Vaginal Obliterative Procedures for Pelvic Organ Prolapse: A Systematic Review

Vaginal Hysterectomy at the Time of Total Colpocleisis: A Single-Center Experience

OBJECTIVE

This study aims to evaluate the five-year experience of a single center regarding the total colpocleisis procedure.

METHODS

This is a retrospective review of 24 women who underwent total colpocleisis at the study center between January 2017 and January 2023. Every participant was informed about this study, and written consent was obtained from each participant who then took Pelvic Floor Distress Inventory-20 (PFDI-20), Body Appreciation Scale-2 (BAS-2) and Decision Regret Scale (DRS) questionnaires consecutively.

RESULTS

Eight patients (33.3%) underwent total colpocleisis, whereas 16 patients (66.7%) had concomitant colpocleisis and vaginal hysterectomy. The number of total colpocleisis cases did not change significantly with respect to the past years (p=0.117). The patients who underwent total colpocleisis and the patients who had concurrent colpocleisis and hysterectomy were statistically similar with respect to age, gravidity, chronic disease, blood group, American Society of Anesthesiologists classification, anesthesia type, surgery timing and preoperative and postoperative hemoglobin values (p>0.05 for all). Operative time was significantly shorter in patients who had colpocleisis alone (p=0.001). Both patient groups were also statistically similar in aspects of blood loss, transfusion need, hospital stay, postoperative complications and follow-up time as well as PFDI-20, BAS-2 and DRS scores (p>0.05 for all). Endometrial atrophy (56.3%), endometrial hyperplasia (18.8%) and adenomyosis (12.5%) were the most common histopathological findings detected in vaginal hysterectomy specimens.

CONCLUSION

The combination of vaginal hysterectomy and total colpocleisis appears as a safe and efficient approach which does not contribute to the surgery-related morbidity despite the significantly longer operative time.

Risk factors for pelvic organ prolapse recurrence following colpocleisis: A meta-analysis

BACKGROUND

Studies aimed to assess risk factors for pelvic organ prolapse (POP) recurrence following colpocleisis with nonconclusive results.

OBJECTIVE

To investigate risk factors for POP recurrence following colpocleisis.

SEARCH STRATEGY

MEDLINE, PUBMED, Embase, Web of Science, and Cochrane databases were systematically searched.

SELECTION CRITERIA

Experimental and non-experimental studies investigating POP recurrence following colpocleisis.

DATA COLLECTION AND ANALYSIS

We assessed the association between preoperative and postoperative physical examination findings, demographics and medical history, and the risk of recurrence following colpocleisis.

MAIN RESULTS

A total of 954 studies were identified, of which five studies comprising 2978 patients were eligible for analysis. Both preoperative and postoperative genital hiatus length were significantly longer in the recurrence group (mean difference [MD] 0.48, 95% confidence interval [CI] 0.01-0.94, P = 0.04, I2  = 0% and MD 1.15, 95% CI 0.50-1.81, P = 0.005, I2  = 0%; respectively). Preoperative total vaginal length (TVL) did not differ between groups (MD 0.05, 95% CI -0.40 to 0.50, P = 0.83, I2  = 6%), postoperative TVL was found significantly longer in the recurrence group (MD 0.07, 95% CI -0.03 to 1.38, P = 0.04, I2  = 68%). Both preoperative and postoperative perineal body did not differ between groups. Women with a previous POP surgery were more likely to experience recurrence following colpocleisis (relative risk 2.09, 95% CI 1.18-3.69, P = 0.01, I2  = 0%). Patient's age and previous hysterectomy did not affect recurrence rates.

CONCLUSION

Wider preoperative and postoperative genital hiatus as well as longer post-operative TVL and previous POP surgery were associated with a higher risk for recurrence following colpocleisis, highlighting the importance of appropriate patient selection and surgical technique in minimizing this risk.

Complete labia majora fusion after obliterative surgical procedure: a video case report

Obliterative surgical procedures have been classically used as a method to reduce pelvic organ prolapse in elderly women who do not wish to preserve the vagina for sexual intercourse. The aim of this video is to demonstrate a surgical technique of repairing complete labia majora fusion in a woman who had previously undergone one of these procedures. We present the case of an 80 year-old woman with a history of progressive difficulty on voiding onset and sensation of incomplete bladder emptying. She reported an obliterative procedure to correct her pelvic organ prolapse (POP) 10 years earlier. On physical examination, complete fusion of labia majora was observed, causing abnormal urinary drainage. Perineal reconstructive surgery was performed without complications and the application of topical Promestriene was prescribed. Optimal genital re-epithelization was observed during follow-up. As observed, patients undergoing obliterative surgery who present with genital atrophy are at increased risk of developing vulvar adherences. Applying vaginal moisturizers or local topical estrogens can prevent this condition. In severe vulvar fusions, early surgical treatment is recommended to prevent potentially serious complications.

Perioperative complication rates of colpocleisis performed with or without concomitant hysterectomy: a large population-based study

INTRODUCTION AND HYPOTHESIS

We aimed to compare perioperative complications for women who underwent colpocleisis with and without concomitant hysterectomy, and report the rate of concomitant hysterectomy.

METHODS

We conducted a retrospective study using the Healthcare Cost and Utilization Project (HCUP) - Nationwide Inpatient Sample 2004 to 2014. We used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify women with pelvic organ prolapse (POP) who underwent colpocleisis with or without concomitant hysterectomy. Trend over time of each procedure type was created. We calculated odds ratios (ORs) to determine the risk of perioperative complications with or without concomitant hysterectomy. ORs were adjusted for age, race, income, insurance plan, and hypertension.

RESULTS

Of 253,100 adult women who underwent POP repair, 7,431 had colpocleisis. Colpocleisis with concomitant hysterectomy was performed in 1,656 (22.2%) and 5,775 (77.7%) underwent colpocleisis alone (2,469 [33.2%] had a previous hysterectomy). Hysterectomy rates among women with POP undergoing colpocleisis remained relatively steady, whereas those undergoing colpocleisis without hysterectomy declined over time. Prevalence of any complications was higher among those with concomitant hysterectomy (11.4% vs 9.5%, p=0.023). Adjusted OR showed that concomitant hysterectomy increased the risk of complications (OR 1.93, 95% CI 1.45-2.57, p<0.001).

CONCLUSIONS

Our large administrative data analysis suggests an increased risk of complications when performing a hysterectomy at the time of colpocleisis. A concomitant hysterectomy was performed in 22% of cases. Whether or not to include hysterectomy at the time of colpocleisis is based on shared decision making, influenced by individual patients' values, comorbidities, and risk of complications.

Risk Factors for Urinary Retention After Colpocleisis

OBJECTIVES

Transient urinary retention occurs frequently after pelvic organ prolapse surgery. While the prevalence of postoperative urinary retention has been reported for reconstructive procedures, a paucity of data exists for colpocleisis. The objectives of this retrospective cohort study were to identify risk factors for transient urinary retention after colpocleisis and to determine the rate of its occurrence.

METHODS

A retrospective chart review was performed for patients undergoing colpocleisis from January 2015 to December 2019 in a high-volume urogynecology practice. Patients were excluded if they required prolonged catheterization postoperatively because of a surgical complication or used a catheter before surgery, or if a suprapubic catheter was placed during surgery. Potential patient and procedural risk factors were analyzed. Transient urinary retention was diagnosed if patients failed their postoperative voiding trial and went home with a catheter.

RESULTS

A total of 172 patients met the inclusion criteria. The incidence of transient postoperative urinary retention was 55%, with rates of 36.7% with LeFort colpocleisis, 51.5% with posthysterectomy colpocleisis, and 64.9% with colpocleisis with concomitant hysterectomy. Logistic regression revealed an increased risk of postoperative urinary retention if hysterectomy was performed at the time of colpocleisis (odds ratio, 2.9; confidence interval, 1.23-6.84; P = 0.015). Patient age, prolapse severity, preoperative postvoid residual volume, and concomitant anti-incontinence procedure were not associated with transient postoperative urinary retention.

CONCLUSIONS

Transient urinary retention occurs in more than half of patients after colpocleisis. Patients undergoing concomitant hysterectomy have the highest risk of postoperative urinary retention. Surgeons can use this information both for counseling and management decisions for individual patients.

Urinary retention is rare after colpocleisis and concomitant midurethral sling: a 10-year experience

OBJECTIVES

The optimal method of managing stress urinary incontinence (SUI) in women undergoing colpocleisis remains unclear, especially in a setting of urinary retention. We aim to compare postoperative retention after colpocleisis with or without concomitant midurethral sling (MUS).

METHODS

A retrospective chart review of all women who underwent colpocleisis with or without MUS from October 2007 to October 2017 was performed. Women with preoperative and 2-week postoperative post-void residual volume (PVR) measurements were included. Urinary retention was defined as PVR of ≥100 ml. Analysis included t tests/Wilcoxon rank, Chi-squared/Fisher's exact, and multivariate linear regression models.

RESULTS

A total of 231 women with a mean age of 77.7 years (± 6.0 years SD) met the inclusion criteria. One hundred and thirty-eight women underwent colpocleisis alone, whereas 93 women had colpocleisis with MUS. Preoperative retention rates were high (44.9% vs 34.4%, for colpocleisis alone versus with MUS, p = 0.114). Postoperative retention rates were lower and similar between the groups (10.1% vs 11.8%, for colpocleisis alone vs with MUS, p = 0.69). Linear regression models showed the adjusted odds ratio for postoperative urinary retention in patients with concomitant MUS was 1.68 (95% confidence interval: 0.64-4.41) compared with patients with colpocleisis alone and this did not reach statistical significance (p = 0.292). Fortunately, after colpocleisis, women had high rates of resolution of retention, regardless of MUS (80.3% vs 90.6% for colpocleisis alone vs with MUS; p = 0.20). Few women required reoperation for retention (3.1%).

CONCLUSIONS

Placement of an MUS at the time of colpocleisis is a safe and effective therapy. This appears to be unaffected by preoperative urinary retention status.

Risk factors predicting the loss of functional independence after obliterative procedures for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

To determine the risk factors associated with loss of functional independence after obliterative procedures for pelvic organ prolapse (POP).

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was used to collect data on women who underwent obliterative vaginal procedures from 2011 to 2016, using current procedural terminology (CPT) codes for LeFort colpocleisis (57120) and vaginectomy (57110). The criterion for loss of functional independence was a transition from a functionally independent status to a dependent status (discharge to a post-care facility) or death within the 30-day postoperative period. Multivariate regression analysis was utilized to determine factors associated with loss of functional independence.

RESULTS

A total of 1847 women were included in the analysis. A loss of functional independence was noted in 50 of the 1847 women (2.6%). The women who suffered loss of functional independence were older than those who were independent postoperatively (mean age 79.3 years, SD 7.47 vs. 76.7 years, SD 8.1, respectively). On multiple logistic regression analysis, age ≥ 80 years (OR 2.8, 95% CI 1.4-5.5), American Society of Anesthesiologists (ASA) classification ≥ 3 (OR 2.3, CI 1.1-4.7) and length of stay ≥ 5 days (OR 15.2, 95% CI 6.2-37.1) remained significantly associated with an increased risk of loss of functional independence.

CONCLUSIONS

Age ≥ 80 years, ASA classification ≥ 3 and longer length of stay are associated with an increased risk of loss of functional independence after an obliterative procedure for pelvic organ prolapse. Consideration of these factors during the preoperative decision-making process may help improve outcomes in this cohort.

Total colpocleisis technique in huge neglected ulcerated uterovaginal prolapse

INTRODUCTION AND HYPOTHESIS

We present a video describing the technical considerations for performing a total colpocleisis in the management of significant, neglected, ulcerated, and symptomatic complete uterovaginal prolapse.

METHODS

A 79-year-old debilitated woman presented with a large, ulcerated pelvic bulge. A previous attempt at pessary treatment failed because of a disproportion of the pessary with the prolapse size. She had a history of liver insufficiency and hypertension. Obliterative colpocleisis surgery was selected because the healing of a large ulcerated vagina was not likely within a short timeframe. Sharp dissection with scissors and de-epithelialisation of the remaining non-eroded vaginal mucosa with the friction of a sharp-edged surgical knife were performed. Closely located purse strings were used to obliterate potential spaces. Two mirror image triangles in the anterior and posterior vaginal walls were removed. After the formation of a new perineal body, the diamond-shaped vaginal incision was closed vertically to narrow introitus.

RESULTS

The patient was discharged on the first postoperative day and an uncomplicated postoperative course ensued. At the 4-week follow-up, there was no evidence of infection, recurrent prolapse, de novo stress incontinence, or voiding with difficulty.

CONCLUSIONS

Total colpocleisis is an excellent surgical option in women with multiple, large cervicovaginal ulcers and multiple comorbidities with no desire for penetrative vaginal function.

Colpocleisis with a skin flap

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse is a common problem affecting up to 50% of women over the age of 50. The various methods of reconstructive pelvic organ prolapse surgery have been reported to be associated with long-term recurrence rates of up to 50%.

METHODS

Management of patients with repeated failure of different surgical procedures is often challenging. Obliterative surgery can be an option for women with a POP-Q stage 2 or larger genital prolapse who are not sexually active. The video of the procedure shows how to address enterocele with frail and puffy vaginal epithelium of the posterior vaginal wall after unsuccessful surgery procedures by employing a perineal skin flap. The repeated enterocele was treated by using a skin flap during a LeFort colpocleisis, and Labhard perineoplasty was added.

RESULTS

In some patients obliterative surgery may fail, especially those with recurrent POP. The use of a perineal skin flap in reoperation of POP is a possible solution for surgical treatment of recurrent enterocele with poor quality of the posterior vaginal wall. This patient's postoperative course was uneventful. At her follow-up visit 2 months later an examination revealed excellent healing.

CONCLUSION

Obliterative surgery can be an option for women with large prolapses who are not sexually active and do not plan to be so in the future. Le Fort with perineal skin flap and Labhard high perineoplasty is one possible surgical technique which can treat recurrent pelvic organ prolapse in older patients where previous procedures have failed.

The underutilization of obliterative and constrictive surgery in the surgical treatment of pelvic organ prolapse

Vaginal length and caliber are necessary for satisfactory vaginal coitus. Surgical treatment of pelvic organ prolapse (POP) can include preservation of vaginal length and caliber, or shortening and narrowing of the vagina (constrictive and obliterative surgery). The latter option is proven to have fewer complications and a lower risk of recurrence of POP. Women undergoing surgical intervention for POP who are not coitally active and choose not to be coitally active for the rest of their lives should be offered constrictive and obliterative surgery.

FPMRS challenges on behalf of the Collaborative Research in Pelvic Surgery Consortium (CoRPS): managing complicated cases : Series 3: Challenging recurrent prolapse in a medically complicated patient

This case presents the work-up and management of a spina bifida patient with recurrent prolapse. Four international experts also provide their evaluation of and approach to this complex case. According to the literature, little is known regarding the approach to the management of this specific patient population.

Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines

OBJECTIVE

We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines.

DATA SOURCES

The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017.

STUDY ELIGIBILITY CRITERIA

We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed.

RESULTS

We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation.

CONCLUSION

Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.