Descensus Surgery

Descensus surgeries (synonym: descensus operations) are surgical procedures for the surgical correction of descensus uteri et vaginae (deepening of the uterus/uterus and vagina/vagina). The degree of descensus (lowering) of the uterus or vagina defines whether the lowering of the uterus or vagina is a descensus or a prolapse (particularly pronounced form of uterine descent; here: prolapse). The descensus surgery should be performed only when conservative therapy (non-surgical) has not brought any improvement and the symptoms of uterine prolapse make surgical intervention unavoidable. Often, the development of uterine prolapse is due to connective tissue insufficiency (weakness of the connective tissue).

Indications (areas of application)

Descensus uteri et vaginae (uterine and vaginal prolapse) with symptoms:

  • Feeling of pressure “downward”
  • Foreign body sensation (occasionally also strong)
  • Dyspareunia – pain during sexual intercourse.
  • Urination disorders (bladder emptying disorders, micturition disorders).
  • Stress incontinence (formerly: stress incontinence) – loss of urine during physical exertion as a result of a bladder closure problem.
  • Urinary urgency
  • Ischuria (urinary retention)
  • Constipation (constipation)
  • Pollakiuria – urge to urinate frequently without increased urination.
  • Recurrent (recurring) urinary tract infections.
  • Back pain (lumbago/lumbalgia)
  • Fecal impaction disorders
  • Ulceration (ulceration) of the uterus (womb)/vagina (vagina).

Contraindications

  • Poor general condition – the vaginal approach (access via the vagina) is gentler than the abdominal approach. Nevertheless, surgery via the vaginal approach may also be contraindicated if the patient is in poor general condition.
  • Pathological (pathological) changes of the uterus (womb), ovaries (ovaries), urinary bladder or intestine (eg, tumors).
  • Infections in the surgical area – inflammatory reactions, such as a urinary tract infection, are a contraindication.

Before surgery

  • Preoperative diagnostics – Gynecological examination consisting of: Inspection (viewing), palpation (palpation examination: vaginal/vaginal and rectal/bowel related), speculum setting (from Latin speculum: “mirror”) is a medical examination instrument used to examine the vagina), urine examination for urinary tract infections, possible residual urine determination (by sonography). Sonography (ultrasound examination): of the genital organs (uterus / uterine and ovaries / ovaries to exclude pathological (pathological) changes, as these may affect the surgical strategy), the urinary bladder (exclusion of infection, residual urine, stones or tumors) and kidneys (exclusion of urinary retention).
  • Discontinuation of anticoagulants (anticoagulants) – in consultation with the attending physician, medications such as Marcumar or acetylsalicylic acid (ASA) must usually be temporarily discontinued to minimize the risk of bleeding during surgery. The re-taking of the drugs may only take place after medical instruction.

The surgical procedures

Of crucial importance for the selection of the surgical procedure is the localization of the descensus in the area of the pelvic floor. Descensus (lowering) can be determined in different areas of the pelvic floor:

  • In the anterior region of the pelvic floor, also known as the anterior compartment, the anterior vaginal wall descends along with the bladder. This results in a cystocele (bladder floor depression; lowering of the bladder with the anterior vaginal wall, possibly out of the vagina, which is then called prolapse).
  • In the middle compartment, the uterus (uterine) lowers or the vaginal end in the absence of the uterus (Douglasocele).
  • In the posterior compartment, the posterior vaginal wall lowers together with the rectum. A rectocele (protrusion of the anterior wall of the rectum into the vagina) is formed.

Surgical therapy of descensus uteri et vaginae (uterine and vaginal prolapse) is based on reconstruction of the position of the organs of the small pelvis.This involves reconstruction of the fascial structures (soft tissue components of the connective tissue) of the retaining apparatus of the bladder, genital organs and rectum.Access routes to the pelvic floor:

  • Vaginal access route (via the vagina) – this access route is most commonly used in descensus surgery, as it is gentler on the patient and further allows easier access to the pelvic floor conducting structures.
  • Abdominal access route (through the abdominal wall) – the abdominal access route is associated with a higher surgical risk and is therefore rarely selected.

Surgical technique

In the case of a pronounced descensus problem that can no longer be managed conservatively, different surgical procedures are considered. The formerly frequently performed vaginal hysterectomy (removal of the uterus through the vagina) with anterior and posterior colporrhaphy (vaginoplasty) and perineoplasty is increasingly used less in favor of organ-preserving procedures. Which surgical intervention is performed depends primarily on the anatomical changes, symptoms and complaints. In other words, the approach today is very individualized and usually attempts to preserve the uterus, regardless of whether or not there is a descensus, i.e. it is lowered or not.Primarily, the surgical approach depends on which compartment is affected. In the case of a cystocele (anterior compartment), an anterior colporrhaphy (anterior vaginoplasty) is performed, and in the case of a rectocele (posterior compartment), a posterior colporrhaphy (posterior vaginoplasty) is performed. If the middle compartment is affected, if the uterus is present, an individual decision is made whether to remove it or leave it in place. If the uterus is removed, the vaginal route is predominantly chosen. If the uterus is retained, it is repositioned (brought back to an approximately normal position) and fixed to the ligaments of the lesser pelvis, which can be done by the vaginal or abdominal route and must be decided individually. If a Douglasocele is present (i.e., the uterus has already been removed and the vaginal end is lowered), this is reduced and fixed to the ligaments. If all three compartments are affected, vaginal hysterectomy (removal of the uterus) with anterior and posterior plastics (anterior and posterior colporrhaphy) is still frequently performed. However, even in such a situation, uterus-preserving (uterus-preserving) surgery is quite possible.This individuality of surgical approach is possible today because the surgical spectrum has expanded with the use of plastic tapes and meshes. With these procedures, it is now possible to better compensate for the congenital tissue insufficiency (tissue weakness). At present, it is still recommended to avoid the use of foreign tissue in primary operations and to reserve this primarily for recurrences, since long-term results are still lacking in some cases and the various tissues have not yet been sufficiently tested.If stress incontinence is present at the same time, the urethra is usually padded in a U-shape with a plastic band that is placed tension-free suburethrally (under the urethra). This is the so-called TVT (tension-free vaginal tape) or TOT (trans-obturator technique) procedure:

  • TVT (tension free vaginal tapes) – this is a plastic tape, which is placed tension-free over the vagina under the urethra, so that the urethra is stabilized at increased intra-abdominal pressure (abdominal pressure); it is discharged retropubically (behind the pubic branch).
  • TOT (trans-obturator technique) – a plastic band is placed tension-free under the urethra and drained via the thigh bends (variant of TVT surgery).

After the operation

  • Diagnostic measures – renal and residual urinary sonography should be performed on the first day after surgery.
  • Physical rest
  • Clinical examination – a physical examination including a gynecological examination is indicated after surgery to determine complications, if any.
  • Weight loss as a function of BMI (body mass index).
  • Pelvic floor training (not immediately after surgery, but many weeks later.

Possible complications

Early complications

  • Intraoperative bleeding
  • Postoperative bleeding
  • Lesions (damage) to the bowel and urinary bladder – a detected injury to these organs is corrected during surgery
  • Hematomas (bruises)
  • Urinary bladder and bowel emptying disorders
  • Defect healing

Late complications

  • Recurrence (recurrence) of the subsidence is possible. The likelihood of recurrence is directly related to the location of the subsidence. The triggers that led to the primary prolapse may also recur, causing a recurrence.
  • Arrosions, shrinkage when using tapes or meshes.
  • Dyspareunia (painful sexual intercourse) and urge symptomatology (newly developed postoperatively) seem to be more frequent after foreign tissue than after surgery with autologous tissue.