The management of vaginal eversion is difficult. If left untreated, there is a risk of decubitous ulceration. Pessaries are often useful, especially if one bears in mind the usually advanced age of this group of patients. However, the surgical management of patients whose pessaries have either fallen out, are causing pain, or are unacceptable, is not clear.
Our experience shows that Le Fort’s obliterative colpocleisis is relatively quick to be performed and necessitates a short postoperative hospital stay. In comparison, sacrocolpopexy has an average operating time of 1 h and 29 min, and the patient requires a postoperative stay of 5.4 days. Sacrospinous fixation has an operating time of 25 min and a mean hospital stay of 5.2 days, but serious intra-operative and postoperative complications, although infrequent, have been reported.
In this series, we had one immediate postoperative complication (4%). This occurred in a woman who was on aspirin and whose medication had not been stopped at the time of surgery. None of this series of patients developed postoperative urinary tract infections, perhaps attributable to the routine use of antibiotic prophylaxis. One patient developed cardiac failure, and another developed a chest infection. Both of these complications demonstrate the risks associated with operations under general anaesthetic in patients of relatively advanced age, who often have concurrent medical problems.
Stress urinary incontinence can be unmasked by colpocleisis as the urethra is straightened, but there were no new cases in our series. All the women were asked about urinary incontinence and investigated as appropriate, prior to surgery. In particular, we made sure that, of those women who had had pessaries, none had complained of stress urinary incontinence for the short duration of time that the pessary was in place. We did not subject women to urodynamic studies routinely, as they were elderly, sometimes lived at a distance from our hospital, and because the availability of this specialised investigation is limited.
The operation failed in three out of 27 patients. Two failures occurred within the first 3 months after surgery, and the other at 1 year. Our failure rate of 11% is in keeping with that of 2.4–27% for sacrospinous fixation [1, 2, 3] and 1.3–16% for sacrocolpopexy [7, 8, 9]. Another study looking at follow up of colpocleisis had no treatment failures and a mean follow-up of 24 months in 38 women [15]. However, this procedure varied from ours and was more extensive, as anterior and posterior repairs were performed at the time of colpocleisis.
Pyometra following Le Fort colpocleisis has also been reported [16], but the case occurred after a repeat colpocleisis, where the alteral channels were narrow. We have not performed a repeat colpocleisis, either in the cohort we are reporting, or subsequently. The risk of pyometra following primary surgery would theoretically be reduced if it were ensured that adequate lateral channels are created to allow drainage of postoperative secretions as occurred in all our procedures. Our routine use of prophylactic antibiotics may also help reduce the incidence of this complication.
The most significant disadvantage of the procedure is the loss of coital function. However, 26 of the 27 women were not sexually active prior to the procedure, and at the 3 month and long-term follow-ups this loss of coital function was not regretted by any of the patients. The high degree of satisfaction that we found reflects the fact that it is possible for one to select women appropriate for this type of surgery. In our series, the discussion regarding coital function took place with a consultant at the time of first assessment in the out-patient clinic and formed part of the decision with the patient, on various different surgical procedures. Women who wished to retain coital function were also identified at this stage, and their surgical management was tailored to take this wish into account.
Colpocleisis can also be performed under local anaesthesia. As already mentioned, two of our cohort had significant postoperative morbidity, one due to cardiac failure and the other due to a chest infection. The technique of a local anaesthetic procedure is attractive, as it avoids the cardio-pulmonary risks of general anaesthesia and allows earlier mobilisation. Our two cases of local anaesthetic colpocleisis were later in the cohort, and one of them subsequently failed. The technique used for suturing involved short runs of continuous sutures, and we suspect that this, rather than the anaesthetic technique, resulted in this failure. We are modifying our technique to account for this possibility.
The investigation of postmenopausal bleeding can be problematic in women who have had a colpocleisis. Clearly, this problem has not arisen in the 20 women in this series who still have a uterus. Speculum examination, blind endometrial biopsy or hysteroscopy may well not be possible, as the lateral channels are very narrow. However, trans-abdominal ultrasound scans or magnetic resonance imaging may be useful.
In our experiences, Le Forte’s colpocleisis is a useful procedure. Clearly, patient selection is of crucial importance, but this caveat applies to all therapeutic interventions.