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.