Le Forte colpocleisis is not only an effective surgical treatment for POP patients but is also favorable for short operative time and low rates of associated complications and morbidity [10, 11]. Colpocleisis is preferred in elderly and fragile patients who are no longer sexually active. In this study, we have compared POP-Q and GPFBQ scores as detected prior to surgery and 12 months after the surgery in the patients who underwent Le Forte colpocleisis in our department. Our analysis revealed statistically significant change in point C, TVL, and Gh measurements at post-operative month 12 compared to the pre-operative measurements as a result of surgery. Although these changes seem clinically insignificant, this result may indicate anatomic recovery. Moreover, among GPFBQ, we have found statistically significant improvement in SUI, frequency, difficulty in urination, and bulging of vagina which implies a positive impact on functional recovery.
Le Forte colpocleisis is mostly applied in elderly women. To this end, the mean age of 325 patients included in the study of Zebede and co-workers was 81.36±5.3 years, and likewise in the study by Reisenauer et al. 58 patients had a mean age of 81.9±6.4 years [4, 12]. In our cohort, mean age was 71.67±7.01 years.
According to the literature, Le Forte colpocleisis features as a low-risk and well-tolerated surgery. The reasons for this are most possibly the ease of application as a surgical technique and the short operative time. A lot of publications reported for its intra-operative and post-operative complications. According to the review by FitzGerald and colleagues, post-operative cardiac, thromboembolic, pulmonary, and cerebrovascular complications were detected in almost 5% of the patients. On the other hand, approximately 15% of the patients had experienced minor complications including UTI, vaginal hematoma, cystotomy, fever, and thrombophlebitis . Another study carried out by Hullfish et al. detected peri-operative complications in 18 out of 94 patients, most frequent of which was UTI experienced by four patients . In our study, a major complication occurred only in one patient (2.56%) who developed atelectasia and a minor complication occurred in two patients (5.12%), both had UTI. The lower rates of major and minor complications attained in our study are most likely associated to the younger mean age in our sample.
POP-Q scoring system is one of the most widely used methods worldwide for the purposes of classification of and surgery success in POP . Subsequent to a successful colpocleisis, POP-Q scores should improve remarkably. In their study of Reisenauer et al., POP-Q scores have been evaluated in 37 patients . At the same study, mean measurement for TVL was 22±9 mm, for PB was 45±13 mm, and for Gh was 17±6 mm. In another study conducted by Fitzgerald M et al., TVL, Gh, and PB were evaluated pre-operatively and post-operatively . In chronological order of their measurements, mean values for TVL were 9 cm and 3 cm; for Gh were 6 cm and 2 cm; and for PB were 3 cm and 4 cm. In our study pre-operative vs. post-operative mean values for TVL were 8.93±1.73 mm vs. 35.1±12.4 mm, for Gh were 4.83±0.94 mm vs.4.26±0.94 mm, and for C point were 6.70±2.44 mm vs. -2.66±1.21 mm, respectively. We believe that the anatomical improvement in TVL is arising from the sutures placed in vertical axis and the improvement in C point is a result of vertical closure performed along the free edges of vaginal apex.
Along with the anatomical improvement, functional improvement is also essential following the POP surgery. Various questionnaires are often used to investigate this aspect, such as those on LUTS. In a study by Neimark et al, 45 women underwent Le forte colpoclesis, high perineoplasty and tension-free vaginal tape (TVT) . When the pre-operative and post-operative 3 months results of these cases were evaluated; SUI and post-voiding residual symptoms were significantly decreased, constipation and irritative voiding symptoms did not change. In addition, the patients were administered the post-operative QoL questionnaires, but it is not possible to make a healthy evaluation because the questionnaire is not administered pre-operatively. In the study of Hullfish et al., patient queries were performed after an average of 2.75 years following the surgery . Accordingly, 34 women who had pre-operative urgency and frequency symptoms who were asked whether they consider their condition had improved, two (5.9%) were not sure, one (2.9%) disagreed and remaining women were agreed. Furthermore, of the 34 women who had pre-operative difficulty of emptying their bladder, four (11.8%) were not sure and another four (11.8%) disagreed. On the contrary to the Hullfish et al. ‘s study, our study did not provide a rank of options, but instead yes/no options for SUI, frequency, difficulty of urination, and bulging of vagina improved by post-operative 12 month as stated by our respondents . In addition to the difference in questionnaire methodology, compared to their results, our findings also indicate a higher rate of patient satisfaction. Koski et al. have conducted Urinary Distress Inventory-6 on 21 women 9.3 months after on average Le Fort colpocleisis . According to the answers provided by the respondents, 7 (%33.3) women had frequent urination and urge incontinence, 5 (23.8) women had SUI, 4 (19%) women had difficulty in urinary leakage and difficulty emptying. In the results of our study, 1 (%2.56) woman had frequent urination and, none of the women had urge incontinence and urinary leakage, 8 (20.51%) women had SUI, 2 (5.12%) women had difficulty urination. The reason underlying the improvement in LUTS may be the anatomical elimination of anterior or posterior compartment defects.
SUI exerts adverse consequences on social life and physical activities of women, particularly those of advanced age. Its incidence varies by a number of factors with figures reported in the range of 16.1-68.8% . The study by Fitzgerald and colleagues included 152 colpocleisis patients of whom 54% had pre-operative SUI that reduced to 15% post-operatively . Glavind et al. have investigated 40 patients for SUI of whom 17 (42.5%) had SUI at pre-operative period, while 7 (17.5%) patients have persisted and one (2.5%) patient had increased SUI during post-operative period . In our patients, pre-operative SUI was detected in 51.28% while 20.51% had SUI at post-operative month 12. The results of the current study are comparable to the results documented in literature. Augmented support to the urethral neck is likely the reason for the improvement we detected in SUI. On the other hand, de novo SUI developed only in one patient.
The entire set of patients were operated in the same center by two surgeons experienced in their field who also followed up the patients post-operatively. This altogether helped standardization of the study data. A strong aspect of this study is that it handles not only anatomic improvement but also improvement in LUTS. Nevertheless, it is limited by its single-center design and small sample size.