Tips and Tricks for Colpocleisis

The patients with pelvic organ prolapse seeking surgical intervention have the option of a reconstructive or an obliterative approach. The treatment choice typically depends on the patient’s level of activity, prolapse severity and medical comorbidities.

A colpocleisis is an obliterative procedure usually reserved for those with significant medical illnesses without a desire for future penetrative sexual intimacy. It is typically recommended for the elderly population with the advantage being that it can be performed expeditiously and under local anesthesia. The procedure was first performed in 1867 by L. Neugebauer of Poland and later popularized in 1977 by L. Le Fort of France.³ The steps of the surgical procedure include dissection of the vaginal tissue off the underlying fibromuscular layers anteriorly and posteriorly. This can be done with or without leaving strips of epithelium creating channels for draining. The anterior and posterior fibromuscular layers are then brought together with either interrupted purse-string or horizontal rows of sutures. Though there are technique variations, the following principles are important:

1. Confirm patient has no future desire for penetrative sexually intimacy.
2. Ensure equivalent anterior and posterior vaginal wall prolapse.
3. Identify ulcerations and prepare vaginal epithelium with estrogen therapy.
4. Liberal use of hydrodistention media i.e., lidocaine the epinephrine.
5. Utilize scalpel blade and minimize direct application of cautery to vaginal epithelium.
6. Perform sharp dissection with Tenotomy and/or Metzenbaum scissors most importantly at the level of the bladder neck and posterior cul-de-sac where fibromuscular tissue can sometimes be attenuated. Aggressive tissue handling in the above areas may potentially result in an enterotomy.
7. Close all dead space limiting the potential for hematoma formation.
8. Ensure full thickness purchase of fibromuscular tissue approximately 1 cm apart.
9. A concomitant sling may be placed if occult stress incontinence is diagnosed.
10. Leave 1.5-2.0 cm of vaginal epithelium intact at the level of the urethra under which a sling is placed.
11. Place interrupted sutures 1 cm apart in a tension free fashion thereby bringing together the distal anterior and posterior vaginal epithelium in a tension free fashion. This will allow for drainage.
12. Ensure adequate hemostasis with use of cautery and suture ligation of bleeding vessels.
13. 2-0 Vicryl or PDS sutures can be used.
14. Finally, perform levator ani plication closing the genital hiatus allowing for adequate visualization of the urethral meatus.

These techniques have resulted in a high rate of anatomical success and low complications. Colpocleisis remains relevant in contemporary medicine as a treatment option for those with symptomatic prolapse. It is my preferred approach for those who are elderly as it affords minimal anesthesia exposure and has a high patient satisfaction.

REFERENCES

1. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007; 369(9566): 1027–1038.
2. Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in the women’s health initiative: gravity and gravidity. Am J Obstet Gynecol 2002; 186(6): 1160–1166.
3. Meriwether KV, Gold KP, de Tayrac R, et al. Joint report on terminology for surgical procedures to treat pelvic organ prolapse. Int Urogynecol J. 2020;31:429–63.