Introduction: Colpocleisis is an obliterative vaginal procedure ideal for women with pelvic organ prolapse who are no longer sexually active or cannot tolerate more extensive reconstruction. There is significant variation in current practices surrounding colpocleisis with one survey-based study showing that 18% of surgeons perform routine hysterectomy concomitantly. It is unclear if the added risk of a vaginal hysterectomy (vascular and bowel injury, increased operative time), is exceeded by the benefit of eliminating the risk of endometrial or cervical cancer, pyometria or difficulty assessing abnormal uterine bleeding. We assessed the utility of vaginal hysterectomy at the time of colpocleisis by describing the probability of endometrial cancer and death after LeFort (uterine sparing) colpocleisis repair using a contemporary population-based dataset.
Methods: Women undergoing colpocleisis in California (2005-2019) were identified using the Office of Statewide Health Planning and Development (OSHPD) datasets. A competing risk analysis with each of three outcomes (alive, endometrial cancer, or death) was modeled for women undergoing Lefort colpocleisis.
Results: A total of 2707 women had colpocleisis performed, of which 381 had concomitant (14.1%) or prior hysterectomy (8.6%). Mean age at time of surgical repair was 78.6 years. Among the 2,093 women undergoing LeFort colpocleisis, 18 (0.9%) incurred an endometrial cancer diagnosis. A total of 280 (13.4%) subjects died over a mean follow up of 10.2 years. Number needed to treat (NNT) with hysterectomy to prevent 1 endometrial cancer diagnosis was 1141 at 3 years. Subsequently, NNT decreased from 283 at 5.5 years to 166 at 10-13 years. Women with endometrial cancer diagnosis lived a median difference of 2242.5 days (6.1 years) less than their counterparts without cancer.
Conclusions: As previously published reports from this dataset indicate, there is an increased risk of complications when concommitant hysterectomy is performed and the benefits of hysterectomy at time of colpocleisis in women over age 70, particularly frail patients with a short overall life expectancy, are minimal. Overall rates of endometrial cancer in the setting of uterine preserving colpocleisis are low, below the published prevalence rates for similarly aged women. Concomitant hysterectomy at time of colpocleisis does not significantly reduce mortality of women at highest risk of endometrial cancer in this cohort.
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