Impaired Detrusor Contractions 14% 13% Chaikin, 1998

  29. Evaluation before Incontinence Procedures • Because elderly patients with severe pelvic organ prolapse have a significant incidence of voiding dysfunction, including bladder outlet obstruction and inadequate detrusor contractions, multi channel urodynamic evaluations, including voiding studies, with the prolapse reduced, should be considered before choosing a surgical procedure.

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