Colpocleisis Techniques: An Open-and-shut Case for Advanced Pelvic Organ Prolapse

Abstract

To highlight several advanced surgical techniques for all types of colpocleisis. Pelvic organ prolapse is a common condition that affects up to 40% of the postmenopausal female population.1-2 Particularly for women with advanced pelvic organ prolapse who no longer desire penetrative vaginal intercourse and with multiple medical comorbidities, the obliterative approach is preferred due to decreased anesthetic needs, operative time, and perioperative morbidity.3 Additionally, colpocleisis is associated with a greater than 95% long-term efficacy with low patient regret, high satisfaction, and improved body image.4-5 MATERIALS AND METHODS: : The umbrella term of "colpocleisis" encompasses a uterine-sparing procedure, the LeFort colpocleisis, colpocleisis with hysterectomy, and post-hysterectomy vaginal vault colpocleisis. We demonstrate the surgical steps of performing each type of colpocleisis as well as levator myorrhaphy and perineorrhaphy, which are typically included to reinforce the repair. To streamline the LeFort colpocleisis procedure, we demonstrate use of electrosurgery to mark out the epithelium and methods to create the lateral tunnels with LeFort colpocleisis with and without the use of a urinary catheter. We also present techniques that can be utilized across all types of colpocleisis including the push-spread technique for dissection, tissue retraction with Allis clamps and rubber bands on hemostat clamps to improve visualization, and approximation of the anterior and posterior vaginal muscularis to close existing space. Attention must be paid not to proceed past the level of the urethrovesical junction to avoid angulation of the urethra. We use an anatomic model to demonstrate appropriate suture placement during levator myorrhaphy to facilitate an adequate purchase of the levator ani muscles in order to adequately narrow the vaginal opening. Ultimately the goal of the colpocleisis procedure is a well-approximated, obliterated vagina, approximately three centimeters in depth and one centimeter in width. The skills demonstrated enable the surgeon to maximize efficiency and surgical outcomes for an effective obliterative procedure for advanced stage pelvic organ prolapse.