COLPOCLEISIS: VAGINAL OBLITERATIVE PROCEDURES

http://www.youtube.com/watch?v=ExQq30qbbJE&feature=youtu.be

      Vaginal obliteration procedure for treatment of advanced pelvic floor prolapse.   Obliteration  of the vagina is an option for the surgical management of advanced symptomatic POP in  women who are not engaging in vaginal intercourse.  These procedures are indicated in a selected group of patients, usually frail elderly patients,     who are unable or do not wish to undergo more involved procedures such as hysterectomy and vaginal vault suspension. These patients are no longer desire for sexual function. These procedures can sometimes be performed under local or regional anaesthesia/ pudendal blocks.

Has relative good success rate  of between 85-100% patients either satisfied or very satisfied with the surgery. There was 5% regrat rate, especially interms of loss of sexual function. 

Indications:

·        Advanced prolapse

·        Medical unfit patients/ Frail elderly patients

·        Patient request simpler operation and failed previous sugeries

·        Patients with advance or Gobal Pelvic floor Failure ( GPFF)

·        Sexually not active

     Advantage

       ·        Short operating time

       ·        Minimal blood loss and complications

       ·        Day care procedure
       ·        Excellent cure rates (85-100%)

    Disadvantage

•     Recurrence of prolapse
•     Injuries to bladder/ rectum
•     Unable to perform sexual intercourse
•     Uterus still in situ, there is a remote possibility of cervical or endometrial carcinoma, pyometra
•    Regrat of loss of sexual function

1. Partial colpocleisis ( Le Port):

First performed by Neugebaucer in 1867, in this procedure the cervix and uterus is left behind and segment of anterior and posterior vaginal mucosa are removed.

Procedure:

·        Can be done under local or regional anesthesia

·       Opposite rectangular areas on the anterior and posterior    vaginal walls   are denuded of the epithelium.

·        The denuded epithelial areas are then sutured to each other with the uterus reduced to a proximal position so that the anterior rectal wall and the base of the perivesical fascia around the bladder base are fused.

·        Approximating the opposing walls of the vagina prevents descent of the uterus and practically obliterates the vagina.

·        The rectangular areas are designed so that a continuous lumen from the vaginal apex on both sides of the obliterated space will persist. This lumen serves to drain vaginal and uterine secretions.

2. Total Colpoclesis ( Complete Colpectomy): In post-hysterectomy vaginal vault prolapse patients or after a vaginal hysterectomy . First described by DeLancey and Morley

          Procedure:

·        The vaginal mucosa is completely excised.

·        A series of purse-string sutures are placed so that the vaginal fascial           and muscular layers are inverted.

·        The vagina is completely obliterated.

Complications:

•        Risk of injuries to bladder or rectum
•        Infection
•        De Nova  or persistance of stress urinary incontinence   (25-30%, FitzGerald & Brubaker et al)
•        Reversible Urethral occlusion ( 10%, Von Pechmann et al) 
•       Vaginal Evisceration ( very rarely)
•       Post operative regret of Loss of sexual function

References:

1.  A Prospective Analysis of Total Colpocleisis for Severe Uterovaginal Prolapse Journal of Pelvic Surgery. 7(2):72-78, March/April 2001. Terry Grody, Marvin H. MD; Merchia, Vikas MD; Nyirjesy, Paul MD; Kaplan, Eugene MD; Chatwani, Ashwin J. MD