Prolapse in the Older Woman


He went on to say that he ‘sought to make the contact intimate and permanent and to restore the anterior and posterior vaginal walls to the same level in reuniting them by suture.’20


be treated ‘if one could keep the vaginal walls in contact with each other, thus preventing one of them from going forward and the other backward.’20


the lateral vaginal fornices and 2cm distal to the urethral meatus. Caution must be employed so as not to overdissect the vaginal tissues beyond the point of reflection or excess tension will occur during closure of the remaining vaginal epithelium and wound breakdown will occur.


The LeFort partial colpocleisis procedure is designed to treat uterovaginal prolapse by closing the vagina, yet leaving the uterus in situ. In this procedure, a segment of the anterior and posterior vaginal epithelium is removed, followed by transverse reapproximation of the anterior and posterior vaginal walls with inversion of the uterus. Tunnels of vaginal mucosa are created at the lateral aspects of the vagina to allow drainage of cervical or other upper-genital discharge.


Advantages of the Le Fort colpocleisis are the safety and relative ease of the procedure, without the need to perform a hysterectomy. Von Pechmann et al.21


reported the total average operating time to be 52 minutes; the operation was longer if hysterectomy was performed at the time of complete colpocleisis.


reported an average operative time for the LeFort group of 75 minutes compared with 150 minutes when a vaginal hysterectomy and anterior colporrhaphy was performed (p<0.001). DeLancey et al. also reported on a series of 33 complete colpocleisis with an average operating time of 104 minutes (range of 10–205 minutes).23


Complete or partial colpocleisis takes significantly less operative time than traditional vaginal hysterectomy with colporrhaphy. Denehy et al.22


Complications can include post-operative urinary incontinence due to excessive fixation of the anterior and posterior surfaces close to the urethral meatus. After closure, the transverse scar exerts traction on the urethra and urinary incontinence can develop.


Other complications include the development of a pelvic abscess secondary to narrowing of the lateral canals, resulting in blockage of cervical and uterine secretions. The formation of a pelvic abscess can require re-operation.


A Modified Surgery


As an alternative to the LeFort colpocleisis, the authors perform a modified version of a procedure described by DeLancey and Morley23 that involves a hysterectomy, colpectomy, colpocleisis and perineal- levatorplasty, as will now be described.


Following the establishment of adequate anesthesia (spinal or general) the patient is placed in dorsal lithotomic position using Allen stirrups. One often places ureteral stents under cystoscopic guidance prior to initiation of the procedure. These serve as palpable landmarks throughout the case, as prolapse often results in a marked alteration of the pelvic anatomy.


Prior to performing the hysterectomy, one circumferentially injects the vaginal epithelial tissue with a solution of 1% lidocaine with epinephrine. To further reduce blood loss, a bipolar cautery device is used to make the initial circumferential incision in the vaginal epithelium. A hysterectomy is then performed.


The peritoneal cavity is closed at the completion of the hysterectomy, and the excess vaginal epithelium is then dissected from the underlying subepithelial tissue to within 1cm of its reflection at


EUROPEAN UROLOGICAL REVIEW


A purse-string reduction of the enterocele is then performed using a delayed absorbable suture. Special attention is focused on an equal approximation of the anterior and posterior vaginal walls. Typically there is excess posterior vaginal wall relative to the anterior wall. If approximation is not equal, there will be a loss of tension in the anterior compartment, predisposing the patient to post-operative urinary incontinence. Once the enterocele is reduced, a levatorplasty procedure is performed.


The levatorplasty is performed by pushing one’s finger pararectally in a lateral direction until the levator pillar becomes visible. The finger should not be inserted too deeply so as to avoid entry into the ischiorectal fossa (recognisable by the ischiorectal fat). The levator borders are then identified and united in the mid-line with three or four interrupted delayed absorbable sutures in a stepwise fashion from cephalad to caudad. During plication, the rectum must be protected by pushing it inferiorly with a retractor or the index finger of one’s non- dominant hand. The final step involves reapproximation of the bulbocavernosus tissue as well as the adjacent perineal tissues, which are united in the mid-line.


When performing the levatorplasty, it is important to start the mid-line placation high enough to prevent the formation of a post-operative rectocele but not so high as to cause excess tension on the muscles, as this will result in significant post-operative faecal urgency and buttock pain. The overall procedure is then completed with trimming and closure of the remaining vaginal epithelium.


The advantages of this procedure over a LeFort colpocleisis are the greater familiarity of the technique and removal of the uterus, which would otherwise require re-operation if subsequent cervical or uterine pathology were to occur. Disadvantages include longer anesthesia time, greater blood loss and transfusion risk.


Colpocleisis Outcomes


Overall satisfaction in patients undergoing colpocleisis is high. Fitzgerald et al. reported the one-year follow-up on a cohort of 152 subjects that had undergone the procedure. Of these patients, 125 (94%) said they were either ‘very satisfied’ or ‘satisfied’ with the outcome of their surgery.24


When subjects were asked “Looking back


on your decision to have vaginal closure for treatment of my prolapse, was this the right decision?”, 94% of subjects were either satisfied or very satisfied. When asked to compare how their body feels compared with before prolapse surgery, 92% reported feeling much or somewhat better. Urinary incontinence is a common complication after colpocleisis, but there are few reports quantifying the risk. Some patients have no incontinence symptoms. Others have high post-void residual volumes while others develop de novo stress or urge incontinence. This aspect of the colpocleisis procedure remains one of the most problematic for both patients and clinicians.


In the setting of advanced prolapse, unmasking ‘occult’ stress incontinence is a priority. Occult urinary incontinence is the presence


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