Pelvic organ prolapse (POP) is the prolapse of the bladder, rectum (the last part of the large intestine), uterus and any part of the intestine together or individually from the anterior, posterior wall or dome of the vagina (female tract). This condition can lead to disorders such as urinary incontinence, urinary retention, discomfort and sagging sensation in the pelvic area, difficulty walking, pain in the pelvic area, frequent urinary tract infections and sexual dysfunctions.
Although it is very difficult to determine the incidence of pelvic organ prolapse in women in society, studies on this subject have found that 30-50% of women have pelvic organ prolapse throughout their lives and the incidence increases in women who have given birth to children, intervention and difficult birth.
Risk factors for pelvic organ prolapse in women include an increase in the number of births, high birth weight of the child, intervention deliveries, aging and weakness in the muscles forming the pelvic floor. In a study on this subject, the risk was found to be 4 times higher in women with one child and 8 times higher in women with 2 children compared to women without children.
When planning the most appropriate treatment for pelvic organ prolapse, the general health status of the patient, the complaints caused by pelvic organ prolapse, the negative impact on quality of life and the severity of pelvic organ prolapse should be taken into consideration. Current treatment options for pelvic organ prolapse in women are non-surgical treatments, mechanical supporters (pessaries) placed into the vagina and surgical treatments.
Mechanical supporters placed into the vagina by a physician in severe prolapse in elderly patients who cannot tolerate surgery are beneficial for patients, but they have side effects such as irritation, feeling of fullness, wound and recurrent inflammation in the vagina.
The main goal of surgical treatment is to restore the patient's pelvic organs to their normal anatomy, thus eliminating complaints related to the urinary tract, bowel system and sexual function. Surgical treatment can be performed through the vagina or abdomen, the uterus may or may not be removed in the same session, and synthetic or biological support materials (mesh) are often used. Pelvic organ prolapse surgery performed through the abdomen can be performed using classic open abdominal surgery or laparoscopic or robotic methods. During pelvic organ prolapse surgery, if the patient also has urinary incontinence due to inadequate urinary retention muscles accompanying pelvic organ prolapse, urinary incontinence should also be treated with suspension surgeries using mesh in the same session.
However, the cause of urinary incontinence must be determined by urodynamic methods (a test that evaluates the emptying and filling stages of the bladder) before surgery. The choice of surgical method is based on the surgeon's experience, the severity and type of pelvic organ prolapse (anterior, posterior wall or vaginal dome prolapse), the patient's age, the patient's complaints, health status and the presence of additional diseases.
Vaginal anterior wall prolapse (cystocele): The classical surgical treatment is often performed vaginally and is based on joining the support tissue extending from the bladder on both sides towards the cervix to the midline. In this technique, the patient's damaged tissues are corrected by direct repair. In this method, synthetic or biological support materials (meshes) are not used under the bladder. Recently, anterior wall prolapse surgical treatments performed through the vagina using synthetic or biological mesh have yielded successful results.
Vaginal posterior wall prolapse (rectocele):Surgical treatment is usually performed through the vagina and the weakened vaginal mucosa is removed and the supporting tissues on both sides of the vagina are joined to the midline. Mesh is usually not used in posterior wall repairs.
Severe prolapse from the dome of the vagina (apical):Uterine prolapse or prolapse of the vaginal vault in patients who have had their uterus removed is treated using both vaginal and abdominal surgical treatment methods. Surgeries performed through the vaginal route consist of sacro-spinous fixation (fixation of the dome of the vagina to the ligament extending from the sacrum to the spinal protrusion in the pelvis (pelvis)) and suspension of the vaginal dome using a 4-arm synthetic mesh. No mesh is used in sacrospinous fixation surgery. However, the use of synthetic or biological support material (mesh) is quite high in 4-armed mesh application.
Sacrocolpopexy is the surgery performed through the abdominal route for sagging from the vaginal dome. In this surgery, if the patient's uterus has not been removed before, the uterus is preserved and the uterus and vagina are fixed to the protrusion called promontorium on the front surface of the sacrum bone through a synthetic mesh fixed to the anterior and posterior wall of the vagina. If the uterus has already been removed and the prolapsed organ is the vaginal stump, the vaginal stump is fixed to the sacrum bone promontorium through a synthetic mesh placed on the anterior and posterior vaginal wall. Sacrocolpopexy surgeries can be performed both with the classical abdominal open surgery method and laparoscopic or robotic method.
Success rates of sacrocolpopexy operations performed through the abdomen have been found to be higher than sacrospinous fixation operations performed vaginally. Since serious complications related to the synthetic mesh have been observed in the mid- and long-term follow-up of prolapse surgeries performed through the vagina using a four-armed mesh, one should be very careful when deciding on these surgeries. In patients with severe prolapse who are too old to tolerate a comprehensive surgery and who have additional serious diseases and who are beyond the age of sexual intercourse, vaginal closure (colpoclezis) surgery can be performed. Pessary application is also possible in this patient group.
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