Vaginal partitioning with vertical septum—an alternative to colpocleisis
© Springer-Verlag 2010
Received: 21 October 2010
Accepted: 8 November 2010
Published: 4 December 2010
The purpose of this study is to design and deploy an effective technique for prolapse repair in sexually inactive, geriatric patients which addresses all associated postoperative issues. A study group of 34 patients underwent vaginal partitioning with vertical septum (VPwVS). All 34 patients could successfully undergo VPwVS. Blood loss and surgical duration were comparable with conventional colpocleisis (CC). Postoperatively, no patient had recurrence of prolapse, de novo appearance, and/or recurrence of urinary or bowel symptoms, and no patient developed hematometra or pyometra. Pap smear collection is possible. This study shows that VPwVS is a holistic solution for prolapse repair among sexually inactive, geriatric patients, addressing all related issues and appears better than CC; however, a larger, multicentric study may be needed to statistically prove its advantage over CC. VPwVS’s relevance is pronounced with an increasing geriatric population.
The Royal College of Obstetricians and Gynecologists recommends CC  for the repair of a prolapse in high-risk and sexually inactive, geriatric patients. Since its inception in 1876 or 1877 (Neugebauer-Le Fort), many modifications [1, 2] of colpocleisis have evolved to improve surgical outcome.
Core colpocleisis techniques address the symptoms of prolapse, but often are associated with urinary symptoms, which may need additional surgeries [3, 4] varying from Kelly’s stitch, pubocervical fascia plication, to TVT or mesh, all with variable success rates. Site-specific  repair for a cystocele and enterocele is also suggested to improve results. After colpocleisis, hematometra [2, 6] and pyometra  have been reported. Pap smear collection is difficult. Rectal prolapse  and evisceration of the small bowel  were recorded after colpocleisis.
To optimize bladder and bowel functions (no appearance of fresh urinary symptoms, enterocele, or rectal prolapse)
To permit natural drainage of uterovaginal secretions to prevent hematometra or pyometra
To permit Pap smear
The aforementioned goals need to be achieved without compromising the patient’s medical condition and with minimal blood loss and surgical duration.
Comparison of CC with VPwVS
Comparison of CC with VPwVS
1. Basic concept
Closure (partial or total) of vagina, usually with approximation of anterior and posterior wall
Partitioning of vagina in bilateral tunnels with a vertical, median, and strong septum
2. Mucosa removal and vaginal shortening
Raw area is created for approximation by removal of equal rectangular flaps of vaginal mucosa of anterior and posterior vaginal epithelium or circumcision of entire vaginal mucosa.
There is no removal of vaginal mucosa. Redundancy is used to make a strong and broad septum.
Mucosa removal and approximation causes vaginal shortening/closure.
Vertical, median septum is created extending to the vault, restoring the vaginal length.
3. Risk and difficulty
Dissection of vaginal mucosa of uniform thickness is difficult.
Linear dissection of vaginal mucosa is easy.
Vaginal mucosa removal carries the risk of damage to paracolpos or to lateral attachment of fibers which are attached to the pelvic bone.
There is no such risk since the mucosa is not removed. Further, even if the deeper supportive tissue gets traumatized, the outcome is not affected due to its integration with the septum while suturing.
4. Septum/suture line
The new suture line is transverse, hence directly exposed to abdominal pressure changes as shown in Fig. 1.
The new suture line is vertical so the abdominal pressure changes are equally distributed on two neo vaginas and the vertical septum as shown in Fig. 2.
An under tension suture line may cause a high incidence of hematoma and its subsequent complications.
Tension-free suturing is possible, preventing hematoma and subsequent complications.
Additional purse-string sutures are needed before approximation if prolapse Baden–Walker grade is 3 or 4.
The procedure is the same irrespective of the Baden–Walker grading.
5. Plication of bladder neck and/or cystocele repair
Kelly’s stitch, TVT, urethral mesh, site-specific repair, etc. are needed to optimize bladder function.
No additional procedure needed.
No reinforcement of supports
Indirect reinforcement of supports
Central defect of the bladder gets supported with a vertical septum. Lateral defects get corrected with inward turning of the vaginal mucosa, indirectly reinforcing bladder support. A small caliber of neo vaginas prevents prolapse too.
Unequal support of urethra and bladder, disturbing UV angle
Equal support to urethra and bladder with no disturbance to UV angle
7. Vaginal drainage and Pap smear
Only a potential canal on either side of the suture line when uterus is conserved, no vaginal canal in total colpocleisis
A 1.5-cm caliber canal on either side of the septum, neo vagina is lined by smooth vaginal epithelium all over as before, eliminating possibility of total closure
Drainage possible; Pap smear difficult
Neo vagina allows vaginal drainage, and Pap smear collection is possible.
VPwVS described herein is an obliterative surgical procedure for prolapse repair, involving a departure from current textbooks and trends. This paper is qualitative in nature and belongs to the category “techniques and instrumentation.” VPwVS is an obliterative procedure for prolapse repair involving partitioning of the vagina in bilateral tunnels, each of around 1.5 cm in diameter, (with or without hysterectomy) with a strong and broad, vertical, median septum along the vaginal length, which gives equal support to both anterior and posterior structures and also restores the vaginal length.
Material and method
Surgical steps in VPwVS
After the sutures are completed on either side, traction is given to them with the result that the edges are out-turned in the lumen on each side. The knot is then tied firmly pushing up the apical point. The knots are at the center, covered by the raw dissected area. This helps to make a vertical septum dividing the vagina longitudinally in two narrow tunnels. The dissected raw area gets plastered with each other creating a broad and strong septum. Similar vertical mattress stitches are taken along the total length of the anterior wall incision.
Since the posterior wall is always longer than the anterior wall, a portion of the posterior wall remains not taken up. A wedge-shaped portion is now removed on either side of the median split, and a routine colpoperineorrhaphy is done after approximation of the levator ani followed by the closure of the perineal skin.
The mean surgical duration was 45 min while the mean blood loss was 35 milliliters, with a p value of zero in both cases. Both are comparable in VPwVS and CC .
More anatomical and less distortive
Independent of extent or site of prolapse
Needs no associated surgery, thus saving on surgical duration and blood loss
Safe, simple, and elegant to perform
Effective and gives long lasting results
VPwVS is also feasible within the given constraints, i.e., without compromising the patient’s medical condition and with minimum surgical duration and blood loss.
Geriatric population is on the rise and so is the incidence of prolapse. The role of obliterative surgery for prolapse repair is now well accepted in geriatric patients disinterested in coital activity. Such obliterative procedures need to be effective, with lasting results, and also need to be safe and simple. VPwVS achieves all the goals of colpocleisis with good success rate, even on long-term follow-up; however, a larger, multicentric study may provide a statistical comparison between VPwVS and CC. Being technically and functionally sound, VPwVS is a definite alternative to colpocleisis and merits larger deployment by the professionals.
Dr. Tushar Panchnadikar, M.D. (ObGy), a professor from Bharati Vidyapith Medical College, Pune; Dr. Anjali Radkar, Ph.D. (statistics), an associate professor at the Gokhale Institute of Economics, Pune; and Mr. Pradeep Kakatkar, FCA, Pune are gratefully acknowledged.
Details of ethics approval
Guidelines prescribed in the Medical Ethics Manual (2009) of WMA are fully complied with.
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