Pelvic organ prolapse

摘要

Pelvic organ prolapse (POP) is very common in women seen for routine gynecologic care, although it may be asymptomatic and its impact on women's quality of life (QoL) markedly varies.1 Many women with POP experience co-morbidity pelvic floor disorders, such as urinary and/or fecal problems, including incontinence which can seriously compromise QoL and limit social, psychological and sexual function. Because of importance of understanding the impact of POP and POP-associated comorbid pelvic floor disorders on QoL, there are a lot of studies available in the literature to provide meaningful suggestions both clinically and for cost-effectiveness research. We are glad to learn that Dr. Huang's study published in this issue of the Journal of the Chinese Medical Association entitled “A bibliometric and social network analysis of pelvic organ prolapse during 2007–2016” attempted to use the PubMed database to emphasize the importance on this issue of POP.2 The authors retrospectively reviewed 3294 articles and found the publications were mainly derived from the developed countries (high-income countries) and the majority of research focused on therapy (74.4% of highly-frequent MeSH/subheading words), suggesting that management of women with POP is frequently discussed, although the recent trend for this-type publication was declined. The number of published articles reached to the highest level (n = 406) in 2012 and dramatically dropped to the nadir (n = 233) in 2015 without a significant change in the next year (n = 252 in 2016).2 The finding of Dr. Huang's study is interesting and worthy of a discussion. First, the close anatomical and functional relationship of the lower urinary tract, lower genital tract and anorectum means that the POP is likely to have symptoms affecting multiple compartments.3 With an increasing elderly population, there is greater demand on the healthcare providers with more complicated patients due to the different etiologies, different modulating factors, and the accompanied co-morbidities.4 Although therapy includes nonsurgical and surgical treatments,3,5 surgical approach increased significantly in the recent 10 years. New surgical techniques have been developed with a reduction of postoperative pain and a shorter period of hospitalization.6 Among these, the development of “mesh”, either made by natural material and/or by biosynthesis, and some modifications of surgical technologies, including laparoscopy, robotic surgery, and vaginal surgery might be most apparent. For this, an update of the Cochrane Database Systematic Review in 2017 summaries the recent advances, such as (1) abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy, because of a lower rate of recurrent vault prolapse (risk ratio [RR] 0.23, 95% confidence interval [CI] 0.07–0.77) and less dyspareunia (RR 0.39, 95% CI 0.18–0.86), but abdominal sacrocolpopexy needs a longer operating time, longer time to return to activities of daily living and increased cost; (2) standard anterior repair (transvaginal anterior colporrhaphy) might significantly increase the recurrent cystoceles compared to the use of mesh (polypropylene mesh) or graft inlays at the time of anterior vaginal wall repair (RR 1.39 or 2.72, 95% CI 1.02–1.90 and 1.20–6.14, based on different types of mesh or graft use, respectively); (3) posterior vaginal wall repair is better than transanal repair for posterior vaginal wall prolapse because of a lower rate of recurrent rectocele and/or enterocele (RR 0.24, 95% CI 0.09–0.64); and (4) the addition of a continence procedure to a POP operation, such as tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36–22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39–3.24) reduced the risk of women developing new postoperative stress incontinence.7 Taken together, surgical trend is clear and evidence is relatively strong, contributing to fewer publications of “POP” topics