COLPOCLEISIS: VAGINAL OBLITERATIVE PROCEDURE

Colpocleisis is a vaginal obliteration procedure for treatment of advanced pelvic organ prolapsed (POP) or Global pelvic floor failure (GPFF).  Obliteration of the vagina is a surgical option for patients with advanced symptomatic POP who are not engaging in vaginal intercourse.

Colpoclesis can be divided into total (complete) colpoclesis or partial (Le Fort) colpocleisis.

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, pudendal blocks, intravenous sedation or regional anaesthesia.

It has  relatively good success rate  of between 85-100% patients claim to be satisfied or very satisfied with the sugery.

Indications:

·         Advanced pelvic organ prolapsed/ Global Pelvic Floor Failure 

·         Medical unfit patients/ patients with comorbidity

·         Frail elderly patients

·         Patient request simpler operation

·         Patient who could not stand long surgery

·         Sexually not active/ disinterested in maintain sexual function

·         Unsuccessful trial of vaginal pessaries or surgeries 

 Advantage:

  ·      Shorter operating time, takes half the time of vaginal  hysterectomy

 ·       Minimal blood loss and complications

 ·       Excellent cure rates or success rate

 Disadvantage: 

·         Recurrence of Pelvic organ prolapse

·         Injuries to bladder/ rectum

·         Unable to perform sexual intercourse

·         If uterus still in situ as in Le Fort operation, there is a remote possibility of cervical or endometrial carcinoma.

A.  Partial Colpocleisis ( Le Fort): 

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, iv sedation, pudendal block or regional anesthesia

·         The rectangular epithelial areas on the anterior and posterior vaginal wall are denuded.

·         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.

B. Total Colpoclesis (Complete Colpectomy):

Total colpocleisis can be performed in post-hysterectomised vaginal vault prolapse patients or after a vaginal hysterectomy. This procedure was first described by DeLancey and Morley.

 Procedure:

 ·         The vaginal mucosa is completely excised from the base of the prolase by a circumscribing incision.                      Subsequently the vaginal skin is denuded. 

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

·         The vagina is completely obliterated. 

·         This can be followed by standard Kelly’s placation, Levator ani plication or perineorhaphy

 Complications:

 Immediate/ Intermediate:

 ·         De novo urinary incontinence in 27%

 ·         Persistent stress urinary incontinence in 28% patients

 ·         Transient Ureteral occlusion in 10% patients

 Late/delayed:

·         Risk of injuries to bladder or rectum

·         Infection

·         De Nova or persistence of stress urinary incontinence   (25-30%)

·         Vaginal Evisceration ( very rarely)

·         Post operative regret of loss of sexual function in 5% of patients

Consent & permission has been taken to publish this pictures & video from the patients for the purpose of teaching junior doctors)

References:

1. Denehy TR, Choe JY, Greori CA et al. Modified Le Fort Partial Colpoclesis with Kelly urethral placation and posterior colpoperineoplasty in medically compromised elderly. Am J Obstet Gynaecol 1995; 173(6): 1697-1702.

 2. Le Fort L. Nouveau precede pour ia guerison du prolapsus uterin. Bull Gen Therp. 1877; 92:337-346

3.  DeLancey Jo, Morley GW. Total colpocleisis for vaginal eversion. Am J Obstet Gynaecol, 1997;176(6): 12278-1235.

 4. FitzGerald MP, Brubaker L. Colpoclesis and urinary incontinence. Am J obstet Gynaecol, 2003;189(5): 1241-1244.

 5. Von Pechmann WS, Mutone M, Fyffe J et al. Total Colpocleisis with high levator plication for the treatment of advance pelvic organ prolapsed. Am J Obstet Gynaecol, 2003;189(1): 121-126

 6. Ubachs JM, Van santé TJ, Schellekens LA. Partial colpocleisis by a modification of Le Fort’s operation. Obstet Gynaecol, 1973; 42(3): 415-420