Graft interposition colpocleisis, perineorrhaphy, and tension-free sling for pelvic organ prolapse and stress urinary incontinence in elderly patients

Study objective: We sought to describe the outcome of combined colpocleisis, perineorrhaphy, and tension-free sling procedure for advanced uterovaginal prolapse and stress urinary incontinence in patients who are elderly and medically compromised. Design: Prospective analysis. Setting: University hospital. Patients: Thirty-nine women were enrolled. Median age of patients was 82 years (76-94 years). Interventions: All patients had advanced uterovaginal prolapse with perineal relaxation and incontinence and each wore a large pessary. Measurements and main results: Median estimated blood loss was 42 mL (range 10-65 mL), median operating time was 58 minutes (range 45-76 minutes), and median hospital stay was 8 hours (range 0-3 days). Thirty procedures were accomplished without general anesthesia. Le Fort colpocleisis was reinforced with excessive mesh strips from the sling by placing mesh between anterior and posterior vaginal walls at the time of closure. No intraoperative complications occurred and none had postoperative voiding difficulty or significant discomfort. One patient required hospitalization for cardiac arrhythmias and 3 others for observation purposes only. Median follow-up has been 24 months. Follow-up physical examinations were performed for postoperative evaluation. One patient required reoperation for minor posterior compartment prolapse and another has started to show some apical prolapse again. Neither patient had a perineorrhaphy at the time of initial procedure. Two patients required some graft excision as a result of exposure from the side without any loss of support or discomfort. In all, 37 patients (37 of 39) are extremely pleased with the prolapse repair and 35 patients (35 of 39) report significant improvement of stress incontinence. Conclusion: Concomitant severe pelvic organ relaxation and stress urinary incontinence can be surgically treated safely and rapidly using a tension-free sling and colpocleisis with perineorrhaphy under local anesthesia and sedation, thereby eliminating potential risks of general anesthesia and invasive surgery. A novel technique of graft interposition colpocleisis has been used.