Incorporating Perineorraphy into Colpocleisis - A Modified LeFort Technique

Objectives: Pelvic organ prolapse (POP) is a frequent condition which is seen mostly in elderly women and its incidence reaches up to 40% after the age of 60. Although precluding coital activity and being an obliterative procedure, colpocleisis is associated with a shorter operative and recovery time, fewer complications and lower reoperation rates compared to reconstructive surgical modalities.

Even though complications are rarely seen with colpocleisis, it should be kept in mind that the frail patients are especially prone to adverse events and overall complication rate could reach up to 23% in this population. Surgical approaches which could potentially increase the effectiveness of the procedure and decrease operative time and bleeding should be discussed to lower complication rates.

Methods: A 66 year old woman presented with bothersome vaginal and rectal bulge for over 8 years. She had occasional urgency without any urinary incontinence. She was G2P2 (1 vaginal birth, 1 cesarean section), sexually inactive and her past medical history was unremarkable. Stage 4 prolapse with urethral hypermobility and kinking was revealed on examination along with a negative cough stress test. Her urodynamics revealed detrusor overactivity, normal post-void residual volume and no incontinence. Although conservative options including pessary placement were discussed with the patient she opted for surgery. A modified Lefort colpoclesis with prophylactic midurethral sling placement was performed.

Our Modifications to Lefort Technique

1- Dissection of the anterior and posterior vaginal epithelium mimics standard colporraphy.
2- Perineorraphy is incorporated into colpocleisis.
3- Attention is paid repairing pericervical ring to avoid future enterocele.
4- A red rubber catheter is used to ensure patency of lateral channels.
5- Cystoscopy was performed once even when mid urethral sling is performed.
6- Anterior vaginal fibromuscular tissue (raw surface) is vertically closed to restore Aa point to a more anatomical position to avoid de novo stress incontinence.

The postoperative course was uneventful and she was highly satisfied with the surgical results at the postoperative 6th week visit.

Clinical Relevance: Our surgical approach which incorporates perineorraphy into the LeFort technique enables less incision and potentially decreased operative time, blood loss and could decrease peri and postoperative morbidity. Additionally, resemblance of the procedure to a combined anterior and posterior colporraphy could enable inexperienced surgeons better understand and perform the procedure.