Editorial: Current Advances in the Understanding and Management of Pelvic Organ Prolapse

Carlo Ronsini^*

• Istituto Nazionale Tumori IRCCS Fondazione Pascale, Naples, Italy

One of the most common assaults on the pelvic floor is undoubtedly childbirth, and the systematic review by Chen et al. [5] offers essential insights into the role of labor characteristics. Their metaanalysis of randomized controlled trials shows that prolonging the second stage of labor in first-time mothers is associated with higher rates of urinary incontinence, pelvic pain, and urinary retention and may increase the risk of later POP. These findings highlight the importance of obstetric practices that focus not only on immediate neonatal outcomes but also on long-term maternal pelvic floor health.Our special issue focused not only on the etiology, but also on the treatment of POP.Several contributions in this Research Topic emphasize surgical management, highlighting the importance of operative intervention for many women with symptomatic prolapse. Innovations in minimally invasive techniques, especially sacrocolpopexy, are prominently featured. Ota et al. [6] compare a newly developed vaginal manipulator with the traditional spatula during robotic sacrocolpopexy and find that the new device improves apical exposure, reduces hospital stays, and enhances postoperative support while maintaining safety and procedural efficiency. However, the need for constant innovation should not always be accepted blindly, as demonstrated by the critical eye presented by Mansour Jamaleddine et al. [7], which critically analyze the literature on robotic sacrocolpopexy, discussing its benefits, including greater surgical dexterity, better visualization, and less blood loss, while also addressing challenges such as operative time, cost, and the lack of standardized techniques across centers. Expanding on these observations, Strauss et al. [8] compare laparoscopic and robotic-assisted sacrocolpopexy in relation to patient characteristics and demonstrate that robotic assistance can attenuate the negative impact of advanced age, higher BMI, and increased parity on operative duration and postoperative recovery, suggesting that robotics may provide particular benefit in anatomically complex or high-risk patients. Surgical decision-making also entails careful consideration of potential complications. A multicenter retrospective study led by my group [9] examines whether the addition of cystopexy during laparoscopic hysterectomy for uterine prolapse improves outcomes. Their findings show a significantly higher rate of postoperative complications when cystopexy is performed, without a corresponding reduction in prolapse recurrence, suggesting that additional procedures should be incorporated selectively rather than routinely. This work follows on from previous research conducted by our group, which demonstrated that, during laparoscopic hysterectomy for POP, certain ancillary procedures such as Shull's colposuspension to the uterosacral ligaments can provide good control of pelvic statics without the need for additional surgical procedures, which would prolong the operation and expose patients to potential comorbidities [10]. Attention to individual surgical steps remains crucial for optimising postoperative outcomes, as also demonstrated by the study by Lu et al. [11] on hidden blood loss in laparoscopic myomectomy. This study provides methodological insights and demonstrates that unrecognized intraoperative bleeding may affect postoperative anemia and recovery, underscoring the importance of precise perioperative management in all minimally invasive gynecologic procedures. Minimally invasive surgery plays a central role in POP, and the sophistication of surgical techniques presents ever-increasing challenges. This compels us, as experts in the field, to critically examine the role of training and the learning pathways required to master this type of surgery. It has previously been demonstrated that a threshold of 20 procedures is the minimum number needed for a surgeon to be considered 'adequate' for the minimally invasive treatment of POP [12].In conclusion, these contributions present a coherent picture. POP is not merely an anatomical failure but results from interconnected biological, mechanical, obstetric, and demographic factors. Advances in molecular profiling and biomechanical modeling deepen our understanding of pathogenesis, while epidemiologic and public health research highlight the urgency of improving access to care. Simultaneously, innovations in surgical techniques, especially robotic and laparoscopic methods, are enhancing our ability to restore function with precision and durability, though cost, standardization, and patient selection remain essential considerations.Taken together, the studies included in this Research Topic advance the field toward a comprehensive, evidence-based approach for managing pelvic organ prolapse. Ongoing interdisciplinary research, along with careful application in clinical practice and public health strategies, will be crucial to reducing the burden of POP and enhancing outcomes for women worldwide.