Treating uterine prolapse gently – uterus-sparing and minimally invasive in Istanbul

Important: A complete prolapse with the inability to pass urine (urinary retention) is an emergency. In this case go to the nearest emergency department immediately.

What does uterine prolapse mean – and when does it need treatment?

Uterine prolapse (descensus uteri) means that the uterus and vagina descend lower into the pelvis with a weakened pelvic floor. The severity is classified in a standardised way, often with the POP-Q system into stages 1 to 4, with the full prolapse being the most pronounced form. What is decisive for treatment is not the finding alone but whether symptoms are present, because a finding without symptoms is not an indication for surgery. In about 30 to 50 % of women with a prolapse the symptoms are so mild that observation and conservative treatment are possible first.

Source: AWMF guideline on female genital descensus

What symptoms does a prolapse cause – and why does it also affect the bladder?

A prolapse is noticeable above all through a feeling of pressure or a foreign body, often described as “something slipping down”. Because the descending uterus presses on the bladder and rectum, symptoms such as urinary incontinence or difficult emptying often arise. An accompanying descent of the bladder or rectum (cystocele or rectocele) is found in a considerable proportion of those affected. In around 30 to 40 % there is additionally a hidden stress incontinence that only becomes apparent during the examination and is important for the planning.

How does a prolapse develop – and who is particularly affected?

A prolapse develops through a weakening of the pelvic floor and supporting apparatus, usually through a combination of several factors. Births are among the most important causes, especially several births or the birth of large babies. The hormonal change during menopause, chronic coughing, persistent constipation and excess weight also increase the risk. Overall, over the course of life up to about 50 % of women who have given birth develop a prolapse of varying degrees.

How is the diagnosis made?

The diagnosis is based on the gynaecological examination, supplemented by a standardised classification of the severity. The pelvic floor is assessed, the POP-Q stage is determined and the organs as well as the residual urine after voiding are checked by ultrasound. Findings brought from the home country are taken into account, so that not everything has to be collected anew. With signs of incontinence an additional functional diagnostic test can be sensible.

Does pelvic floor training help – and when is it no longer enough?

Targeted pelvic floor training is often the first and effective step with mild prolapses. It can strengthen the musculature, slow a further descent and relieve the symptoms, even if it does not reverse an existing prolapse. With mild forms (stage 1 to 2) the symptoms improve noticeably under consistent training in a large proportion of women. If the training is not enough or the prolapse is more advanced, a pessary or surgery come into question.

When is a pessary a good alternative to surgery?

A pessary is a sensible alternative when an operation is to be avoided or postponed. It is inserted into the vagina, supports the organs and thereby relieves the symptoms without addressing the cause. Some women manage well with it over years and need no surgery, while others find no suitable model. Especially at an older age or with existing accompanying conditions, the pessary is a gentle and at any time reversible option.

Source: National Institute for Health and Care Excellence (NICE), guideline on pelvic organ prolapse

When is surgery sensible – and what methods are there?

Surgery is sensible when relevant symptoms are present and conservative measures are not enough or are declined. In principle, procedures through the vagina (native-tissue vaginal repair) and minimally invasive procedures via laparoscopy (laparoscopic sacrocolpopexy) are available. The operation takes about 30 to 60 minutes depending on the method, and the clinic stay is usually only around 1 to 2 days. Which method fits depends on the finding, the age and which compartments are affected.

Does the uterus have to be removed during the surgery?

In most cases the uterus does not have to be removed during a prolapse operation. In many patients the supporting apparatus can be reconstructed in a uterus-sparing way, so that the uterus is preserved. Important to know: removing the uterus does not protect against a prolapse; on the contrary, a previous hysterectomy is itself regarded as a risk factor, and the later prolapse risk is given in the literature in a wide range of about 0,2 to 43 %. We therefore first check whether a uterus-sparing approach is medically justifiable for you, and discuss openly when removal is actually the better solution.

Do I need a mesh – and is that safe?

A synthetic mesh is not automatic in a prolapse operation, but sensible only with a clear indication. The data situation on this is an important point that we explain honestly: regulatory authorities such as the FDA have warned of complications from vaginally placed meshes, and several countries such as England, Ireland, Australia and New Zealand have restricted or suspended the use of transvaginal meshes. A mesh exposure or erosion occurs, depending on the method, in about 5 to 10 % of vaginal mesh placements, while with laparoscopic sacrocolpopexy it is much rarer and usually below around 3 %. We therefore prefer, wherever possible, reconstruction with native tissue and use a mesh only where it has a clear benefit according to current evidence, for example with certain recurrences.

Source: U.S. Food and Drug Administration (FDA), safety notice on transvaginal meshes for pelvic organ prolapse

What does our treatment approach look like – and why does the same responsible hand treat you throughout?

Our treatment approach begins with one principle: first the gentle, then the interventional. We first check pelvic floor training and a pessary before we talk about an operation, and when we operate, we plan uterus-sparing and minimally invasively. Associate Professor Dr. Cengiz Andan brings around 18 years of experience, has performed more than 2,000 laparoscopic procedures and works with a complication rate of about 2 %. We accompany you ourselves throughout from the first consultation to the aftercare, instead of handing you over to changing teams, and follow the same international guidelines as the centres in your home country.

How does recovery after a prolapse operation proceed?

Recovery after a minimally invasive prolapse operation usually proceeds quickly and without large scars. Most patients leave the clinic after about 1 to 2 days and can return to light everyday activities after a few days. Heavy lifting, strong physical strain and intercourse should be avoided for about 4 to 6 weeks so that the tissue heals stably. Pelvic floor training remains important after the operation too, to secure the result in the long term.

Can the prolapse come back after the operation (recurrence)?

A prolapse can occur again after an operation, which is why honest expectations are more important than promises. Depending on the method and the initial finding, the recurrence rate is in the range of about 10 to 30 %, with careful technique and the choice of the right method lowering the risk. A previous operation and weakened connective tissue increase the recurrence risk, as do persistent strains such as chronic coughing or heavy lifting. We therefore combine the operation with clear recommendations for the time afterwards, to protect the result.

Source: American College of Obstetricians and Gynecologists (ACOG), guideline on pelvic organ prolapse

Is a prolapse operation in Istanbul safe for international patients?

A prolapse operation in Istanbul is, with good preparation, just as safe as at home, because the same methods and guidelines are applied. Serious complications are rare with minimally invasive procedures and usually below about 1 to 2 %, and only in under around 5 % of cases is a switch to open surgery needed. We take time before every procedure for a thorough preliminary examination and explain the risks openly, instead of promising safety that no one can guarantee. What is decisive is that diagnosis, surgery and aftercare remain in one hand.

Home country or Istanbul – what is the difference?

The difference lies not in the quality but above all in waiting time, continuity of care and cost. The medical quality is very high at good centres in both cases, and the same methods and standards are used. That treatment in Istanbul is often cheaper has to do with the exchange rate and lower operating costs, not with a lower standard. You also receive an understandable surgical report that you can present directly to your doctor at home.

How does the process from abroad work – from enquiry to aftercare?

The process is structured into clear steps so that you always know what comes next. At the beginning are the online second opinion and the review of your findings, followed by appointment planning and travel. The stay in Istanbul usually lasts about 5 to 10 days depending on the procedure, including preliminary examination, surgery and a first check. Afterwards we support the aftercare remotely and provide you with all documents for your practice at home.