As the focus of this chapter is the discussion of perioperative complications , it is beyond our scope to describe, in detail, the nuances of each surgical technique. However, it is important to note that preoperative counseling and perioperative management unequivocally aid in decreasing the rates of postoperative adverse sequelae. Prior to undergoing a partial colpocleisis, it is recommended that women should have their upper genital tract evaluated with either transvaginal ultrasound or endometrial biopsy. Papanicolaou smear must be performed prior to surgery to assess for abnormal pathology. Women who require upper genital tract surveillance, such as those with preinvasive conditions of the cervix or endometrium, should be considered for other forms of repair.

If overt stress urinary incontinence (SUI) is present, consideration should be given to a concomitant anti-incontinence procedure. However, women with significant POP may be subjectively continent because the bladder base descent may mechanically kink and dynamically compress the urethra [9]. In these cases, the SUI uncovered only after POP reduction is called occult SUI and its incidence in the literature fluctuates significantly from 6 to 80% [10–15]. The wide range reflects the lack of universal criteria for the diagnosis of occult SUI and the multitude of techniques described for POP reduction [11]. A recent multi-institutional study from the Netherlands found that women with occult SUI had a higher risk of reporting SUI after POP surgery compared with women without occult SUI [16]. Adding a midurethral sling (MUS) to POP surgery reduced the risk of postoperative SUI and the need for its treatment in women with occult SUI. Of women with occult SUI undergoing POP-only surgery, 13% needed additional MUS. Hence, preoperative evaluation with POP reduction should merit strong consideration.

Upper urinary tract evaluation is another preoperative consideration. In one retrospective study of 121 women with POP, the overall incidence of hydronephrosis was 20.6% [17]. The incidence of hydronephrosis in patients with severe vault POP was 7.1 and 22.4% in women with severe uterovaginal POP. The incidence of renal impairment was 3.3%. Of interest, 64% of the 25 patients with hydronephrosis had complete resolution after treatment while 20% had residual but smaller degrees of hydronephrosis. Preoperative renal ultrasonography and postoperative surveillance may be considered.

As the majority of postoperative morbidity is related most closely to surgical stress on the elderly, a medical and cardiac, clearance may be necessary. This will often dictate the method of intraoperative anesthesia, and these surgeries have been performed under both regional and local anesthesia with success [18, 19]. The ultimate choice of anesthesia is at the discretion of the surgeon, anesthesiologist, and patient. As the incidence of rectal and small bowel injury is very low, preoperative bowel regimen may be omitted, but should be considered in women with a history of significant constipation or multiple previous vaginal surgeries [20, 21].

Finally, preoperative counseling and a thorough discussion of risks and benefits, as well as options to colpocleisis, should be undertaken. Although long-term anatomic cure rates of colpocleisis typically exceed 90%, intraoperative and postoperative complications do occur [22]. Additionally, if an anti-incontinence procedure is performed in the same setting, the risks of this surgery should be included in the informed consent process. Furthermore, approximately 10% of women experience regret after undergoing colpocleisis and should be counseled appropriately regarding the loss of vaginal depth [23].

Prophylactic intravenous antibiotics are given within an hour of surgical “cut” time (first or second-generation cephalosporin, gentamycin and clindamycin, or a fluoroquinolone) [24]. As rates of deep vein thrombosis (DVT) approach 15% for benign pelvic surgery, a prophylactic strategy should be employed in each surgery [25]. Intermittent pneumatic compression (IPC) devices are applied prior to induction of anesthesia. Also, as age >60 years alone places women undergoing colpocleisis into the high-risk category for DVT, consideration should be given to combination therapy with IPC plus low-dose unfractionated heparin (LDUH) or low molecular weight heparin ( LMWH) , unless the bleeding risk is considered unacceptably high. The presence of additional risk factors, such as smoking, obesity, immobility, estrogen-containing oral contraception or hormone replacement therapy, or heart or respiratory failure, places the woman into the highest risk category and LDUH or LMWH is strongly recommended [25]. If required, pubic hair is clipped in the operating room to minimize skin trauma. We prefer to keep an indwelling urethral catheter to continuous drainage during the surgery. A Scott/Lone Star retractor may be of assistance in obtaining exposure. Finally, general tenets, such as cautious intraoperative hydration, minimization of blood loss, meticulous hemostasis, and consideration for transfusion to minimize anemia and cardiac compromise, are imperative adjuncts to any surgical procedure in the elderly population [22].

While each surgeon performing these procedures on a regular basis has their own routine to optimize anatomic outcomes and minimize adverse sequelae, we propose several general tenets that are germane to any colpocleisis protocol. First, while the “deep” plane of dissection into the true vesicovaginal space may be preferred for the placement of interposition grafts or transvaginal mesh, we keep our plane of dissection superficial to the pubocervical and rectovaginal fasciae. This lessens the possibility of injury to pelvic viscera, urethra, or ureters, as the latter may be rotated forward significantly from significant anterior compartment prolapse. Second, intraoperative stenting with temporary urethral catheters may potentially lessen the chance of ureteral injury, and definitely assist in recognizing such an injury, should it occur. Also, we perform intraoperative cystoscopy with each colpocleisis surgery, regardless of concomitant anti-incontinence procedure. This step assists in identifying any bladder injury and has a sensitivity and specificity for identifying ureteral obstruction of 94.4% and 99.5%, respectively [26]. Rare false negative cases may occur with partial obstruction. Third, as recommended by Fitzgerald and coworkers, we typically preserve at least 1.5 cm of the anterior vaginal epithelium proximal to the urethrovesical junction [22]. The purpose is to avoid downward traction on the urethra when it is approximated to the posterior vaginal muscularis. Fourth, a concomitant MUS may be placed through a separate 1 cm suburethral incision to minimize migration towards the bladder neck. If the patient opts for an autologous rectus fascia pubovaginal sling, a single incision is used for the sling and colpocleisis. The sling is anchored to the underlying pubocervical fascia to keep it from dislodging. Regardless of sling choice, sling tensioning is performed after all of the POP surgery has been performed. Finally, a levator myorrhaphy or perineorrhaphy (our choice) is performed to decrease the size of the genital hiatus and minimize POP recurrence [22].

In a PubMed review of available literature (1996–2004), FitzGerald and coworkers cited “success” rates of 91–100% [22]. The authors note that the early literature is fraught with poor characterization of preoperative symptoms and inconsistent postoperative follow-up. Outcomes of more recent studies by Zebede and coworkers and Koski and colleagues support the low anatomic recurrence rates of colpocleisis [27, 28].

Colpocleisis for POP is also associated with high subjective success rates. A recent prospective study assessed quality of life (QoL) in women >65 years of age undergoing obliterative and reconstructive procedures and found significant postoperative QoL improvement without an increase in depression or body image [29]. Vij and colleagues performed a longitudinal study involving 34 women who underwent colpocleisis with a median follow-up of 3 years and demonstrated that 91% of women would recommend colpocleisis to a relative or friend [30]. Likewise, in von Pechmann’s series, telephone follow-up revealed that 90.3% of patients achieved subjective cure and were either satisfied or very satisfied with how surgery resolved their POP [31].

Intraoperative complications can be divided into hemorrhage and injuries to surrounding structures. Zebede and colleagues cited intraoperative complications in 1.6% of their patient population [27]. These included bowel injury and hematoma during concomitant suprapubic catheter placement in two patients, two small bladder punctures during trocar passage for MUS placement, and one uterine injury during hysteroscopic resection of a mass. Of interest, the added complication rate appears to be strongly associated with concomitant surgery, and specifically hysterectomy [22]. Outcomes of two studies, in particular, both revealed low rates of intraoperative complications; however, mean operative times, estimated blood loss, postoperative transfusion rates, and length of hospital discharge were significantly higher in the groups undergoing concomitant hysterectomy [21, 31].

Ureteral injury and obstruction has been estimated to occur in 0.3–11% of all types of pelvic reconstructive procedures [32, 33], while the rate of ureteral obstruction during colpocleisis, specifically, is approximately 4% [26]. Ureteral obstruction is hypothesized to occur from kinking at the trigonal level secondary to anterior vaginal wall distortion. Intraoperative identification of obstruction and injury is imperative to prevent long-term complications requiring complex ureteral reconstruction. As vaginal surgery does not allow easy identification of the ureters, cystoscopy after administration of intravenous dye can confirm ureteral and bladder integrity [26]. If an obstruction is suspected, removal of the offending suture intraoperatively will relieve the ureteral obstruction in about 90% of cases, whereas other patients may require a ureteral stent for 2 weeks to allow resolution of the intramural ureteral edema with no residual kinking seen on postoperative imaging [26, 31].

Conversion to laparotomy is a rare event and has been associated with concomitant hysterectomy [31]. Whereas vascular injury secondary to a bleeding ovarian vessel at time of concomitant adnexectomy was reported in one patient, the second laparotomy was due to rupture of a diverticular abscess upon entry into the pouch of Douglas. Furthermore, a proctotomy was identified on a third patient and was repaired without incident [31].

While the elderly are at higher risk for complications during vaginal surgery, those women undergoing colpocleisis may experience fewer overall complications. A recent retrospective analysis of 264,340 women from the Nationwide Inpatient Sample found that the overall in-hospital mortality risk was 0.04% after POP surgery [34]. When compared with women <60 years of age, the odds ratio of mortality in women >80 years of age was 13.6. The overall complication rate was 14.4% with 20% of women >80 years of age having one or more complications. Those octogenarians who underwent obliterative procedures were less likely to suffer a complication as compared to those receiving reconstructive procedures (17% vs. 24.7%).

A retrospective, multi-institutional study involving 145 medical centers reviewed over 4700 colpocleisis procedures dating from 2002 to 2012 and cited overall complication rates of 6.82% [35]. Despite 53% of the procedures being performed in octogenarians, the intensive care unit (ICU) admission rate was only 2.8% and there were seven deaths for a mortality rate of 0.15%. Readmissions were uncommon, with an overall 30-day readmission rate of 4.2%. Higher volume centers had lower ICU admission rates and shorter length of stay.

In another retrospective review of colpocleisis procedures from the American College of Surgeons NSQIP database, Catanzarite and colleagues cited an 8.1% overall complication rate within 30 days [36]. The most common complication was UTI in 6.4% and only 2.1% required a return to the operating room within 30 days. Concomitant sling placement did not increase the 30-day complication rates. In another study of 245 women, postoperative UTI occurred in 34.7% [21].