1. Introduction

Pelvic organ prolapse (POP) involves abnormalities in the position and function of the pelvic organs, resulting from their descent from the normal anatomical location into the vagina or even outside the vaginal opening.[1] While not life-threatening, POP significantly impacts a woman’s daily activities and quality of life, often referred to as“social cancer.”[2] A U.S. study predicts a rise in the number of patients undergoing pelvic organ prolapse surgery from 170,000 to 250,000 by 2050 compared to 2010, with about one-third requiring a second surgery.[3,4] Treatment options for POP include non-surgical and surgical approaches. Non-surgical methods are suitable for young, fertile patients with mild prolapse (POP-Q stage II and below), while surgery remains the primary treatment for patients with moderate-to-severe prolapse significantly protruding from the vagina.[5]

Various surgical methods are available for treating pelvic organ prolapse, including classic traditional surgery, pelvic floor reconstruction using mesh, and pelvic floor reconstruction using fascial tissue.[6–9] The main types of surgery involve classic traditional techniques, reconstruction with mesh, and reconstruction with fascial tissue. Advancements in modern pelvic floor theory, surgical instruments, and medical biological substitute materials have led to continuous updates in reconstructive pelvic surgery methods over the last 2 decades.

Bibliometrics provides a rapid insight into research focus areas and trends within a specific field by presenting an objective overview of all literature, countries, authors, research institutions, journals, and keywords.[10] This emerging research tool, bibliometric analysis, has found widespread application across various medical fields. Visualization software like CiteSpace aids in visually representing the results of bibliometric studies.[11–14]

Based on this background and theoretical support, this paper aims to summarize the current status of research in the field of pelvic floor reconstruction for the treatment of pelvic organ prolapse over the past 20 years using bibliometric methods. The goal is to discuss research hotspots and trends in this field, promoting subsequent research in pelvic floor reconstruction and providing references and ideas for future basic and clinical research.

2. Materials and methods

Bibliometric analysis was performed using the Web of Science database Core Collection database. Advanced search was utilized to set the search term as (TS = (pelvic organ prolapse) AND TS = (reconstructive pelvic surgery), with a time limit of January 2002 to December 2022 (retrieved on May 31, 2023), and the type of literature was limited to Article, and a total of 612 articles were retrieved. 612 articles were retrieved. The retrieved literature data were filtered and de-weighted, and the final number of literature included in the visualization analysis was 607. The time span of English literature sources was set from January 2002 to December 2022, with a time slice of “1” year, and the topic sources were selected as Title, Abstract, Author Keywords, DE, and Keywords Plus, ID. Node types were selected as Country, Institution, Author, and Keyword for co-occurrence analysis; node analysis thresholds (Selection Criteria) and Pruning were selected based on different node types. This study was a descriptive study using numbers and percentages to describe each indicator. Excel 2019 (Microsoft, Redmond, WA) software was used to perform data analysis and generate statistics.

2.1. Ethical compliance

This article does not contain any studies with human participants or animals. It does not need ethical/institutional review board approval.

3. Results 3.1. Annual trend analysis of communications

Figure 1 displays the statistics on the number of publications per year, revealing a consistent increase in literature related to total pelvic floor reconstruction for POP from 2002 to 2022. The average annual publication count stands at 30.35, with the last 5 years averaging 48.4 publications annually. The peak of 64 publications in 2021 suggests a continuing upward trend post-2022. This trend indicates a growing focus on pelvic floor reconstruction for POP in recent years, warranting further investigation by future researchers.

Figure 1.:

Trends in annual literature articles on pelvic floor reconstruction for POP from 2002 to 2022.

3.2. Analysis of study countries

Taking the country as the node, the WoS core collection is used for visual analysis of inter-state cooperation network in the global research field of pelvic floor reconstruction treatment for POP. As illustrated in Figure 2, nodes increase in size with higher posting frequency and closer connections indicate stronger cooperative relationships. The outermost purple ring signifies the intermediary center, with nodes having centrality >0.1 considered key nodes. The national cooperation network involves 58 countries/regions, with the United States leading in both article frequency (317 articles) and intermediary centrality (0.49). Following the United States, Australia (0.4) and the United Kingdom (0.2) also play significant roles. Notably, the majority of countries engaged in inter-state cooperation and those with high publishing frequency are developed countries, representing 60.1% of total documents. Among them, the United States contributes 42.3% of the total, while China accounts for only 5.3%.

Figure 2.:

Analysis of pelvic floor reconstruction research countries for POP.

3.3. Analysis of research institutions

The institutional co-occurrence map illustrates the independent and collaborative publishing dynamics among research institutions. In Figure 3, larger nodes represent higher publication frequencies, indicating closer cooperative relationships between institutions. The outermost purple ring signifies betweenness centrality, with key nodes having a centrality >0.1. The network comprises 346 nodes, 871 connections, and a density of 0.0146. A total of 346 institutions have engaged in research on pelvic floor reconstruction for POP treatment. The top ten institutions by publication frequency are detailed in Table 1. The Cleveland Clinic Foundation leads with 49 publications and an intermediary centrality of 0.12, highlighting its significant influence in the cooperation network. Chang Gung Memorial Hospital follows with 28 publications but lacks connections with other nodes, reflected in a centrality of 0. The University of California system ranks third with 27 publications and a centrality of 0.03. In the future, it is necessary to strengthen the cooperation and exchange among institutions to promote the research progress in the field of POP treatment.

Table 1 - Top 10 research institutions in terms of frequency of publications. Number Organization Frequency Centrality 1 Cleveland Clinic Foundation 49 0.12 2 Chang Gung Memorial Hospital 28 0 3 The University of California System 27 0.03 4 Chang Gung University 25 0 5 The University of Texas System 21 0.12 6 Pennsylvania Commonwealth System of Higher Education (PCSHE) 18 0.02 7 Case Western Reserve University 17 0 8 University of Texas Southwestern Medical Center Dallas 16 0.02 9 Brown University 15 0.02 10 University of Pennsylvania 13 0.01
Figure 3.:

Pelvic floor reconstruction for POP research institution.

3.4. Analysis of study authors

The author’s co-current map can reveal the independent and cooperative publishing of researchers. The author’s co-authorship network can provide insights into the collaborative efforts of researchers. As illustrated in Figure 4, nodes representing authors increase in size based on their posting frequency, with connections indicating cooperative relationships. The network consists of 546 nodes, 710 connections, and a network density of 0.0048. From the network density and connections depicted in the figure, it is evident that there are 3 distinct collaborative groups. Two of these groups are comprised of academic researchers from the fields of urology, gynecology, and pelvic reconstruction surgery at the Cleveland Clinic in the United States. The first group, including Matthew D. Barber, Mark D. Walters, Chi Chiung Grace Chen, and others, has a longer history of collaboration. The second group, which has emerged more recently, consists of researchers like Sangeeta T. Mahajan, David Sheyn, and Graham C. Chapman. The third group represents an academic research team from Peking Union Medical College Hospital in Beijing, China, led by authors such as Lan Zhu, Tao Xu, and Shuo Liang. However, there appears to be limited cooperation and interaction between these groups, with all authors having a centrality score of <0.10. This suggests that no single author has established significant influence within this field.

Figure 4.:

Analysis of study authors in the field of pelvic floor reconstruction for the field of POP.

3.5. Analysis of issuing journals

A statistical analysis of publication frequency from 2002 to 2022 revealed that 134 journals worldwide focus on pelvic floor reconstruction treatment for POP. These journals cover a wide range of categories including obstetrics and gynecology, female pelvic medicine and reconstruction surgery, neurourology and urology, minimally invasive gynecology, urology, reproductive medicine, and other related fields. The top 10 journals with the frequency of postings are shown in Table 2. INT UROGYNECOL J ranks first with 156 articles. The JCR partition belongs to the Q2 area with an impact factor of 1.932. FEMALE PELVIC MED RE ranks second with the number of articles published. For 61 articles, the JCR partition belongs to the Q3 area with an impact factor of 1.913. AM J OBSTET GYNECOL ranks third with 59 articles. The JCR partition belongs to the Q1 area with an impact factor of 10.693. AMONG THESE 10 JOURNALS, JCR IS 3 JOURNALS IN Q1 AND Q4 DIVISIONS, AND 2 JOURNALS IN Q2 AND Q3 DIVISIONS. THE IMPACT FACTOR DISTRIBUTION IS BETWEEN 1.226–10.693, OF WHICH AM J OBSTET GYNECOL IS THE HIGHEST IMPACT FACTOR.

Table 2 - Top 10 journals in terms of frequency of publication. Number Journals Number of publications IF JCR 1 INTERNATIONAL UROGYNECOLOGY JOURNAL 156 1.932 Q2 2 FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY 61 1.913 Q3 3 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 59 10.693 Q1 4 NEUROLOGY AND URODYNAMICS 24 2.367 Q3 5 JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY 16 4.314 Q1 6 EUROPEAN JOURNAL OF OBSTETRICS & GYNECOLOGY AND REPRODUCTIVE BIOLOGY 15 2.831 Q3 7 CURRENT UROLOGY REPORTS 9 2.862 Q2 8 JOURNAL OF UROLOGY 9 7.6 Q1 9 JOURNAL OF OBSTETRICS AND GYNAECOLOGY RESEARCH 9 1.697 Q4 10 JOURNAL OF OBSTETRICS AND GYNAECOLOGY 9 1.226 Q4
3.6. Keyword co-current analysis

Keyword co-occurrence analysis involves identifying recurring keywords in a large body of articles within a specific field. These keywords often highlight the research trends within that field. A visual representation of keyword analysis was created using literature related to pelvic floor reconstruction for treating pelvic organ prolapse. The relevant literature of 607 pelvic floor reconstruction for the treatment of pelvic organ prolapse is made into a visual image of keywords. The visualization, depicted in Figure 5, consists of 301 nodes, 575 connections, and a network density of 0.0127. The top 3 keywords in the study were “pelvic organ prolapse,” “women,” and “urinary incontinence,” appearing 395, 172, and 127 times, respectively. This was followed by “repair” and “organ prolapse,” among others.

Figure 5.:

Keyword co-occurrence analysis of pelvic floor reconstruction for POP.

3.7. Analysis of keyword heat over time

A clustering timeline of keywords generated for pelvic floor reconstruction for pelvic organ prolapse is shown in Figure 6. The publication years of the literature included in the study were 2002 to 2022, with a total of 301 nodes, 575 connecting lines, and a network density of 0.0127. The clustering analysis yielded a modular value of 0.7205 and an average profile value of 0.7985, which indicates a better network clustering and a high degree of similarity of the cluster members, and a higher degree of similarity of the members of the clusters in the years 2002 to 2022 Hot issues in pelvic floor reconstruction for pelvic organ prolapse research formed 12 clusters around the key nodes, mainly in 0 rectocele, involving keywords such as “rectal bulge repair,” “uterosacral ligament suspension,” “ surgical treatment,” etc; 1. stress urinary incontinence, involving keywords such as “suburethral sling,” “standardization,” etc; 2. symptoms, involving keywords such as “prevalence,” “risk factors,” “age,” etc; 3. conservative, involving keywords such as “prevalence,” “risk factors,” “age,” etc; 4. sexual function, the key words involved include “sexual function,” “prediction,” “stress incontinence,” etc; 5. transvaginal mesh involves Keywords include “transvaginal mesh,” “polypropylene mesh,” “vaginal reconstructive surgery,” etc; 6. pelvic floor disorders include “postoperative complications,” “safety,” etc; 7. vaginal mesh includes “quality of life,” “urinary retention,” “dysfunction,” etc; 8. urinary incontinence involves keywords such as “urinary incontinence,” “recurrence,” etc; 9. pelvic reconstructive surgery contains “pelvic floor reconstructive surgery,” “uterine prolapse” “vaginal vault suspension,” etc; 10. tissue engineering involves key words such as “mesh,” “biomechanical features “, “animal model,” “tissue engineering,” etc; 11. mesh complications include “pelvic floor reconstruction surgery “, “prolapse repair,” “mesh complications,” “bacteria” and so on.

Figure 6.:

Analysis of keyword heat over time in the field of bottom reconstructive surgery for POP.

4. Discussion

This study utilized bibliometric methods to investigate the current global research status, analyze research hotspots, and identify trends in pelvic floor reconstruction for pelvic organ prolapse from 2002 to 2022. The visual research method, based on statistical analysis of big data, provided more objective and reliable results. Judging from the number of global publications in the past 20 years, the research in the field of POP pelvic floor reconstruction is generally on the rise, which indicates that with the development of society, POP pelvic floor reconstruction has received more extensive attention. By analyzing the volume of publications by countries, research institutions and authors, we found that the United States has published the most papers over the past 20 years, and its media quality also ranks first among countries. It can be seen that the United States has been a leading country in the field of POP pelvic floor reconstruction for nearly 20 years.

The Cleveland Clinic Foundation has the highest number of articles on pelvic floor reconstruction for POP in the past 20 years, with its research centrality ranking first among all organizations. American scholar Matthew D. Barber holds the highest number of publications in the field of pelvic floor reconstructive surgery for POP over the past 2 decades. Chinese scholar Zhu Lan ranks third in terms of publication frequency. Three distinct academic groups have emerged. Matthew D. Barber leads the academic group that has collaborated extensively, particularly before 2010, focusing primarily on the correlation between obesity and the prevalence of pelvic floor disorders, as well as the relationship between traditional surgery and pelvic floor reconstruction for new complications of rectal prolapse.[15,16] The second group, led by Chapman, Graham C, et al, focuses on the incidence of urinary retention after pelvic reconstruction, as well as the complications of vaginal/laparoscopic hysterectomy and uterosacral ligament suspension.[17–19] Third is the Chinese academic research group represented by Zhu Lan, whose main research interests are the analysis of risk factors for pelvic organ prolapse and the clinical translation of basic and applied anatomical research on pelvic floor dysfunction disorders,[20] In recent years, Professor Zhu Lan main research interests include the study of the mechanism of pelvic organ prolapse,[21] the exploration of the “gold standard” surgical procedure for apical prolapse, and the standardization of the registration of complications after implantation of synthetic mesh pelvic floor reconstruction.[22,23] The number of articles published in China is the second largest in the field of pelvic floor reconstruction for the treatment of POP, indicating significant research efforts and contributions. However, the lack of research institutions and authors with mediated centrality >0.1 suggests that the influence of pelvic floor reconstruction in China needs further enhancement. This could be due to limited cooperation among researchers and institutions, as well as the relatively lower research funding compared to developed countries. To address this, researchers in China should focus on research hotspots, leverage the large population base and the use of Chinese medicine in pelvic floor reconstruction, and strengthen collaboration for conducting more extensive clinical studies and innovative trials. It is anticipated that with ongoing scientific research reforms and increased funding, China’s influence in POP treatment through pelvic floor reconstruction will significantly grow. Regarding journals, notable publications in the past 2 decades include AM J OBSTET GYNECOL, J MINIM INVAS GYN, and JOURNAL OF UROLOGY. The top 3 journals in terms of article numbers are INT UROGYNECOL J, FEMALE PELVIC MED RE, and AM J OBSTET GYNECOL, with the latter having an impact factor of 10.693, ranking first among all journals. Researchers interested in POP treatment through pelvic floor reconstruction are advised to closely follow these journals.

Through the visual analysis of keyword time stacking, it was observed that the period from 2002 to 2013 contained the most abundant research content. From 2002 to 2004, research concentrated on the early phases of pelvic floor reconstruction for pelvic organ prolapse in clinical settings, along with the primary research focus on the epidemiology of pelvic organ prolapse. Studies have shown that pelvic organ prolapse is a complex condition influenced by multiple factors, with higher parity and age being associated with a higher risk.[24] Research on complications associated with vaginal mesh emerged around 2005 to 2006, with polypropylene mesh being the most commonly used surgical material. Notable complications included poor healing, mesh erosion, and pain. Concurrently, investigations on animal models and underlying mechanisms expanded from clinical to experimental research on disease mechanisms.[25,26] Subsequent years, from 2007 to 2010, saw studies on quality of life, sexual function, and recurrence.[27] Despite the ongoing controversy surrounding mesh-related complications, transvaginal mesh remains a popular surgical method for treating POP due to its high anatomical cure rate.[28] However, strict control over the indications for the procedure is essential. It is recommended to carefully select the surgical style and material, and engage in multidisciplinary cooperation to advance pelvic floor reconstruction surgery for complications.[29,30] This includes the establishment and enhancement of a registration and treatment system for complications in pelvic floor reconstruction surgery.

While this study offers a relatively comprehensive and objective analysis, there are certain limitations to consider. The analysis was based solely on documents from the Web of Science database, potentially limiting the completeness of the data. Additionally, only English documents were included, excluding Chinese and other non-English literature, which may have impacted the comprehensiveness of the findings. The bibliometric method utilized in this article indicates a growing trend in research related to pelvic floor reconstruction for POP over the past 20 years, garnering significant attention. Researchers have made notable contributions to pelvic floor reconstruction surgery for POP, enhancing understanding and development in this field. Moving forward, it is essential to focus on research hot spots, foster collaboration, drive innovation, enhance research quality, and bolster academic influence. This study aims to serve as a helpful reference for future academic research on POP pelvic floor reconstruction.

Acknowledgments

KM was supported by Science and Technology Beneficiary Program of Ningxia Hui Autonomous Region, China, No. 2023CMG03027 (to LY); Ningxia Hui Autonomous Region Key Research and Development Program of China, No. 2022BEG03167 (to LY); the National Natural Science Foundation of China, No. 82060275 (to LY).

Author contributions

Data curation: Yueyue Shi, Zhuo Wang, Ngenzi Richard Djurist.

Project administration: Yan Li.

Software: Yao Hao.

Writing – original draft: Min Kong.

Writing – review & editing: Yan Li.

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