Management of pelvic organ prolapse after hysterectomy in elderly is challenging because laparoscopic route is frequently not possible. Most vaginal procedures are not always good solutions because of high stage prolapse and high rate of recurrence.
Colpocleisis (Lefort procedure) consist in closing the vagina, sticking anterior and posterior vaginal wall keeping lateral gutter allowing draining of uterus and vaginal scar. Epidural anesthesia is possible because of short duration and low tractions necessary on pelvic organs. Satisfaction rate is around 95% with good long term results[1 ].

This patient is an 78 years old female with history of vaginal hysterectomy and respiratory insufficiency, hospitalized in emergency for urinary sepsis. A CT scan revealed an urethral and ureteral  wrapping responsible for an acute obstructive pyelonephritis. The clinical examination found a stage IV anterior wall with vaginal dome prolapse.
Two types of pessary were tried but they immediately dropped resulting in a recurrence of urinary retention. Thus, a Foley catheter was kept until the procedure.

The surgery was made under epidural anesthesia in gynecological position. 
The hysterectomy scar was recognized and caught with a Cott grasper. Anterior and posterior wall were infiltrated with adrenaline and xylocaine. 
Firstly, a rectangular incision of 6 cm length and 4 cm width were made on the posterior wall with scalpel. The mucosa was totally removed with sharp dissection. 
Secondly, the same procedure was made on the anterior wall.
Interrupted X-shaped sutures of absorbable 0 wire was used proximally, allowing to approach both walls keeping lateral gutters free.  
The closing from the top to the bottom of the incision, allowed to push up the prolapse progressively and reduce it totally.
Draining was assured by some non-absorbable wire running from one side to the other and crossing the upper bound of the incision. The total operating time was 32 minutes.
Drain and Foley catheter were removed on the first postoperative day and the patient was discharged to come back at home. 
At 8 months follow up, the patient empty totally the bladder and no recurrence of prolaps nor of upper urinary tract obstruction occurred. Nevertheless, a stress incontinence was revealed by prolapse reduction.

Hence, colpocleisis is a safe and efficient treatment of high grade prolapse and history of total hysterectomy, offering a free-mesh procedure with minimal operative time.

Long-term follow-up after LeFort colpocleisis: patient satisfaction, regret rate, and pelvic symptoms, Song et al., Menopause, June 2016