9 Obliterative Procedures for the Correction of Pelvic Organ Prolapse

Benjamin M. Brucker, MD , Denise Chow, MD , Victor W. Nitti, MD

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9-1 Le Fort Partial Colpocleisis

9-2 Complete Colpectomy and Colpocleisis

9-3 Complete Colpectomy and Colpocleisis After Failed Previous Colpocleisis

Public health data indicate that the number of patients 60 years of age and older can be expected to double in the next 30 years from 11% to 22%. In addition, the life expectancy of women is longer than that of men. As a result there is a global trend toward aging and feminization of the population. Specific attention needs to be paid to disorders that affect this ever-growing elderly female population. Pelvic organ prolapse is extremely common in older women, and age is one of the most important risk factors for this disorder, which has a substantial negative impact on a woman’s quality of life.

When conservative treatment with a pessary has failed, surgical intervention is the only way to address the bothersome symptoms of prolapse. Geriatric patients with pelvic organ prolapse often have multiple comorbid conditions that make them less than ideal candidates for complex, time-consuming reconstructive procedures.

Obliterative procedures may be considered as an alternative in the appropriate setting, because they represent a safe, durable, and effective surgical option for frail elderly woman who do not wish to preserve sexual function and desire a rapid recovery. The term colpocleisis comes from the Greek root kolpos, which means “hollow,” and cleisis, which means “closure.” The technique has been described both in patients with an intact uterus and in patients who have previously undergone hysterectomy, and is termed a Le Fort partial colpocleisis (uterus present) or a complete colpectomy and colpocleisis (after hysterectomy).

Preoperative Evaluation

At the preoperative discussion, it is imperative to select a procedure that will achieve the following:

• Effectively treat the patient’s condition

• Minimize the patient’s perioperative risk

• Allow the patient to attain her treatment goals and expectations

The preoperative evaluation should begin with taking a thorough history and performing a physical examination. Specific questions should be asked about symptoms related to the pelvic floor, including prolapse symptoms, vaginal irritation, voiding problems, defecatory problems, lower urinary tract symptoms, and urinary incontinence. The use of validated symptom questionnaires can be very helpful.

It is also important to take a complete sexual history. The patient should fully understand that the procedure is aimed at closing the vagina and thus vaginal intercourse will no longer be possible. Sexual activity does decrease with increasing age, but nothing should be assumed, because very commonly elderly women remain sexually active into their eighth decade and beyond.

The vagina should be examined with the patient in both the supine and standing positions, if possible. The patient should be asked to strain during the examination so the extent of the prolapse can be determined. The position of the anterior wall, posterior wall, and apex of the vagina should be recorded. Use of a standardized measuring and recording system, such as the Pelvic Organ Prolapse Quantification (POP-Q) system or the Baden-Walker system (see Chapter 1), can be helpful.

An assessment of the patient’s continence is also recommended, because stress urinary incontinence commonly affects this population. Stress incontinence on prolapse reduction (also know as occult or latent stress incontinence) may be discovered preoperatively, which allows the patient and the physician to make a more informed decision about preforming a contaminant antiincontinence procedure. One way of assessing continence status is a “cough stress test.” The patient performs maneuvers that increase intraabdominal pressure with a relatively full bladder while the examiner observes for leakage of urine. If no incontinence is demonstrated, the prolapse should be reduced and the provocative maneuvers repeated. Another option is urodynamic testing. We find this helpful especially if the stress test result does not correlate with the patient history or if there are mixed incontinence symptoms, urinary retention, or other lower urinary tract complaints.

The preoperative assessment should also include measurement of a postvoid residual, since elderly women with pelvic organ prolapse are at risk for urinary retention. Ureteral obstruction from kinking of the distal ureter has also been described in this population, especially in patients with Pelvic Organ Prolapse Quantification (POP-Q) stage IV prolapse. Renal ultrasonography can be useful to rule out hydronephrosis or at least to provide a baseline so that the degree of hydronephrosis can be followed after surgery. Urinalysis is also recommended as part of the initial evaluation to ensure that the patient does not have a urinary tract infection or hematuria that may require treatment or further evaluation.

Once a Le Fort partial colpocleisis is carried out, the cervix and uterus can no longer be accessed vaginally. Thus, it is mandatory that any premalignant or malignant conditions of the cervix or endometrium be ruled out. The surgeon should document that cervical cytological analysis yields normal findings and that either the endometrial stripe is less than 5 mm by transvaginal ultrasonography or histological examination of an endometrial biopsy specimen shows no pathological changes.

Based on the patient’s age and potential comorbid conditions, medical or geriatric preoperative evaluation should be considered. Cardiology or pulmonary consultation can help in risk assessment and may be valuable in the event that additional expertise are needed postoperatively. Obliterative procedures can be done using general anesthesia, regional anesthesia, or even local anesthesia with intravenous sedation if the patient is very medically fragile.

Surgical Technique for Le Fort Partial Colpocleisis

1. After a Foley catheter is inserted into the bladder, two tenaculum or allis clamps are placed on the cervix to fully evert the vagina. A marking pen is used to outline two rectangles on the anterior and posterior surfaces of the vagina. This leaves a 2- to 3-cm strip of epithelium down each side of the everted vagina. The markings should be extended to approximately 2 cm from the tip of the cervix and approximately 3 to 4 cm below the urethral meatus. This will ultimately permit creation of a channel to allow egress of drainage from the cervix or uterus, should it occur, after the procedure is completed.

2. Lidocaine (0.5%) with 1:100,000 epinephrine is used to infiltrate underneath the epithelium. Hydrodissection helps in finding the correct plane and allows for a relatively bloodless dissection.

3. The anterior vaginal wall rectangle is incised with a scalpel. Sharp dissection is carried out with Metzenbaum or Mayo scissors (Fig. 9-1, A

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