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.