Pelvic organ prolapse (POP) is one of the most common chronic medical condition, which attracts wide attention like diabetes, hypertension and coronary heart disease (Barber and Maher, 2013; Pang et al., 2021). Epidemiological studies have found that the incidence rate of POP in postmenopausal women is as high as 50% (Richardson et al., 2009; Barber and Maher, 2013). Most patients with POP have vaginal foreign body sensation and bulge symptom, and severe POP will affects the patient’s urination function, defecation function, and even the quality of sexual life (Mattsson et al., 2020; Raju and Linder, 2021). Conservative treatment, such as pelvic floor muscle exercise, biofeedback therapy and pelvic floor electrical stimulation, has limited therapeutic value for severe POP, pelvic floor repair surgery is the mainstay of treatment for severe POP and is indicated once conservative measures have failed to fully alleviate the symptoms (Hagen and Stark, 2011; Li et al., 2016; Wallace et al., 2019). POP surgery involves multiple organs and disciplines, and there is no unified standard, resulting in a variety of surgical methods (Mattsson et al., 2020; Geoffrion and Larouche, 2021). Up to now, more than 100 surgical procedures have been developed to treat POP (Maher et al., 2019). Therefore, the focus of POP surgery is to develop an efficient, safe, standardized and personalized surgical program.

In the past, traditional operations, such as anterior or posterior plication (vaginoplasty), uterosacral ligament suspension (USLS) or sacrospinal ligaent fixation (SSLF), mainly repair pelvic floor defects by folding, sewing and strengthening their native tissue (Murphy et al., 2021; Yadav et al., 2021). Several studies report that the recurrence rate of traditional surgery is between 17% and 20% 10 years later, which increases the need for further additional treatment and even re-operation (Lowenstein et al., 2018; Cola et al., 2022). In order to overcome the recurrence rate of traditional pelvic floor surgery, gynaecologists tried to implant mesh in the abdomen for POP repair in the 1970s, referring to the hernia mesh repair operation (Zhu and Zhang, 2014; Fleischer and Thiagamoorthy, 2020). Subsequently, these meshes began to be implanted through vagina for POP repair in the 1990s (Dallenbach, 2015; Ugianskiene et al., 2019). In 2002 the FDA approved Gynemesh^® PS, which was the first pre-configured transvaginal mesh for surgical repair of POP (Adhoute et al., 2004; Darrow et al., 2021). Since then, due to the excellent anatomical success rate, the application of synthetic mesh in urological surgery has become rapidly popular, leading to a large number of relevant medical devices on the market before obtaining complete clinical trial data (van Geelen and Dwyer, 2013; Heneghan et al., 2017). With the increasing use of synthetic mesh, mesh complications have aroused widespread controversy and concern (Ellington and Richter, 2013). In 2008 and 2011, the FDA of the United States issued safety communication on the transvaginal surgical mesh (TVM) repair for two consecutive times (Winkelman et al., 2019). In 2016, the FDA finalized the devices of TVM for the treatment of prolapse was reclassified as Class III (high-risk) equipment (Food and Drug Administration HHS, 2016). In April of 2019, the FDA banned the sale and distribution of all TVM for POP repair in the United States. Subsequently, the United Kingdom, Canada, Australia, New Zealand and other countries issued bans on TVM (Fairclough et al., 2020; Ng-Stollmann et al., 2020; Shoureshi et al., 2021). However, trans-abdominal mesh pelvic floor repair and TVM surgery in most mainland European countries, Asia, and South America still available as a surgical option for POP correction (Ng-Stollmann et al., 2020). How to use pelvic floor mesh is still a key and puzzling problem in pelvic floor surgery. In addition, tissue engineering technology, new materials and new technologies have been continuously applied in pelvic floor reconstruction surgery, which has expanded the application scope of mesh in pelvic floor defect repair (Yang et al., 2021). However, in the last 2 decades, a number of academic literature on pelvic floor mesh surgery have not been well summarized and discussed. It is necessary to comprehensively analyze the current application trend, progress and hot spot direction of POP repair with mesh.

Bibliometrics is a popular tool for the qualitative and quantitative evaluation of publications in specific fields using mathematical and statistical methods (Ninkov et al., 2022). At present, as a new and promising method, it has been widely used in many biomedical and material fields (Cooper, 2015; Tarnok, 2021). Unfortunately, there is no bibliometric analysis that focused on pelvic floor mesh surgery. In our study, we aim to systematically summarize and sort out the “pelvic organ prolapse repair with mesh” over the last 2 decades by bibliometric analysis. This study combines bibliometrics, mathematics, statistical methods and data visualization to conduct systematic annual, national/regional, institutional, journal/co-cited journals, co-rated reference, timeline view, and the keyword co-occurrence and citation bursts analysis, so as to determine the research trend and hotspot of pelvic floor mesh surgery. It was hoped that this study would provide new interesting insights for the subsequent study of pelvic floor mesh surgery.

Pelvic floor defect repair surgery is an important sub direction of gynecological surgery (Giannini et al., 2019).The prediction study shows that the cumulative risk of women undergoing prolapse surgery at the age of 80 is 11% and the re-operation rate is estimated at 17%–30% (Denman et al., 2008; Maher et al., 2010; Wu et al., 2014). Even, the total number of POP operations will continue to increase by 50% in the next 40–50 years due to the continuous aging of the population (American College of O et al., 2019; Larouche et al., 2021). There are many types of pelvic floor surgery, the past 20 years have witnessed the initiation and important concerns of the application of pelvic floor mesh surgery (Wu et al., 2014; Mancuso et al., 2020). Since 2002, FDA has approved synthetic mesh for POP transvaginal mesh repair (van Geelen and Dwyer, 2013). At the initial stage, the preliminary application of pelvic floor mesh surgery showed a good application prospect because of its high anatomical success rate and low recurrence rate (D'Angelo et al., 2019). With a surge of mesh medical devices coming to the market, pelvic floor mesh surgery was rapidly popular. Over time, FDA noted an increase in reports of applications related to vacuum mesh, and issued two safety warnings in 2008 and 2011 (22). Finally, in the past 3 years, the competent authorities of the United States and parts of countries have successively issued bans on the sale and distribution of all transvaginal meshes (Hudson et al., 2020; Mao et al., 2021). In addition, advances in new fields such as biomaterials, tissue engineering and 3D printing have provided new prospects and directions for the development of safe and efficient individualized mesh surgery (Farmer et al., 2020; Farmer et al., 2021). In the face of policy changes and information explosion in this field, we conducted a bibliometric analysis to determine the current research hotspots, key points, keywords and trends of pelvic floor mesh surgery.

In the present study, we analyzed the relevant information of 2,550 articles, which were published in 349 journals by 2,294 institutions in 65 countries/regions, with 39,787 citations. Trend and annual analysis shows that there is a overall upward trend in the number of pelvic floor mesh-related publications and citations, although the number of publications fluctuated between 2013 and 2016. This phenomenon may be related to major events in the field of pelvic TVM surgery, especially the two safety warnings issued by the United States FDA (Clemons et al., 2013). It is worth noting that after some mesh products were banned and delisted in 2018, a relatively large number of pelvic floor mesh studies are still carried out internationally, reflecting the reflection and prospect of pelvic floor mesh surgery in the international community (Palmerola and Rosenblum, 2019; Sassani et al., 2020; Skorupska et al., 2020). The output of the United States, France, the United Kingdom, Italy, Australia and China ranks in the top six countries/regions of publications. The explanation for this may be that these countries are both countries with high incidence of POP and relatively developed science and technology (Huang et al., 2018). The institutional distribution is basically consistent with the national/regional distribution, the United States and France took the lead in terms of research Institution. In addition, countries/regions and institutions have close cooperation in this field, and cooperation between institutions is closer than that between countries/regions. Journals and co-cited journals analysis showed that the journals that published the most pelvic floor mesh surgery papers were International urogynecology journal (21.49%), Neurourology and urodynamics (4.902%), and Female pelvic medicine and reconstructive surgery (4.824%). International urogynecology journal (1,578 total citations) and Female pelvic medicine and reconstructive surgery (401 total citations) were frequently co-cited. Although the influencing factors and JCR divisions of these journals are not high, they are the main journals for pelvic floor disease research (Gupta et al., 2020).

The network analysis of 584 key words in the literature shows the research interest, and it is divided into 8 clusters: mechanism, type of prolapse, mesh complications, minimally invasive surgery, middle pelvic repair, anterior pelvic repair, quality of life, imaging examination, and bioengineering technology. These clusters mean that the research in these areas is popular and concerned in this field in the past 20 years. It is worth paying attention to that in cluster 1, it is related to the research on the molecular mechanism of POP. The current research mainly focuses on the metabolism and regulation of extracellular matrix, especially TGF-β, HOXA11, FBLN5, LOXL1, MMPs/TIMPs and other important target genes can enable us to better understand POP and provide new therapeutic targets for POP(Jameson et al., 2020; Deng et al., 2021; Li et al., 2021; Fang et al., 2022). In cluster 3, we have noticed that mesh complications was still a problem that needs high attention. On the one hand, we need to apply the standard terminology jointly developed by the International Urodynamic Association (IUGA)/International Continental Society (ICS) to register complications on a dedicated website (Haylen et al., 2011). On the other hand, we also need to be cautious about the indications of mesh, improve surgical techniques and attach importance to evidence-based evidence (Reid et al., 2021). In cluster 8, we found that tissue engineering has made excellent progress in POP treatment, especially scaffolding, seed cells, and growth factors may replace surgery to reconstruct natural tissues or use implants to treat POP(Yang et al., 2021; Radwan-Praglowska et al., 2020; Hennes et al., 2021). By keywords citation bursts analysis, the time-series showed that validation, lifetime risk, native tissue repair, tissue engineering and mesenchymal stem cells had appeared most recently. This result shows that clinical research is still the hot research topic of POP research, and prediction models and tissue engineering are research priority (Laursen et al., 2022; Oh et al., 2022; Zhang et al., 2022). In essence, overcoming mesh complications through increasing technical strategies is the core problem of pelvic floor reconstruction surgery. Another highlight of this study is that we also conduct in-depth manual classification of the network data of keywords, so as to overcome the shortcomings of machine classification strategies and further explore the research status of keywords. Manual classification divides keywords into the following 8 clusters: prolapse classification, risk factors, imaging progress, mesh surgery, mesh complications, quality of life, tissue engineering and new research directions. In addition to the similar results of machine reference analysis, four different new results are found based on the current research progress and the results of manual analysis. First, the fine diagnosis of three cavities and three levels is the basis for effective treatment (Petros, 2011; Chen et al., 2021); Second, imaging research may be one of the important directions to overcome mesh complications (Gavlin et al., 2020; Mahoney et al., 2020; Ram et al., 2021); Third, clinical research is an effective method to find answers to clinical questions, especially the clinical prediction model based on real world data (Barber and Maher, 2013; Weber LeBrun et al., 2018; Morcos et al., 2021); Finally, the new direction of tissue engineering technology and pelvic floor research is worthy of our expectation and further exploration (Hennes et al., 2021; Laursen et al., 2022).

To our knowledge, this is the first in-depth bibliometric analysis of pelvic floor mesh surgery, there are several limitations that need to be explained. First, the retrieval, download and analysis of this study from a single WoSCC database may lead to the loss of relevant important literature, which may lead to selective deviation of research conclusions. Second, the search deadline is 31 December 2021, excluding 2022 data, and relevant literature is still emerging in the database. Third, the bibliometric analysis carried out by machine algorithm does not carry out in-depth discussion on a single literature, and may not fully reflect all information. Last, international concerns about the indications for the use of mesh in pelvic floor reconstruction are growing rapidly, and bans in many countries and regions may have an important impact on relevant research. Nevertheless, based on limited data information and scientific methods, our research may help to intuitively understand the pelvic floor mesh surgery’s research hotspots and development trend.

In summary, to the best of our knowledge, this study is the first to use bibliometric methods to explain the current research status and global emerging trends of pelvic floor mesh surgery research in the past 20 years. This study shows that even though mesh complications have not been completely solved, international interest in pelvic floor mesh has always been strong. The United States is the country with the largest output, and England, Italy, Australia, Germany, France and China are the main participants, and close multidisciplinary collaborative networks can be found among institutions and among authors. The research focuses on the rational use of pelvic floor mesh and overcoming mesh complications, involving research hotspots in such areas as prolapse classification, risk factors, imaging progress, mesh surgery, mesh complications, quality of life, tissue engineering and new research directions.