Culpoclysis is a safe and effective treatment for uterovaginal prolapse. Careful counseling is essential to avoid patient regret for loss of sexual function. Though rare, recurrent prolapse or patient regret may necessitate takedown of prior culpoclysis scarring. This is the case of a 62-year-old G4P4 who underwent culpoclysis at an outside institution eight months previously for stage 3 uterovaginal prolapse. She presented to our office with a symptomatic rectocele to three centimeters below the hymen, desiring prolapse repair and return of vaginal patency to allow for intercourse. On exam, her anatomy was consistent with a prior Lefort culpoclysis with an obliterated vagina and patent bilateral vaginal tunnels leading to the cervix. Here a clamp demonstrates the vaginal tunnel on the left, and another clamp shows the tunnel on the right. It was clear that the tunnels were patent on either side, but it was unclear whether there was adequate vaginal caliber remaining for reconstruction, so an MRI was obtained. These dynamic MRI images with Valsalva demonstrate anterior and posterior vaginal wall prolapse. This drawing by Nichols demonstrates the bilateral vaginal channels forming an inverted U-shape as they connect proximally in front of the cervix after a culpoclysis. In this cross-sectional MRI image, the urethra can be seen here, the rectum here, the coapted vagina in the midline, and the bilateral vaginal tunnels are seen here, measuring approximately 1.5 centimeters in diameter. In the mid-sagittal view, contrast gel can be seen in the distal vagina up to approximately the level of the vesicle neck where the culpoclysis starts. Then again, contrast is seen at the level of the cervix or at the top of the inverted U. We devised a surgical plan by focusing on the bilateral vaginal tunnels. With this anatomy in mind, the surgical plan was to connect the bilateral tunnels in the midline to reveal the cervix and restore vaginal length. After discussion of options, the patient elected to proceed with takedown of culpoclysis scarring, vaginal hysterectomy, and prolapse repair. We began by opening the vaginal epithelium sharply in the midline, extending this incision laterally in either direction toward the vaginal tunnels. The underlying tissue was then carefully dissected away from the vaginal epithelium. Once the tunnel was large enough to accommodate a finger, the cervix was palpated behind the remaining scar tissue. The intervening tissue was carefully dissected using the bilateral vaginal tunnels as a guide toward the cervix. A tonsil clamp was then introduced through the right tunnel to meet the left. A Robinson catheter was then delivered behind the remaining scar tissue to connect the two tunnels and to bring the dissection more distally. Using the catheter as a guide, the remaining scar tissue between the vagina and cervix was then taken down sharply. Once the last of the scar was dissected overlying the catheter, the prolapsed cervix was revealed coming to 5 centimeters below the hymen. The cervix was grasped, and the peritoneum was entered posteriorly to begin the hysterectomy. The remainder of the vaginal hysterectomy was performed in the usual fashion. Once the hysterectomy was complete, we began to prepare for the vaginal suspension. At the conclusion of the hysterectomy, with a laparotomy pad in the peritoneal cavity, the bilateral utero-sacral and utero-ovarian pedicles remain tagged. As expected, the posterior vaginal wall was foreshortened. Attention was then turned to the sacrospinous ligament suspension. The peritoneum was grasped, and the retroperitoneal dissection was started toward the right sacrospinous ligament. With two passes of the Deschamps ligature carrier, four stitches of OPDS were passed through the sacrospinous ligament and secured to the drape for later attachment to the vaginal cuff. With the stitches through the sacrospinous ligament, attention was turned to vertical closure of the epithelial edges and anterior repair. The anterior vaginal epithelium was grasped and elevated. The epithelial edges are outlined here. Our goal was to close the anterior and posterior epithelium vertically to restore vaginal length and create a new vaginal cuff in the center through which the suspension sutures would be placed. The underlying fibromuscular layer of vaginal wall was serially placated. The vaginal epithelium was then closed vertically in an effort to preserve length of the anterior vaginal wall. The posterior vaginal epithelium was similarly closed vertically. The PDS sutures were then sequentially brought through the vaginal cuff. The sacrospinous stitches were then tied down, assuring good approximation of the vaginal cuff to the ligament. At the completion of the procedure, vaginal patency and support were restored with a normal vaginal length of 8 centimeters. Counseling prior to copal clysis is critical. In the rare instance of patient regret, deconstruction of prior surgical scarring is a feasible procedure that may be offered to patients with recurrent prolapse or desire for vaginal patency.

62-year-old woman

culpoclysis

uterovaginal prolapse

rectocele

surgical steps