Value of obliterative procedures for POP is their lower failure rate




I commend Dr. Harmanli on highlighting the importance of obliterative procedures for pelvic organ prolapse (POP). An obliterative procedure should always be offered to women who are certain that they will not be having intercourse in the future.

Dr. Harmanli states that “the fundamental reason for choosing an obliterative procedure…is to treat the prolapse with the least invasive technique in the shortest time.” I disagree.

The fundamental reason my patients choose an obliterative procedure is because it has significantly less chance of failure than the alternatives. Dr. Harmanli suggests that hysterectomy in this setting “often adds 30 to 80 minutes to the procedure” and argues that the LeFort procedure is better than hysterectomy followed by colpectomy. Again, my experience is at variance with this position.

There is no evidence that vaginal hysterectomy followed by colpectomy carries more morbidity than a LeFort procedure when a regional anesthetic is used. In addition, if the genital hiatus (levator hiatus) is closed at the time of colpectomy, a separate anti-incontinence procedure is rarely needed because the urethrovesical angle is supported by the approximation of the levator muscle. In a LeFort procedure, the urethrovesical angle is pulled down by the procedure and may increase the risk of stress urinary incontinence postoperatively.

When one of my patients opts for an obliterative procedure, I almost always choose to perform a colpectomy.

Michael Valley, MD
St. Louis Park, Minn

Dr. Harmanli responds: For frail elderly, LeFort procedure is best

I agree with Dr. Valley that one of the advantages of colpocleisis is its lower failure rate. Although the literature lacks a good comparative study, most likely because of the differences between patients who might be candidates for obliterative and reconstructive surgery, the success rate of over 90% reported in all of the colpocleisis case series may be an attractive reason to consider this approach for many elderly patients.

However, I kindly disagree with Dr. Valley about the lack of evidence in favor of LeFort partial colpocleisis. As I stated in my article, the patients who underwent concomitant vaginal hysterectomy with total colpocleisis had a procedure that was 52 minutes longer than those who underwent the LeFort procedure, and 5% of them required laparotomy.1 No one can dispute that the longer operating time and potential for laparotomy may add to the morbidity of this high-risk surgical population. Therefore, it is incumbent on those who advocate hysterectomy and colpectomy over LeFort colpocleisis to support it with evidence.

I failed to find any data indicating that this more time-consuming and potentially complicated approach improved the success rate. Therefore, for frail single women, I continue to recommend LeFort colpocleisis, which can be performed in less than 1 hour—even with sedation and local anesthesia—by any gynecologist who knows how to do colporrhaphy using the technique described in my article.

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