ST. LOUIS — Vaginal cerclage, a novel surgical procedure for pelvic organ prolapse, is proving effective as a treatment option for severe and refractory prolapse in select patients.
Also known as introital cerclage, the procedure involves permanent suturing of the introitus, and is often performed in conjunction with vaginectomy. This obliterative approach is suitable only in those who are certain they no longer desire coital function, but on its own, vaginal cerclage also can serve as a bridge to nonobliterative repair, Dr. S. Robert Kovac and Dr. Carl W. Zimmerman said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.
Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the Emory Center for Reconstructive Pelvic Surgery at Emory University, Atlanta, used a video demonstration to show the surgical technique in an 82-year-old woman who had undergone two prior procedures for the treatment of prolapse, including a total abdominal hysterectomy followed by transvaginal repair with graft augmentation.
She presented with recurrent prolapse and complaints of vaginal bulge and discomfort, difficulty with voiding, and recurrent urinary tract infections.
A decision was made to perform vaginectomy augmented by the placement of a simple introital cerclage.
Dr. Kovac adequately infiltrated the introitus with 0.5% Marcaine with epinephrine, then used nonabsorbable braided sterile polyester suture beginning at the 12 o'clock position. The suture was placed away from the mid-urethra and closer to the bladder neck to decrease the risk of de novo stress urinary incontinence.
Suture placement continued in a circumferential manner toward the 6 o'clock position in several steps, ending at the 7 o'clock position to minimize discomfort. The suture ends were cut and tied down to obliterate the vagina and reduce the prolapse, and the ends were buried under the skin to decrease discomfort.
The same approach was used in a 77-year-old patient who had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy, as well as multiple prior prolapse repairs, including transvaginal repair with graft augmentation, a pubic bone sling, and transvaginal enterocele repair with graft augmentation and repeat enterocele repair with colpocleisis.
The patient presented with vaginal bulge, pressure, discharge, defecation dysfunction, and abdominal pain; she was diagnosed with stage IV vaginal vault prolapse. As in the first patient, vaginectomy was performed and augmented by vaginal cerclage. The patient's vagina was obliterated, and her prolapse reduced with no change in urethral angle.
Both patients were doing well at 8 months' follow-up, Dr. Kovac said.
Dr. Kovac, who argued that vaginal cerclage is superior to the “very outdated” LeFort colpocleisis procedure that's used in patients with severe prolapse who still have their uterus, noted that the new technique also can be used as an intermediate procedure in certain patients awaiting nonobliterative prolapse repair.
For example, he described a patient with a significant prolapse who was unable to undergo surgery because of elevated creatinine. Vaginal cerclage allowed for temporary relief over the 8-9 days required for her creatinine levels to normalize.
“This approach provided improved comfort and quality of life, and reduced her hydronephrosis, which was causing the elevated creatinine, thus enabling her to undergo the full repair,” he said.
Similarly, Dr. Zimmerman, professor of obstetrics and gynecology at Vanderbilt University in Nashville, Tenn., described a patient who was preparing to undergo liver transplant and was found to have severe prolapse during a pelvic exam prior to surgery. Vaginal cerclage was used as a rescue procedure so that she could undergo the transplant surgery. The prolapse was reduced, the cerclage was placed, and the transplant was successful, he said.
Vaginal cerclage is a simple and “clever” procedure that can be accomplished in about 5 minutes, is reimbursed as a colpocleisis, and vastly improves patient comfort, Dr. Kovac said.
“It has great advantages, and we're doing it routinely today on select patients who come in with recurrent prolapse after multiple attempts at correctional surgery – with excellent results.”
The availability of such a technique is important because, typically, the repair used for a failed colpocleisis is a repeat colpocleisis.
Also, an increase in patients who seek treatment is anticipated, given that U.S. Census data indicate that the number of adults older than age 65 is expected to reach 90 million by 2050, and that 30%-50% of women experience prolapse in their lifetime, 11% undergo surgery for prolapse, and a third of prolapse and incontinence surgeries are for recurrent prolapse.
Improved techniques are needed, particularly in light of the high rate of repeat repairs, Dr. Kovac said.