Introduction
Pelvic organ prolapse (POP), defined as the herniation of the pelvic
organs to or beyond the vaginal walls, is a common condition. Uterine
procidentia is hernia of all three compartments through the vaginal
introitus. POP commonly occurs in the elderly and risk increases with
age.1 Beyond advancing age and vaginal delivery,
obesity and in cases where intra-abdominal pressure increases
repetitively or continuously such as chronic constipation, chronic
obstructive pulmonary disease, or occupations that involve heavy lifting
are established risk factors.2-5 Anatomic support of
the pelvic organs in women is provided by the pelvic floor muscles and
ligaments or connective tissue attachments to the pelvis. Excessive
caudal movement of pelvic organs occurs with the loss of support impairs
the ability of that support to resist caudal forces that include
gravity, inertial forces and intra-abdominal pressure. The compliance of
these structures, defined as the deformation of the structure divided by
the change in force that caused the deformation, describes the
pliability or flexibility of pelvic floor and abdominal wall structures.
Intra-abdominal pressure (IAP) is defined as the steady state pressure
concealed within the abdominal cavity. IAP, intra-abdominal hypertension
(IAH) and abdominal compartment syndrome/pathophysiology have become the
focus of attention in many disciplines.6 A normal IAP
varies from sub-atmospheric values to 7 mmHg in normal weight
individuals, with higher baseline levels in morbidly obese patients of
about 9 to 14 mmHg.7 IAH is defined as a sustained
increase in IAP ≥ 12 mmHg. The adverse physiologic effects of increase
in IAP impacts the pulmonary, cardiovascular, renal, splanchnic,
musculoskeletal and central nervous systems.8 However,
little concern has been dedicated to the potential importance of the
structure of the pelvic floor and its compliance. Abdominal compliance
is defined as a measure of the ease of abdominal expansion, which is
determined by the elasticity of the abdominal wall and diaphragm. The
abdomen may be considered a closed box. This box has rigid structures,
i.e. the spine and pelvic bones, with partially flexible sides, i.e. the
abdominal wall, diaphragm and pelvic floor.9 Levator
hiatus is the opening of this closed box to the atmosphere. Pelvic organ
prolapse might be the consequence of the compensation of abdominal
compliance to chronic increased IAP. We hypothesized that we could
disrupt this feasible compensation with relatively stable reconstructive
procedures like sacrocolpopexy or obliterative procedures. The aim of
this study was to evaluate the effect of pelvic reconstructive surgery
in patients with severe uterovaginal prolapse on IAP.