Repair of a Large Rectovaginal Fistula Due to a Neglected Pessary With Lefort Colpocleisis

INTRODUCTION: Treatment of pelvic organ prolapse (POP) in elderly frail patients with numerous medical co-morbidities often poses a significant challenge for the urogynecologist. Pessaries are commonly used as treatment in these scenarios, but unfortunately can become neglected and lead to complications such as vaginal fistulas. Particularly, in the era of COVID-19, there has been an increase in this occurrence. The use of colpocleisis as part of the repair of vaginal fistulas from pessaries has been described in the literature; however, this video demonstrates a unique technique in fistula repair and colpocleisis closure. OBJECTIVE: The objective of this video is to illustrate repair of a complex rectovaginal fistula due to a neglected pessary as well as treatment of POP with colpocleisis. METHODS: The principles of fistula repair include removal of surrounding necrotic epithelial tissue and a tension-free multilayer closure over the fistula defect. Lefort colpocleisis is a highly effective surgical technique for treatment of POP which involves obliteration of the vagina and creation of lateral channels to allow for drainage after surgery. The combination of fistula repair with colpocleisis in cases, like the one presented here, allows for a multilayer closure of the fistula and concomitant treatment of POP. RESULTS: We present the case of an 81-year-old woman with a complex medical history including, heart failure, COPD, DVT/PE, chronic dysphagia s/p g-tube, severe osteopenia with a recent L4 compression fracture who was admitted to the hospital for her medical comorbidities. Urogynecology was consulted for a known rectovaginal fistula from a neglected pessary, and the patient was taken to the operating room for removal of her pessary, repair of rectovaginal fistula, and treatment of POP with colpocleisis. Intraoperative findings noted an 8- by 5-cm rectovaginal fistula, which was repaired in multiple layers (Figure 1). Due to the extent of the fistula, the right side of the vagina was completely obliterated, and an L-shaped transverse channel was created for the Lefort colpocleisis (Figure 2). Colorectal surgery was present for the case and confirmed appropriate fistula closure on sigmoidoscopy. Postoperatively, the patient recovered well without fistula recurrence and with resolution of her POP. CONCLUSIONS: This case demonstrates successful treatment of a large rectovaginal fistula due to a neglected pessary as well as treatment of POP with colpocleisis. Urogynecologists should consider this surgical technique in the appropriate patient for the treatment of complex vaginal fistulas and POP.