Discussion
In this prospective controlled study, we evaluated the effect of prolapse surgery with mesh on IAP alterations. We observed that the postoperative IAPs after uterovaginal prolapse surgery were elevated in comparison to the preoperative values. The question of this study was raised at an urogynecology congress at which an experienced anesthesiologist hypothesized that the reentrance of pelvic contents and fixation of the vaginal wall with rigid materials may have long-term health consequences. There is no answer to this question to date, according to the current evidence. There have been no studies on the consequences of gynecologic procedures on IAP measurements or the effect of IAP changes on short- or long-term outcomes. Although there have been limited studies relevant to the effect of pregnancy and cesarean delivery on IAP, in case reports after gynecologic emergencies, there is a lack of data after gynecologic surgery, especially urogynecologic procedures commonly dealing with the elderly and frail population.11-13 With increasing age, cardiovascular and respiratory comorbidities may complicate pelvic organ prolapse in those older patients who are more susceptible to IAP alterations and need to be more cautions.14
Midterm postoperative IAPs after laparoscopic sacrocolpopexy were elevated in comparison to the preoperative values. This may be explained by a variety of mechanisms. The fixation of relatively rigid and non-absorbable polypropylene mesh diminishes vaginal wall distension and movement properties. Rubod et al. reported that vaginal tissue from prolapse patients exhibits larger deformations and behaves in a hyperelastic manner with increased compliance.15
Although the aim of the mesh is to strengthen the impaired vaginal wall, mimicking autologous tissue without reducing its compliance, the stiffness of the material, shrinkage and new tissue formation are associated with poor compliance.16 The usage of synthetic materials could be related to the increase in IAP secondary to a disruption or compensation mechanism.
Another probable mechanism may be related to an increase in the pelvic contents after prolapse surgery, due to the introduction of the bladder, bowel and uterus into the pelvic cavity, leading to a subsequent increase in IAP. Similar mechanisms can also account for increased IAP or IAH after abdominal wall hernia repair. In a few studies examining the association between hernia repair and intraabdominal pressure, ventral hernia repair can be associated with perioperative intra-abdominal hypertension (IAH), respiratory dysfunction and complications .17-19 In a study on large incisional hernias, 87% of patients showed a mean increase in IAP of 2.7 mmHg after surgery; about 9% saw no change in pressure.20In a cadaveric model, IAP increased by about 4.6 mm with increasing volume in the pelvic cavity.21 The rise in IAP during abdominal surgery observed in our study can be explained by the stretch of the abdominal wall following hernia repair [19]. Also, IAP can increase under high-tension abdominal wall closure and can be considered the cause of complications such as recurrences and respiratory insufficiency and post-operative pneumonia, but there is a lack of long-term data about these alterations in pressure.22, 23
We found a strong correlation with parity and increased IAP in our study. IAP may increase postoperatively due to abdominal cavity characteristics. The abdominal wall will modify its constitutional properties to maintain them as close as possible to normal functioning under the alterations in IAP. The high IAP after pelvic reconstructive surgery in women with high parity can be explained by weak compliance of the abdominal musculoaponeurotic system after repeated pregnancies.24 Although a BMI and IAP correlation was not found in our study population, we matched the control group with similar BMI to eliminate the BMI limitation.