Pelvic Floor Surgery

Uterine, urinary bladder prolapse, rectal prolapse, urinary bladder dysfunction and urinary incontinence problems can be operated effectively and successfully with the new treatment techniques in pelvic floor surgery, which we also call Pelvic Reconstructive Surgery. The pelvis is the area in the lower abdomen where the reproductive organs are located in women. We can define the pelvic floor as the layer that forms this area, consisting of muscle, connective tissue and ligaments. Problems with the urinary bladder and pelvic floor are seen in one out of every three women.

” I can't hold my urine, I’m urinating every hour, I know almost every toilet, I can't go out because of my fear, I can't go to the neighbor, i feel like I constantly have to urinate, I often go to the toilet at night, I have back and groin pain that does not go away, I can't control (hold) my stool like I used to, I have to support it with my finger while I'm doing it or there's something coming down below, something is coming out”

It is not only the problem of older women as it is thought. According to recent studies, “one out of every three women after childbirth has problems with the bladder” and only a few of them return to normal. The main cause of all these problems is loosening of the muscles and connective tissue in the pelvic floor due to births, operations and age. As a result, significant and negative changes occur in the quality of life of these people. Patients change their lifestyles and restrict their social lives. By drinking less water, kidney stones, urinary tract infections, processes leading to depression by limiting the body's water need are experienced. We had to perform dialysis in our patients with severe renal failure due to the mass effect. Their sexual lives are also severely restricted for reasons such as embarrassment, loss of self-confidence and fear of their partners noticing the problem. In the surveys, it has been seen that sexual life is prevented up to 60%.

Although the problems are increasing, it is seen as a "taboo" to express their problems as it used to be, and these patients rarely seek help. Some patients are ashamed to tell their doctor or their relatives about their complaints, while others think that these problems are normal at their own age. One of the main reasons was that there were no permanent and effective treatment methods until recent years and the physician did not have many options. Supporting the urinary tube with synthetic tape, such as transvaginal tape (TVT) and trans obturator tape (TOT), which have been applied recently, is a very effective new operation technique. However, they are the proper operations for only 15% of patients with urinary incontinence.

Due to “Integral Theory” based approaches and initiatives, which were put forward in 1990 by Prof. Dr. Peter Petros from Australia and Prof. Dr. Ulmsten from Sweden, great advances have been made in pelvic floor surgery. With the contribution and work of Prof. Dr. Klaus Goeschen from Europe, surgeries that were initially performed only for urinary incontinence began to be applied on the entire pelvic floor with the principle of "Integral Theory". All injuries in the pelvic floor were evaluated with careful and comprehensive examinations, and not only the damaged area, but the entire area was started to be addressed. For about 85-95% success has been achieved with these techniques instead of surgeries that provided 40-50% success and temporary improvement in the past.

After a careful examination and necessary research, the operation is performed vaginally (from the vagina), almost without bleeding and with small incisions. The weakened, loosened bonds are strengthened by using synthetic materials if necessary, overhanging layers are conveniently overlapped without removal, thus Post-operative scarring is prevented, and at the same time, the elasticity and functionality of the vagina is preserved. At the end of these surgeries, patients are allowed to return to their normal lives in a short time. Apart from having intercourse, they can return to their normal lives in a few weeks.

How the pelvic floor functions?

In the light of new information, pelvic floor functioning has been likened to a trampoline.

The pelvic floor is similar to a trampoline, consisting of muscles (the blue colored jump net section in the middle) and ligaments (attached to the sides) that form the jump spring section. The ligaments attach to the pelvis anteriorly, in the middle and posteriorly. The bladder rests on the trampoline like a rubber balloon. When the bladder is full, the trampoline net and spring stretch and hang down. With the filling, the nerves at the base of the bladder send a signal to the brain, informing that the bladder is full. After a certain stage, the brain sends a signal to the bladder to empty. If the person is not in a position to urinate at that time, the muscles at the floor of the pelvis contract, allowing the trampoline net to rise, thus preventing the base of the bladder from compressing. Thus, the feeling of tightness decreases and the person relaxes. But of course, this perfect system is only possible if the trampoline is intact.

Especially if the muscles are not weak and tense due to childbirth, the base of the urinary bladder will not be sufficiently lifted and balanced. Ligaments and muscles will sag, and the person will go to the toilet with urination even when the bladder is filled with a small amount. Depending on the site of the damage on the pelvic floor, the disorder in the trampoline system will manifest itself with different complaints.

In case of a weakness in the anterior regions, the mouth of the urinary bladder will not be able to close enough during activation such as coughing, sneezing, straining, walking, and sports and there will be uncontrolled urinary incontinence.

At the same time, since the ligaments in the anterior region play a role in defecation control, involuntary stool incontinence may occur in these patients. Damages in the middle region of the pelvis usually appear as frequent urination, a feeling of urgency, and urinary incontinence before reaching the toilet. In connective tissue damage in the posterior region; we see urination difficulties, frequent urination at night, back and groin pain, and uterine or bladder prolapse.

In this complex and unified structure, each patient is carefully evaluated and sometimes many corrections (Total Pelvic Reconstruction) are required for a single complaint. This shows why, "past surgeries that were performed only for complaints were not fully successful."

Organic causes of sexual problems?

Sex isn't an issue for most people, as long as there is not a problem. But if it is hindered one day, troubles begin. Problems may grow especially after births, lower genital area surgeries, bladder or uterine prolapse, and with aging. The person chooses to share these problems with their physicians rather than their spouses. Sometimes, they may encounter reactions that lead to humiliation and resentment. Healthy integrity of the pelvic floor is essential for a problem-free sexual life. Here, the functions of the organs in that region during intercourse are as important as bladder or uterine prolapse, damage due to previous surgeries. As can be expected, urinary, gas and stool incontinence during intercourse puts these people in even greater trouble. These problems are actually more common than you might think. It is possible to help patients of all age groups with a detailed examination and interview. A healthy sexual life can be achieved by detecting prolapse, enlarged areas in the bladder and providing corrections.

Birth

In most cases, births are responsible for a uterine or bladder prolapse that may occur later in life (births are only the most common cause, prolapses may also occur in those who have never given birth). Most women state that their vaginas are enlarged and they feel that they cannot satisfy their spouses. There are also spouses who come to us and say this themselves. Damages due to childbirth can occur in any part of the vagina and pelvic floor. Prolapse of the vagina walls manifests as weakness in the pelvic floor muscles, nerves, and ligaments. In addition, it is necessary to pay attention to birth-related tears around the vagina entrance. These problems can lead to an inability to enjoy intercourse, urinary incontinence, and pain during intercourse.

Prior Operations

Surgeries on the lower genital area may cause sexual problems in the later stages of life to a considerable extent. As a result of uterine surgeries and prolapse surgeries performed through the vagina; new troubles, continuation of complaints, pain during intercourse and a lack of pleasure may result. Although there are so many organic (non-psychological) sexual problems, it is still considered taboo to go to the doctor for these reasons today. With the “Integral System”-based operations that we have implemented and further developed, we can help our patients to have a trouble-free sexual life

How we can help?

After the exact location of the damaged part of the pelvic floor we can offer you a schedule for your individual problems of bladder, pelvic floor or organic sexual dysfunction. The decision on what is to be done depends on the results of the examination. Help is available either in form of a non-surgical approach (Petros concept) or as an operative procedure (Goeschen/Caliskan concept).

The non-surgical treatment

Pelvic floor exercises

Based on the trampoline example, exercises have been developed to strengthen important pelvic floor muscles. People can perform these exercises in their daily lives and without spending extra time. In this sense, two very important muscle groups that control the urinary bladder and bowel function are targeted.

The first one is the striated muscle group and provides the opening and closing of the urinary bladder, the last part of the intestine (rectum) and the area where the anus is located. The smooth muscle group, on the other hand, provides elasticity, which is very important for the organs in this region. It keeps the genital organs in their normal position and prevents them from moving unnecessarily. Electrical stimulation is effective to strengthen these muscles. Studies have shown that as a result of electrical stimulation, blood supply increases in damaged tissues. Therefore, with the increase of oxygen and energy in the region, the muscles have been strengthened. This increases the endurance of the muscles.

A recent study by a group we work with showed up to 70% improvement in these problems. However, if the ligaments that provide communication between the organs (urinary bladder, urinary tract, vagina, intestines) and muscles are damaged, these exercises will not work. For example, when the Achilles tendon ruptures, you cannot move your foot backward even though the muscles are normal.

If the connective tissue is damaged, the muscles cannot provide flexibility and strength to the vagina wall.

In this case, we provide the connection between the muscles and the vagina with a special band.

In some patients who do not have connective tissue damage we do not consider an operation; Electrotherapy devices are available for personal use as an alternative therapy or to strengthen the muscles after surgery.

Surgery

If the ligaments that hold the pelvic region organs (urinary bladder, urethra, vagina, last part of the large intestine) and the muscles together are damaged, such electrotherapy will not be beneficial. If the ligaments that provide the connection between the organs and muscles are not strong enough, the interventions will not work. In the light of all this up-to-date information and with the Goeschen/Çalışkan method supported by scientific studies, we perform surgeries with

* a higher success rate
* less pain
* minor surgery scar
* short hospital stay
* quick return to daily life
* intervention through the reservoir which is the natural way
* fewer complications

Contrary to many surgeons, one of the basic principles in all these surgeries is "not removing the uterus". The uterus provides the form and stabilization of the pelvic floor. All ligaments are gathered here. If the uterus is removed, the nourishment and support of the ligaments are blocked. Removing it makes it easy for this harmonious structure to collapse. In some rare cases, the uterus may need to be removed, which we already perform when necessary. However, removing a healthy uterus, on the contrary, will increase urinary problems in the future, the patient will have lost an important organ, and young patients will no longer be able to have children.

What is our difference from traditional surgeries?

The reason for the ineffectiveness of the surgeries that are still applied in Europe and most of the world today is that the appropriate techniques have not been selected. The uterus is removed with the cervix (pericervical ring), which is the attachment point of all ligaments, the vagina wall is cut as it’s considered redundant and joined blindly. These forcibly joined tissues heal poorly and cause failure with the slightest force. Structures that seem to have improved anatomically at first, are damaged by the lack of elasticity and forcing in a short time, and the ligaments that have not been strengthened are weakened even more. Sometimes, in operations performed by opening the abdominal wall, physiological aspects are ignored, causing major surgery scars and post-operative pain.

The basis of new techniques is to take into account the new functional changes, not to remove any tissue that seems to be redundant, on the contrary, to create elastic and functional structures by using these tissues in addition to the correction. Instead of weakened bonds that are no longer strong, synthetic materials that are compatible with the human body-tissues, strong, and extremely safe when used well, are used, and these materials are placed in the necessary places in the pelvic region with the help of specially developed instruments. We have performed more than 5000 operations on patients aged between 24-88 years with the Goeschen/Çalışkan technique.

Surgical approach to anterior region injuries

If there is an injury to the ligaments in the front that allow the opening of the bladder to function, the muscles in this area cannot function properly and the control of urination and sometimes defecation is lost. In this case, we replace the damaged ligament with a synthetic band. With two small incisions made on both sides of the vagina, the tape is placed under the bladder opening and the ends are removed from the groin. The width of this band is 1 cm on average and the process is completed without any sutures in the outer region. As a result of the reactions of the body around this band, a solid and permanent connective tissue is formed after about 3 months.

In the above picture, you can see a simple schematic of the operation. Below are the materials used in these operations.

Advanced surgical techniques for damage in the middle region

In the middle part, the anterior wall of the vagina is attached to both sides by a large connective tissue layer. You can think of it as a towel suspended between two clotheslines. The bladder sits on this towel. If the middle of this towel collapses, the bladder and anterior vaginal wall will prolapse. This is seen as a feeling of urgency, urinary incontinence and urinary discharge problems in the patient.

In the picture, the prolapse of the urinary bladder from the weak area towards the vagina is schematized. Similarly, it is described below in the side section.

It is very difficult to repair this damage with traditional surgeries. One-third of patients come back. The reason for this is that weak tissues stretch again. We re-strengthen the vaginal wall with specially produced synthetic bands or nets. The prolapsed tissues are never cut away, but reused to strengthen the layers.

Sometimes the ropes on which the towel is hanging can also collapse. In a similar situation, the anterior wall of the urinary bladder and vagina collapses down. Our patients come to us because of similar complaints and saying that something is coming from below to their hands. In the same way, permanent treatment and correction can only be achieved with the help of these synthetic materials.

You can see the example of towel/clothing line and the damages that can occur in different ways, which I tried to explain in the figures above. The complaints of the patients are similar.

The final image above shows the operation using a wide mesh (yellow colour) along with the operation images.

Surgical approach in posterior region injuries

If damage occurs in the connective tissues in the posterior region, patients often present with uterine prolapse and prolapse of the posterior vagina wall. There are complaints of defecation difficulty, inability to completely empty the stool, groin / low back pain, difficulty urinating, feeling of urgency, stool incontinence, and frequent urination at night.

In the figure above, you can see how the last part of the large intestine is displaced towards the vagina due to the weakened tissues. With the same principle, the chance of success is limited with classical surgeries in this case as well. With the Goeschen/Çalışkan method, loosened bonds are strengthened with synthetic bands. At the same time, the vagina wall is repaired with a special technique without using a synthetic mesh. Thus, the vagina and breech are brought back to their original position. After 2-3 months, the placed synthetic band starts to work as a part of the body. These bands do not cause pain, because they are not tightly fixed and do not need to be fixed.

As with the tissue fixation system, we use multiple bands (shown in yellow) to return the organs to their normal position.

In the picture above, by suturing the blue-colored synthetic bands to the yellow sacrospinal ligament with the special tool we developed (Goeschen-Handke Medizintechnik Gmbh Germany), we can bring the prolapsed uterus to its normal position in a very effective and permanent way.

Some of the tools we use in “Total Pelvic Reconstruction” are shown in the pictures above.

Tethered vagina syndrome

* urinary incontinence as a result of previous pelvic floor surgery
* urinary incontinence as a result of removal of the uterus
* urinary incontinence as a result of previous vagina correction operation
* urinary incontinence after bladder surgery
* urinary incontinence as a result of operations using tape or mesh

Due to the scar tissue that may form on the neck of the bladder after these operations, some patients may experience severe uncontrolled urinary incontinence, especially when standing up, in the form of emptying all the urine in the bladder. Due to this undesirable situation created by us, the hardened bladder neck prevents the opening and closing functions of the urinary bladder. Applications such as Teflon, microballoon etc.made to fix it worsen the situation. In order to prevent urinary incontinence, the neck of the bladder needs to be restored to its former elasticity. For this purpose, we use the tissue patch, which was taken from the vagina entrance with the “muscle-fat-skin graft” technique that was modified, and successfully applied in hundreds of patients by Prof. Goeschen for the first time in Turkey, we achieve about 80% treatment success.

The uterus, the central anchoring point of the pelvic floor, acts like the keystone of a roof

For the above reasons we try to conserve a healthy uterus whenever possible. A hysterectomy using the procedure of Goeschen/Çalışkan is rarely necessary. Pregnancy after keyhole approach is still possible. However, we recommend then that delivery should take place by Caesarean section.

Figure: Hysterectomy may weaken the fascial side-wall support and the ligaments by removing a major part of its blood supply. Conservation of the uterus is important in the long-term prevention of vaginal prolapse and incontinence

Should I worry about using mesh?

Surgical mesh is a medical product that is applied to establish additional support when repairing and renewing weakened or damaged tissue. Surgical mesh is made usually from synthetic or biological materials. Reconstructive pelvic floor surgery is a fascia and ligament surgery (connective tissue). Without the synthetic mesh, there would be no effective, permanent, anatomical, physiological repair.

We reconstruct all damaged compartments simultaneously by using artificial mesh (synthetic). Mesh related complications, particularly “erosion”, is a major discussion regarding POP surgery.

Because of these concerns, surgical mesh has been banned only in the UK, Australia and Commonwealth countries, but surgical mesh has still been used in the rest of the world, including the USA (except transvaginal mesh kits) and Europe for pelvic reconstructive surgeries.

The problem isn't the mesh, it's how it's applied. Industrial, prefabricated and standard size mesh kits are widely used for every defect and each patient. However, this is one of the main problems according to our opinion. Patients and defects are not standard. Therefore, shrinkage, contraction, pain, pain during intercourse and erosion are inevitable.

The following are also important and substantially impact the result of the surgery:

• How well patients are prepared before the surgery,
• The technique and experience of the treating doctor,
• The location and the amount of mesh that will be used

We use self-tailored lightweight macropore monofilament polypropylene meshes and are cutting the mesh off during the surgery appropriately for the defect. Our mesh related complication rates are about only 1% as minimal erosion, which is one of the lowest in the literature.

Before surgery

We call all our patients with an empty stomach the day before the surgery, early in the morning. After the necessary tests and consultations are conducted before the surgery, we usually send the patient home in the afternoon. We tell them to come early in the morning of the surgery, hungry and without drinking water. If they are using drugs such as aspirin, or blood thinners, we ask them to stop taking them at least 10 days before

After surgery

Depending on the type of surgery, we keep you in the hospital for 1-2 days. Your urinary catheter stays overnight. Under normal conditions, there is no bleeding. After you get home, you can do all your daily work carefully and gently. You can start working after a few weeks. Only the first 3 months require special attention. Sudden and forceful movements may damage the sutures. Full recovery takes 3 months due to the nature of the area. At the end of 3 months, you continue your free life. During this period, there will sometimes be light bloody discharges.

Surgery results;

There is no absolute guarantee of success for any surgery. From our own experience, and according to our communication with physicians who apply similar techniques, our long-term (1-14 years) anatomical success rates, which were published in international journals, are between 90-98%. Our recurrence rates are below 1%, and this rate rises to 60% in operations performed with classical techniques.

What we treat?

* Uterine prolapse
* Vagina prolapse
* Urinary bladder prolapse
* Anal prolapse (breech prolapse)
* Uncontrolled urinary incontinence with body movements (Stress incontinence)
* Severe urinary incontinence due to previous surgeries
* Constant urination sensation, sudden urgency
* Frequent urination during the day
* Frequent urination at night
* Problems emptying the bladder
* Unexplained groin and lower back pain during intercourse or at other times
* Stool incontinence and defecation problems
* Narrowing or changes in the vagina due to previous surgeries
* Sexual problems due to organic causes

Questions and answers

**How is the Goeschen/Çalışkan method different from other inspection methods?

Classical examination methods, such as measuring bladder pressure (Urodynamics), may indicate a problem. However, it does not indicate where the bladder or pelvic floor is damaged. With the Integral System examination and diagnosis algorithm we apply, the damaged area in the bladder or pelvic floor that creates the problems can be determined exactly.

** What is the difference between urinary incontinence (incontinence) operations performed with the Goeschen/Çalışkan method from classical methods?

In classical methods, the bladder neck is suspended by entering mostly from the abdomen. These operations cause major surgery scars, more pain, prolonged urinary catheterization, more complications, longer hospital stays, and a non-physiological correction with lower success rates. In the Goeschen/Çalışkan method, urinary incontinence operations are performed through the vagina. Damaged connective tissue is regenerated with the prepared synthetic band (TOT or TVT operation). The vagina approach also allows us to repair other damaged areas. Because we know that 85% of patients' complaints are caused by damage in many areas of the pelvic floor at different rates. The success rate in TOT -TVT operations, which we have developed and applied in patients with urinary incontinence only in situations such as movement, coughing, lifting something, etc., is around 97%. Less post-operative pain, short-term urinary catheter stay, and single night stay in the hospital are other advantages. The patients can return to their daily life in a short time and can do activities such as shopping, housework and driving.

** What are the important differences between the Goeschen/Çalışkan method and the classical prolapse operations?

In classical operations, the uterus and prolapsed vagina are removed, and serious problems may occur in the relationship due to a shortened and hardened vagina due to scar tissue. With the removal of the cervix, the strongest support area of the pelvic floor disappears, and urinary and defecation problems occur over time. Bed rest is often recommended for days or even weeks after the operation, and a long-term tampon is applied. However, the problem is not the prolapse of the 60-gram uterus. It is the damage to the ligaments and surrounding tissues that hold it. As a rule, the uterus is not removed in the Goeschen/Çalışkan method, patches are made with synthetic materials without cutting out any tissue pieces. Thus, the normal length, width, and functions of the vagina and other organs are preserved. As a result of the correction logic, sudden urgency, frequent urination day and night, unexplained groin pain, and defecation problems can also be resolved in the same session. The catheter and tampon are withdrawn in 12 hours, and they are discharged within a few days, sometimes even the next day.

** Success rates

* Objective anatomical success 95-98%
* Stress incontinence 95%
* Urge incontinence 78%
* Frequent urination 85%
* Frequent urination at night 80%
* Sudden feeling of tightness 80%
* Difficulty defecating 97%
* Complete improvement in quality of life 80%

** If my complaints recur, does this mean the surgery was unsuccessful?

It is not always the case. Pelvic floor ligaments work like shock absorbers. Over time with intra-abdominal pressure, the ligaments on the other side may weaken. Thus, new complaints can be seen as if old complaints have been repeated. In large and long-term patient series, our complete failure rate is 2.6%. This rate has been below 1% in recent years.

** What happens if the operation fails?

Since the operations with the Goeschen/Çalışkan technique are performed with low tension and without tissue removal, the damaged structure can be corrected with another operation. Because we apply preventive surgery to our patients, the operation can be tried again easily. In our 17-year follow-up, the rate of patients who need to be operated on again is 4%. As experience increased, this ratio decreased below 1%.