Hysterectomy

at the time
of colpocleisis :
a decision analysis

Fadil Hidayat
Modul Uroginekologi
Oktober 2016
Introduction
In the 19th century surgical obliteration of the vagina was
introduced as a treatment for pelvic organ prolapse

Neugebauer original colpocleisis without hysterectomy

In 1887 Leon le Fort, partial colpocleisis

In the 20th century,

advances in anesthesia and surgical technique
include hysterectomy
eliminate the risk of endometrial or cervical cancer, pyometra,
and difficulty in diagnosing future bleeding
 Introduction

Ongoing debate on the role of concomitant

hysterectomy at the time of colpocleisis

Concomitant hysterectomy increases operating time,

blood loss, and conversion to laparotomy with no
improvement in patient satisfaction or surgical success

The objective of this study was to assess the utility of

vaginal hysterectomy at the time of a colpocleisis using
decision analysis techniques

Decision analysis models are often utilized when it is

difficult to conduct a long-term randomized controlled trial
 Materials and
methods
This study was deemed exempt by our institutional review board
as it did not involve human subject research

Hypothetical cohort
Patient with advanced prolapse with a uterus in situ that no longer
desired coital function
No history of post menopausal bleeding

Decision analysis was used to evaluate the two surgical

alternatives: Le Fort colpocleisis (C) and colpocleisis with
concomitant hysterectomy (CH)

Complication evaluated : Ureteral injury, bowel injury, blood

transfusion, and surgical site infection (SSI)
C : EMC and pyometra
CH : Conversion to laparatomy
Fig.1 Decision tree Material
s
and
Methods
 Material
A MEDLINE search on colpocleisis from its
s
inception to October 2015 to obtain rates of
complications associated with each procedure. and
Methods
Table 1. Probability values for the complications

Probability
values define
the likelihood
of outcomes
on each path
 Material
s
and
Table 2. Utility values associated with
Methods
the occurrence of complications
Result
Table 3. Expected utility values of colpocleisis (C) and colpocleisis
with concomitant hysterectomy (CH) alternatives for different
age and 90 % confidence interval

alternative C outperformed the alternative CH with

positive upper and lower bounds of the 90 % CI
Fig.2 One-way sensitivity analysis for Result
endometrial cancer(EMC)

When the probability of EMC

was greater than the
threshold, alternative CH was
preferred over C
Fig.3 One-way sensitivity analysis for the Result
probability of conversion to laparotomy

If the probability of
conversion to laparotomy
during a CH procedure was
higher than the threshold,
the alternative C was
preferred over CH
Discussion
In our decision analysis, comparing Le Fort colpocleisis with
colpocleisis with concomitant hysterectomy, we found that Le
Fort colpocleisis was more favorable

Specifically, as patients get older, it appears that the

difference between the two alternatives widens

Because the primary reason for performing hysterecto- my at

the time of colpocleisis is to avoid cancer, the incidence of
EMC becomes a key factor in this decision- making
 Discussio
n

Limitation
inherent to decision analysis, in which a model is created
based on input from published data

Studies utilized were overall small and nonrandomized

we could not incorporate the risk of pyometra after

colpocleisis with uterine conservation, as rates of
pyometra are low, with only 4 cases reported in the
literature
 Discussio
n

There is a paucity of data to guide surgeons regarding the

removal of uterus in patients with advanced prolapse who are
candidates for an obliterative procedure

Le Fort colpocleisis should be the preferred option when faced

with this patient

Each patient is an individual and all factors should be

considered when planning surgery for prolapse

Postmenopausal patients with abnormal bleeding are not

good candidates for uterine preservation.
Thank You