The 100 most-cited articles on pelvic organ prolapse: A bibliometric analysis

Objective : This study aimed to analyze the top 100 most cited papers in the field of pelvic organ prolapse by utilizing bibliometric methods. Method : On the 1st of October 2022, articles with the title pelvic organ prolapse were listed in order of citation on the Web of Science database. The first 100 articles were included in the study without a publication time limit. The number of citations, number of citations/year, title, author, journal, publication year, country and institutional information of the articles were recorded. Results : The highest number of citations in the first 100 most cited studies was 3,081 while the lowest was 95. The mean total number of citations of the 100 most cited studies was 248.7±380.2. The annual mean number of citations of the studies ranged between 118.5 and 3.7 and the mean number of studies was 16.8±17.8. In the ranking of the most cited papers, three journals were included in the list 70 times in total, accounting for 70% of the articles. Pelvic floor exercises were mentioned in 27 articles in total. Conclusions : This study provides medical researchers with bibliometric information relating to pelvic organ prolapse. The United States was clearly ahead in our study in terms of first authors, institutions


INTRODUCTION
Pelvic organ prolapse (POP) is the sagging of the pelvic organs and protrusion of the vagina orifice in the advanced stage.Women frequently experience the medical condition that includes at least one of uterus (cervix), apical vaginal prolapse, anterior, posterior, and lateral vaginal wall prolapse (American College, 2019).According to the anatomical region where the sagging occurs, it is named as cystocele, enterocele and rectocele.POP is observed in half of the women on the gynecological examination table (Weintraub et al., 2020).One or more discomforts, such as a sense of slipping and fullness inside the vagina and a sense of voiding dysfunction, are frequently experienced by women with POP.These symptoms significantly lower quality of life and may cause issues with social functioning, mental health, and sexuality (American College, 2019).Considering these effects, it is an important public health problem.Today, although awareness of the pelvic floor has increased, we are only at the beginning of the road.
Science advances by the creation of new articles by adding one more piece of information and referencing the previous article.In this case, emphasizing the knowledge of the previous article is called citation (Gupta et al., 2020).Although the quantity of citations does not completely reflect an article's quality, it is our main indicator of its effectiveness in that field.Citations reveal the success of the authors and journals, the institution with which they are affiliated, and even the country, and have significant benefits (Chen et al., 2016).Bibliometric analysis examines citation to evaluate research performance (Brandt et al., 2019).When the literature is examined, there are original research studies that examine the most cited articles in gynecological diseases as well as in various medical fields (Gupta et al., 2020;Chen et al., 2016;Brandt et al., 2019;Xiao et al., 2022;Brandt et al., 2010;Garfield, 1987).In the literature, it is observed that such bibliometric studies originate from the article that Garfield reviewed the most cited articles using the Web of Sciences database (Garfield, 1987).Towards the end of the twentieth century, urogynecological education began as a subdivision of gynecological diseases (Gupta et al., 2020).
There is no bibliometric analysis for POP in the literature as of yet.We aimed to use a bibliometric approach to evaluate the top 100 articles in the POP research area with the most citations.

METHODS
On October 1, 2022, published articles on pelvic organ prolapse from January 1975 to October 2022 (ie without date limitation) were retrieved by searching the Web of Science (WOS) database.Searches were made with the user profile of Karabuk University.Searches were performed without selecting any other restrictive additional features by typing "pelvic organ prolapse" in the cited title search pane.A total of 3935 articles were found titled Pelvic organ prolapse.These articles were sorted by citation count from most to least.In-depth analysis was done on the top 100 articles with the most citations.PubMed data was also used when examining these articles and determining the type of article.All studies were written in English.There was no exclusion criteria from the study.
Two researchers (AA and AA) compiled detailed article data.Items were categorized as original research, multicenter study, review, randomized controlled trial, clinical trial, comparative study, special contribution, meta analysis by using PubMed.The publication date of the article, the first author's name, and the first author's institution were noted.The article's overall citation count and yearly citation were calculated.In addition, the total number of citations received by the authors whose more than one article was cited was collected.The journals and institutions cited in more than one article were also identified.Additionally, the article's specific mention of anterior compartment and posterior compartment prolapse was assessed.It was also evaluated whether urinary and fecal incontinence accompanying POP and whether surgical approaches to POP were presented.Pelvic floor exercise (kegel exercise) or training questioned at article level.The majority of first authors and journals originated from America (USA; United State of America).For the purposes of statistical analysis, they were split into two groups: Americans and non-Americans.In addition, papers were divided into groups according to median citation value and median publication date.
Since this study was a bibliometric analysis and handled publicly available information, the study was initiated without the need for an ethics committee decision.

Statistical Analysis
The SPSS 21.0 (Statistical Package for Social Sciences, Chicago, IL, USA) program was used to conduct the statistical analyses.Categorical variables were presented as numbers, while continuous variables were presented as mean ± standard deviation (SD).The Kolmogorov-Smirnov test was used to determine whether the data were normally distributed.For group comparisons, the Kruskal-Wallis test and the Mann-Whitney U test were applied.In all statistical comparisons, p<0.05 was regarded as significant.

RESULTS
In the top cited study 3,081 citations were made, while 95 were the fewest study.The mean total of citations was 248.7±380.2.The annual mean citations of the studies ranged between 118.5 and 3.7 and the mean number of studies was 16.8±17.8(Table 1).
Table 2 shows the first authors who have at least two articles in the top list.Three authors were listed with five papers.Among the candidates who were included in the list more than once, the most cited author with total 3314 citations was an author who was included in the list three times.The total was 229 with the least citations.
In the ranking of the most cited papers, three journals were included in the list 70 times in total, accounting for 70% of the articles (Table 3).The three journals with It takes special names according to the region where the pelvic organ prolapse occurs.The anterior compartment is more concerned with urinary complaints and is called a cystocele (Maher et al., 2013).The posterior compartment is mostly associated with bowel (enterocele) or rectal (rectocele) complaints (Woodley et al., 2017).In our study, both the anterior and posterior compartments were covered approximately equally in four out of five articles.Although there was no statistically significant difference, the articles that mentioned these special nomenclature had higher citation scores.

Atıgan et al.: Pelvic organ prolapse
There was no statistically significant difference in the number of citations or annual citations received by the articles, depending on the age of the article being older than the median.However, the annual citation count of the articles that have more citations than the median value was statistically significantly higher.The total number of citations for the top ten most cited articles was roughly 40% of the total number of citations for the top 100 cited articles."The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction" by Bump et al., (1996) published in AM J OBSTET GYNECOL in 1996 had the highest number of citations and the highest number of citations per year.At the same time, when the total number of citations of all authors is considered, Bump RC had the most citations as the first-name author, despite the fact that there were authors with more studies included in the top 100 studies.In the recent bibliometric study on endometrial carcinoma, it was stated that the United States constituted the overwhelming majority of the articles (Xiao et al., 2022).American journals and firstname authors from the United States accounted for a larger proportion of the top 100 most cited articles.However, there was no statistically significant difference in the mean number of citations or citations per year when non-American journals and first-name authors were compared.
In the urogynecology study of Gupta et al. (2020), more than half of the 100 most cited articles were urinary incontinence articles.POP articles were about onefifth of urogynecology studies (Gupta et al., 2020).In our study, the relationship with urinary incontinence was mentioned in almost all POP articles.Articles on incontinence had more citations per year in our study.
In particular, the frequency of POP will increase as the average life expectancy increases.Currently, one in ten women in the population undergoes lifetime POP surgery and the rate of reoperation is higher (Vergeldt et al., 2015).Surgical approaches were discussed in almost all papers in our study.Therefore, it is necessary to manage patient information very well in order to prevent the development and recurrence of POP.In fact, there are things that need to be explained, starting with the healthy population.It is available in the literature that pelvic floor exercises (Kegel exercises), which were first described in 1948, can prevent urinary incontinence and pelvic organ prolapse (Kegel, 1948;Ashton-Miller and DeLancey, 2007).Pelvic floor muscle training was mentioned in roughly a quarter of the articles in our study.It can be said that this number is quite unsatisfactory when looking at other parameters.Furthermore, articles that mentioned exercise had fewer mean citations.In fact, treatments for pelvic organ prolapse are a huge economic burden (Sung et al.,2010).Therefore, preventable methods should be emphasized before treatment.We believed that the scientific community did not place enough emphasis on pelvic floor muscle training.
In the study of Khajuria et al., articles were classified according to the study design (Khajuria et al., 2021).However, statistical analysis was not performed.In our current study, the studies were classified and it was evaluated whether there was a difference between them according to the number of citations.While there was no difference in the total number of citations, the number of citations per year was found to be statistically significant in our study.

Limitation
Similar limitations as in all other bibliometric studies are also present in our study.The number of citations may vary between databases.In our study, WOS data was taken into account and confirmed via PubMed.It is insufficient to look only at the number of citations to show the quality of an article.

CONCLUSION
We analyzed the most cited articles on POP, which is usually the keyword of urogynecology articles.The oldest one among the top 100 most cited studies is not even thirty years old yet.From this point of view, we can liken the POP issue like a greening sapling, with increased quality of life and long life expectancy.Because it is a significant public health issue, we believe that articles on exercise and lifestyle changes will be prominent in the future.

Table 1 :
The top 100 most cited papers on pelvic organ prolapse

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Table 2 :
First named authors with more than one article in the top 100 most cited articles

Table 5 :
Features of article content with more than one article in the top 100 most cited articles