Obliterative Procedures for Pelvic Organ Prolapse

10 Obliterative Procedures for Pelvic Organ Prolapse



Janelle Evans, MD, Mickey Karram, MD



image Video Clips online



10-1 Le Fort Partial Colpocleisis


10-2 Complete Colpectomy and Colpocleisis (Example 1)


10-3 Complete Colpectomy and Colpocleisis (Example 2)


As women live longer and healthier lives, pelvic floor disorders are becoming prevalent and increasingly important health and social issues. An estimated 63 million women will be 45 years old or older by 2030, and 33% of the population will be postmenopausal by 2050. In the United States, the largest segment of the population growth-wise is the woman above 60 years of age. Approximately 10% of women will undergo surgery at some point for pelvic organ prolapse or incontinence. Some studies have noted a reoperation rate for failures up to 30%, mainly in the anterior compartment. As a result of an increasing number of women entering the eighth and ninth decades of life, these individuals often develop symptomatic pelvic organ prolapse often after unsuccessful attempts at pessary therapy or surgery. These women frequently have concomitant medical issues and are not sexually active, making extensive surgery less than ideal. Procedures have been described to alleviate the symptoms of pelvic organ prolapse by obliterating the vaginal canal. Specifically, these procedures are classified as a Le Fort partial colpocleisis, in which the patient maintains her uterus in place, and a partial or complete colpectomy and colpocleisis is performed in the patient after hysterectomy. This chapter discusses the indications and techniques of these procedures.



Le Fort Partial Colpocleisis


A Le Fort partial colpocleisis is an option if the patient has her uterus and is no longer sexually active. Because the uterus is retained, evaluating any future uterine bleeding or cervical pathologic abnormalities is difficult. Therefore endovaginal ultrasound, endometrial biopsy, and Papanicolaou smear (Pap smear) must be performed before surgery. (Denehy et al, 1995) The ideal candidate for such a procedure is the patient who has complete uterine procidentia with symmetric eversion of the anterior and posterior vaginal walls (Figure 10-1).


image

Figure 10-1 Complete procidentia.




Case 1: Le Fort Partial Colpocleisis



image View: Video 10-1


An 82-year-old woman has symptomatic pelvic organ prolapse, secondary to a protrusion of her uterus and eversion of the vagina well beyond the introitus. Her medical history is complicated by chronic obstructive pulmonary disease and hypertension. She is widowed and has no interest in becoming sexually active in the future. After two previous attempts at pessary therapy, which failed secondary to her inability to maintain the pessary in place, she seeks definitive therapy. Her pelvic examination notes a complete uterine procidentia with the cervix extending 8 centimeters beyond the introitus and symmetric eversion of the anterior and posterior vaginal walls. She also complains of some recent voiding dysfunction and difficulty emptying her bladder. A simple office filling study documents a void of 200 ml with a residual of 120 ml. She is then filled to a maximum capacity of 250 ml; the sign of stress incontinence is not shown with or without a reduction of the prolapse. She has had a recent negative Pap smear, and an endometrial biopsy in the office notes an atrophic endometrium. After a detailed discussion, plans are made to proceed with a Le Fort partial colpocleisis, a Kelly-Kennedy plication of the bladder neck, and a levatorplasty and perineoplasty. Because of her chronic obstructive pulmonary disease, this procedure is to be performed under monitored anesthesia care (MAC) anesthesia with a pudendal block placed and local infiltration of an anesthetic.



Procedural Steps




1. The procedure is begun by placing the cervix on traction to evert the vagina. The vaginal mucosa is injected with 0.025% bupivacaine or 2% Lidocaine with 1 : 200,000 epinephrine just below the vaginal epithelium. A Foley catheter with a 5- to 10-ml balloon is placed in the bladder for identification of the bladder neck.


2. The areas that are to be denuded are marked anteriorly and posteriorly. The area should extend from approximately 2 cm from the tip of the cervix to 4 to 5 cm below the external urethral meatus. A mirror image on the posterior aspect of the cervix and vagina are also identified.


3. The previously outlined areas are removed by sharp dissection (Figure 10-2, A and C). The surgeon should leave the maximum amount of muscularis behind on the bladder and rectum. Hemostasis is an absolute must. While removing the posterior vaginal flap, one should not attempt to enter the peritoneum. If the peritoneum is inadvertently entered, the defect should be closed with an interrupted delayed absorbable suture.


4. The cut edges of the anterior and posterior vaginal walls are sewn together with interrupted delayed absorbable sutures. The knot should be turned into the epithelium-lined tunnels, when possible, which have been created bilaterally (see Figure 10-2, D–E). After the vagina has been inverted, superior and inferior margins of the rectangle can be sutured together (see Figure 10-2, F).


5. In the author’s opinion, a plication of the bladder neck or a synthetic midurethral sling should be routinely performed because of the high incidence of postoperative stress incontinence (see Figure 10-2, B). (Denehy et al, 1995) In addition, an aggressive perineorrhaphy with a distal levator plication should be performed to narrow the introitus, decrease the caliber of the genital hiatus, and build up the perineum. For the technique of levatorplasty, see page 172. (See Video 10-1, “Le Fort Partial Colpocleisis,” for a video demonstration of the procedure. image)


image image image image image image

Figure 10-2 A, Denuding of the anterior vaginal epithelium. B, Plication of the bladder neck. C, Denuding of the posterior vaginal epithelium. D, Approximation of most of the proximal surfaces. E, Lateral sutures are placed to allow for drainage canals. F, Distal sutures are placed to complete the colpocleisis.


(Drawings modified from Baggish MS, Karram MM: Atlas of pelvic anatomy and gynecologic surgery, ed 3, St Louis, 2011, Elsevier.)



Case Discussion


In general, approximately 90% to 95% of patients will have complete relief of symptoms with good anatomic results after undergoing a Le Fort partial colpocleisis. Complete breakdown or partial recurrence can be expected in 2% to 5% of patients, which is mostly because of either poor hemostasis with hematoma formation or an infectious process. Goldman and colleagues (1985) reported results and complications from a modified Le Fort partial colpocleisis in 118 patients; 91% of the patients had good anatomic results, whereas 85% had complete relief of symptoms, 2.5% had recurrence of their prolapse, 10.2% developed incontinence or a worsening of their incontinence, and 1.8% had late vaginal bleeding.


In general, postoperative complications are low in comparison with vaginal hysterectomy and compartmental repairs. De novo stress urinary incontinence is a known risk after obliterative procedures and should be thoroughly evaluated preoperatively with urodynamic testing to ensure that the patient has a normal postvoid residual volume and no evidence of genuine or occult incontinence. (Fitzgerald, 2003) Both the surgeon and the subspecialists should thoroughly assess the postoperative risks of thromboembolic events, cardiovascular issues, and other systemic abnormalities in the patient with multiple co-morbidities to ensure an appropriate surgical and anesthesia plan. (Gerten et al, 2008)


In the opinion of the authors, a concomitant levatorplasty and perineorrhaphy should be a component of any Le Fort colpocleisis because of the theoretical risk that anatomic failure may be minimized by supporting the perineum with a tighter pelvic outlet as well as decreasing the size of the genital hiatus.

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Related posts:

Preoperative Evaluation and Staging of Patients with Pelvic Organ Prolapse Robot-Assisted Laparoscopic Colposacropexy and Cervicosacropexy Surgical Anatomy of the Pelvis and the Anatomy of Pelvic Support Surgical Management of Anterior Vaginal Wall Prolapse Surgical Correction of Posterior Pelvic Floor Defects Surgical Management of Apical Vaginal Wall Prolapse

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Jul 24, 2016 | Posted by in UROLOGY | Comments Off on Obliterative Procedures for Pelvic Organ Prolapse

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