Colpocleisis
Colpocleisis is an obliterative vaginal surgical procedure designed to treat severe pelvic organ prolapse by partially or completely closing the vaginal canal, thereby providing support to prolapsed pelvic structures while precluding vaginal intercourse.[1][2] Primarily indicated for elderly women with advanced prolapse who do not desire future sexual activity and often have significant comorbidities precluding more extensive reconstructive surgeries, the procedure involves excision of vaginal epithelium and approximation of the anterior and posterior vaginal walls.[3][4] The most common variant, partial colpocleisis or Le Fort procedure, preserves a small transverse channel between the urethra and rectum for urinary and rectal drainage, whereas total colpocleisis or colpectomy removes the entire vaginal epithelium.[2] Performed transvaginally under anesthesia, colpocleisis demonstrates high anatomic success rates of 91% to 100% in resolving prolapse symptoms, with objective cure rates exceeding 95% in long-term follow-up for appropriately selected patients.[5][6] Complication rates remain low at 6% to 15%, including risks such as urinary tract infection, stress urinary incontinence, or rare mesh erosion if concomitant procedures are used, though regret over loss of coital function is infrequent at under 5%.[5][7] This approach prioritizes durability and minimal invasiveness over vaginal preservation, offering a viable alternative to reconstructive techniques in non-sexually active populations where prolapse severely impairs quality of life.[8][9]Definition and Overview
Procedure Description
Colpocleisis is an obliterative vaginal surgery designed to correct severe pelvic organ prolapse by shortening and narrowing the vaginal canal through approximation of the anterior and posterior vaginal walls. The procedure entails excision of strips of vaginal epithelium from the anterior and posterior walls, followed by suturing the denuded muscularis layers together in an anterior-to-posterior fashion to obliterate the vaginal lumen partially or completely.[10] This supports the prolapsed uterus or vaginal vault by creating a fibrotic septum that elevates and stabilizes the pelvic organs.[11] The surgery is typically performed under general or regional anesthesia in a lithotomy position, with the patient catheterized to protect the bladder and urethra. Initial steps include infiltration of the vaginal epithelium with local anesthetic containing vasoconstrictor to minimize bleeding, followed by marking and sharp dissection to remove rectangular or triangular segments of mucosa, sparing the urethral meatus and a small posterior introitus for drainage.[12] The raw edges are then closed with delayed-absorbable sutures in a buried fashion, ensuring hemostasis and avoiding tension that could lead to dehiscence.[10] Partial colpocleisis, often via the LeFort modification, preserves lateral channels adjacent to the urethra and rectum for urinary and fecal drainage, distinguishing it from total colpocleisis which fully occludes the canal.[1] Operative time averages 60-90 minutes, with low blood loss due to the vaginal approach and vascular control measures.[13] The technique prioritizes patients with intact cognitive function and no future sexual activity desires, as vaginal intercourse becomes impossible post-procedure.[11]Etymology and Terminology
The term colpocleisis originates from Ancient Greek roots: kolpos, denoting a fold, hollow, or the vagina, combined with kleisis (from kleíō, to close), signifying occlusion or closure.[7][14] In medical nomenclature, it specifically describes the obliteration of the vaginal canal through surgical approximation of its anterior and posterior walls, distinguishing it from reconstructive prolapse repairs that preserve vaginal patency.[15] Terminologically, colpocleisis serves as an umbrella designation for obliterative procedures addressing pelvic organ prolapse, including uterine-sparing variants like partial colpocleisis (also termed LeFort colpocleisis, after surgeon Anna Inglis LeFort who described it in 1878) and non-uterine-sparing forms such as complete colpocleisis, often performed post-hysterectomy.[16][1] These distinctions reflect procedural intent—partial variants leaving a functional channel for drainage while fully occluding the canal in complete forms—though the core term emphasizes vaginal closure over reconstructive alternatives like sacrocolpopexy.[7] Alternative descriptors include vaginal closure or obliteration, used interchangeably in clinical literature to highlight the procedure's endpoint of narrowed or absent vaginal access, precluding penetrative intercourse.[17]Indications and Patient Selection
Primary Criteria
The primary indications for colpocleisis include symptomatic severe pelvic organ prolapse (POP), typically stage III or IV by POP-Q classification, affecting the anterior, posterior, or apical vaginal compartments, in patients who have failed or declined conservative treatments such as pessaries.[7] [1] This procedure is reserved for cases where reconstructive options like sacrocolpopexy or native tissue repairs pose excessive surgical risk due to patient frailty or comorbidities.[18] Patient selection emphasizes postmenopausal women who are sexually inactive and have no desire for future vaginal intercourse, as colpocleisis obliterates the vaginal canal and precludes coital function.[7] [18] [1] It is most commonly performed in elderly patients, with mean ages ranging from 69 to 84 years across studies, particularly those over 75-80 years with significant medical comorbidities such as cardiovascular disease or reduced functional status that contraindicate longer operative times or general anesthesia.[18] [1] Preoperative evaluation requires ruling out contraindications, including untreated cervical or uterine pathology (e.g., abnormal Pap smears, postmenopausal bleeding, or suspected malignancy), which necessitate prior hysterectomy or staging.[7] Adequate informed consent is essential, ensuring patients understand the permanent loss of vaginal access and potential impacts on urinary or bowel function, alongside assessment for baseline incontinence or retention (e.g., post-void residual >200 mL).[7] Colpocleisis may be considered in select younger women (<70 years) only with severe comorbidities and confirmed sexual inactivity, though it is generally avoided in those under 40 without exceptional risk factors.[1]Partial versus Complete Variants
Partial colpocleisis, typically executed via the LeFort technique, is indicated for patients with advanced pelvic organ prolapse (POP-Q stage ≥3) who retain a uterus lacking pathology, necessitating preoperative assessments such as endovaginal ultrasonography, endometrial biopsy, and cervical cytology to exclude conditions like endometrial hyperplasia or malignancy.[19] This variant preserves the uterus while apposing denuded anterior and posterior vaginal walls to form a septum with lateral channels for drainage and potential diagnostic access.[2] It suits postmenopausal women who are sexually inactive and have comorbidities precluding extensive reconstructive surgery, with patient profiles often featuring mean ages of 69–84 years and up to 48.9% over 80 years old.[20] Complete colpocleisis, by contrast, involves total vaginal obliteration and is selected for individuals post-hysterectomy or requiring concomitant uterine removal due to prolapse-associated pathology, eliminating any residual vaginal canal or channels.[2] This approach is favored when uterine preservation is unnecessary, providing broader support but potentially increasing operative complexity if hysterectomy is included.[20] Like its partial counterpart, it targets frail, non-coitally active patients with severe prolapse, emphasizing those intolerant of longer procedures.[20] Patient selection for both prioritizes informed consent on permanent forfeiture of vaginal intercourse capability, with low regret rates (under 5%) following proper counseling, though partial variants may appeal more to those valuing minimized blood loss (mean 90 ml versus 149 ml for complete with hysterectomy) and shorter operating times.[20] No strict age thresholds apply, but high surgical risk profiles drive preference over native tissue repairs, yielding anatomic success exceeding 90% across variants.[2]Surgical Technique
Preoperative Preparation and Evaluation
Preoperative evaluation for colpocleisis emphasizes confirming patient suitability, ruling out contraindications, and optimizing health to minimize perioperative risks, particularly in elderly patients with comorbidities. Candidates typically include postmenopausal women with stage III or IV pelvic organ prolapse who do not desire future vaginal intercourse and for whom reconstructive procedures pose excessive risk. Informed consent must detail the obliterative nature of the surgery, permanent forfeiture of coital function, potential need for concomitant procedures like hysterectomy, and alternatives such as pessary use or reconstructive repairs.[21][22] A comprehensive medical history assesses prolapse symptoms (e.g., bulge, pressure, urinary or bowel dysfunction), sexual history to verify disinterest in intercourse, obstetric and gynecologic history, and comorbidities such as cardiovascular disease, diabetes, or pulmonary issues that may necessitate cardiology or primary care clearance. Physical examination includes a pelvic organ prolapse quantification (POP-Q) staging to confirm advanced prolapse, bimanual exam for adnexal masses or uterine pathology, and evaluation of urinary incontinence or defecatory dysfunction. Contraindications include active pelvic infection, untreated uterine or cervical malignancy, or desire for future fertility.[23][6][9] Laboratory and diagnostic tests routinely include cervical cytology (Pap smear), endometrial sampling via biopsy or aspiration to exclude hyperplasia or cancer—performed in approximately two-thirds of cases despite debate on utility in low-risk patients—and urinalysis to detect urinary tract infection. Additional evaluations may involve basic blood work (e.g., complete blood count, coagulation profile), electrocardiogram or echocardiography for cardiac risk stratification in frail patients, and selective urodynamic testing if stress incontinence is suspected. Transvaginal ultrasound or endometrial assessment is recommended if abnormal uterine bleeding is present. No universal bowel preparation is mandated, but perioperative antibiotics are standard.[2][24][25]Partial Colpocleisis (LeFort Procedure)
The partial colpocleisis, known as the LeFort procedure, is an obliterative surgery for advanced pelvic organ prolapse (POP) that partially occludes the vaginal canal while maintaining lateral channels for urinary drainage and potential future access.[1] It is indicated primarily for elderly or frail women with stage III or IV POP who do not desire future vaginal intercourse, preserving the uterus without requiring hysterectomy.[26] [1] Preoperative evaluation includes confirmation of no sexual activity desire and assessment for occult stress urinary incontinence via urodynamics if indicated.[26] The patient is positioned in dorsal lithotomy under general or regional anesthesia, with hydro-dissection of the vaginal walls using diluted vasopressin to minimize bleeding.[26] Surgical steps commence with midline incisions on the anterior and posterior vaginal walls, approximately 0.5 cm from the introitus and 2-3 cm from the urethra and perineum, to delineate lateral flaps preserving drainage channels.[26] Excess vaginal epithelium is excised, and purse-string sutures (typically 3-4) are placed to reposition the bladder and rectum toward the midline.[26] The denuded anterior and posterior walls are then approximated with interrupted or continuous absorbable sutures, forming a central septum while leaving lateral tunnels wide enough for a finger's passage.[26] [1] A perineoplasty follows, involving removal of a diamond-shaped perineal flap and levator plication with interrupted sutures to narrow the genital hiatus and reinforce support.[26] Intraoperative hemostasis is ensured throughout, with packing or drains placed temporarily to prevent hematoma formation.[26] Modifications may include U-shaped fascial sutures for added reinforcement and reserving proximal vaginal wall for potential anti-incontinence procedures.[26] This technique yields high anatomic success rates of 62.5-100% (POP-Q stage ≤1) and subjective success of 88-100%, with operative times around 53 minutes and blood loss under 250 mL in reported cases.[1] [26] Complications such as urinary tract infections occur in 4-9% of cases, with rare bowel or urinary injuries (0-9%).[1]Complete Colpocleisis
Complete colpocleisis, also known as total colpocleisis, is an obliterative surgical procedure that fully closes the vaginal canal by denuding the anterior and posterior vaginal walls and suturing them in apposition, thereby eliminating any vaginal lumen and precluding future vaginal intercourse.[1] [11] This variant differs from partial colpocleisis (e.g., LeFort procedure), which preserves small lateral channels for drainage, particularly when retaining the uterus.[1] [11] It is typically performed in elderly women with severe pelvic organ prolapse who are not sexually active and have high surgical risk profiles precluding reconstructive options.[1] [10] Preoperatively, patients undergo evaluation to exclude endometrial pathology via cervical dilation and uterine curettage if the uterus is present, alongside inspection of the vaginal walls for ulcerations or irritation.[10] Regional or general anesthesia is administered, with a urinary catheter and compression stockings placed to mitigate thromboembolism risk.[11] If a uterus or cervix remains, vaginal hysterectomy is often performed concurrently to prevent retained secretions and associated complications.[1] Intraoperatively, equivalent trapezoidal areas of vaginal epithelium are marked on the anterior and posterior walls, infiltrated with 1% lidocaine with epinephrine for hemostasis, and sharply dissected from the underlying muscularis using a scalpel and Metzenbaum scissors.[10] The denuded muscularis layers are then imbricated with interrupted or running full-thickness 2-0 or 0 absorbable sutures (e.g., Vicryl) in anterior-to-posterior fashion, ensuring complete obliteration without residual channels.[10] [1] A high perineoplasty follows, involving excision of a diamond-shaped perineal flap and levator plication with 1-0 or 2-0 sutures to narrow the genital hiatus to accommodate one finger breadth.[10] Cystoscopy with intravenous indigo carmine (5 mL) verifies ureteral patency and excludes bladder injury, while a rectal examination checks for enterotomy.[10] The procedure typically lasts about 1 hour and emphasizes meticulous hemostasis via electrocautery to prevent hematoma formation.[11] [10] This technique achieves anatomical success rates of 87.5% to 100% (no prolapse beyond the hymen) with low perioperative morbidity, though it carries risks such as urinary tract injury (0-9.1%) and requires careful patient selection to avoid regret over loss of coital function.[1]Intraoperative Considerations
Colpocleisis is typically performed under regional anesthesia, such as spinal or epidural, or local anesthesia with sedation, particularly in frail elderly patients to minimize cardiopulmonary risks, though general anesthesia may be used depending on patient comorbidities and surgeon preference.[22][11] Patient positioning in dorsal lithotomy is essential, with careful padding to prevent nerve compression or pressure injuries, as prolonged positioning increases risks of peroneal or common peroneal neuropathy.[22] Intraoperative hemostasis is achieved through electrocautery (e.g., Bovie) and direct pressure following epithelial dissection and muscularis imbrication, with estimated blood loss generally low at 135-227 mL depending on partial versus total variants, though higher in procedures with concomitant hysterectomy.[10][3] Prophylactic broad-spectrum antibiotics are administered per institutional guidelines to reduce infection risk, and thromboembolic prophylaxis includes sequential compression devices or pharmacologic agents.[22] Cystoscopy with intravenous indigo carmine is routinely performed to verify bladder integrity, ureteral patency, and absence of injury during anterior wall dissection, especially near the urethrovesical junction.[10] Potential intraoperative complications include hemorrhage leading to hematoma formation, managed by meticulous layered closure and suture ligation, and inadvertent injury to adjacent structures such as the bladder (cystotomy) or rectum, which requires immediate recognition via rectal examination or cystoscopy and repair.[10] Operative times average 60-75 minutes, influenced by concomitant procedures like mid-urethral sling placement for stress incontinence or perineorrhaphy for posterior support.[11][3]Postoperative Management
Patients undergoing colpocleisis typically receive immediate postoperative monitoring for vital signs, bleeding, and pain control, with intravenous or oral analgesics administered as needed; patient-controlled analgesia is rarely required.[22] Prophylactic antibiotics are continued if indwelling catheterization persists, and thromboembolism prevention involves compression stockings or pharmacologic agents based on risk assessment such as the Caprini Score.[22] Voiding trials are initiated early, often on postoperative day 1 for those without concomitant midurethral sling (mean day 1.8) or day 3 with sling, with first-trial failure rates of 33-41% resolving by day 7 in most cases (78% overall success within 7 days) and complete resolution within 3 weeks via intermittent catheterization.[27] Hospital stays are brief, with same-day discharge common for low-risk patients and 23-hour observation for those with high cardiopulmonary frailty; mean recovery activity time is 3 days (range 2-6), and hospitalization averages 6 days (range 4-13) in some cohorts.[6] Upon discharge, patients are prescribed oral pain medications such as ibuprofen or acetaminophen with hydrocodone, alongside instructions for hydration (6-8 glasses daily) to support bladder and bowel function.[22] Indwelling catheters, if used, are removed 24-48 hours postoperatively or following successful office-based voiding trials, with postvoid residual urine assessed to detect retention.[28] Home recovery emphasizes gradual mobility, with walking encouraged but avoidance of heavy lifting, straining, or vigorous exercise for 6 weeks to minimize recurrence risk and complications like wound dehiscence.[29] Patients monitor for signs of infection (fever, purulent discharge), excessive bleeding, or voiding dysfunction, seeking prompt evaluation if persistent incomplete emptying occurs beyond 2 weeks, as preoperative elevated postvoid residual predicts early trial failures.[27] Bowel regimens with stool softeners prevent constipation, given the procedure's potential to transiently affect defecation. Follow-up visits occur at 2 weeks to review pathology (if hysterectomy performed), assess postvoid residual, and inspect wounds; subsequent evaluations at 6 weeks, 3 months, and 1 year monitor anatomic integrity, symptom resolution, and quality of life, with high satisfaction rates (over 90% in long-term studies) contingent on addressing any de novo urinary or pelvic issues early.[22]Efficacy and Clinical Outcomes
Anatomic and Functional Success Rates
Anatomic success rates for colpocleisis, defined as absence of recurrent prolapse (typically Pelvic Organ Prolapse Quantification stage 0 or I at the apex), exceed 95% in multiple cohort studies. A series of 310 elderly women undergoing partial colpocleisis reported a 98.1% anatomic success rate at follow-up, with minimal apical descent observed.[7] Similarly, a prospective study of 54 patients with stage III/IV prolapse achieved a 98.15% objective cure rate post-LeFort procedure, assessed via standardized examinations up to 12 months postoperatively.[6] Smaller series confirm these outcomes, with one-year anatomic success reaching 100% in 50 cases, though longer-term data beyond five years remain limited due to patient comorbidities and mortality.[30] Functional success, encompassing symptom resolution such as bulge sensation relief and urinary/bowel function improvement, aligns closely with anatomic outcomes but shows greater variability. Subjective cure rates hover around 92-95%, with 92.59% of patients in one study reporting no prolapse symptoms at follow-up.[6] Quality-of-life metrics, including validated tools like the Pelvic Floor Distress Inventory, demonstrate significant postoperative gains in prolapse-specific domains, though de novo or persistent stress urinary incontinence affects 10-20% of cases, often managed conservatively.[31] Bowel function typically improves, with reduced obstructive defecation in over 80% of patients, attributed to apical support restoration without mesh-related complications.[23]| Study | Sample Size | Anatomic Success (%) | Subjective/Functional Success (%) | Follow-up Duration |
|---|---|---|---|---|
| Zebede et al. (largest series) | 310 | 98.1 | 92.9 (satisfaction) | Variable (up to years)[7] |
| Recent LeFort cohort | 54 | 98.15 | 92.59 | 12 months[6] |
| 1-year follow-up series | 50 | 100 | >90 (symptom relief) | 1 year[30] |