Surgery is a very important and final treatment in the treatment of pelvic organ prolapse (POP) and pelvic floor dysfunction (PFD). In the past two decades, with the deepening of the understanding of pelvic floor anatomy and the etiology of POP, the improvement of surgical instruments and the invention of repair materials, there have been revolutionary advances in the surgical treatment of POP in China and abroad, with no less than dozens of new procedures and new applications of old procedures, which have improved the clinical treatment results. However, new problems have arisen, such as the selection of various surgical applications, the recognition and prevention of complications specific to new procedures, the erosion and exposure caused by repair materials, the efficacy of new procedures, recurrence characteristics, causes and other issues still confuse clinicians and require further in-depth study. When considering whether a patient with POP or PFD needs surgery, the first thing we need is to evaluate the extent of the patient’s disease, and to understand whether this extent affects her life and whether it can no longer be cured by conservative methods. The uterine prolapse scoring method used in China for decades is no longer applicable to the current requirements for POP treatment because it is not precise and quantitative enough. There are two quantitative systems for evaluating POP that are more widely accepted and used internationally, one is the vaginal half-way system grading method proposed by Baden-Walker, and the pelvic organ prolapse quantitative staging method (POP-Q) proposed by Bump in 1996 and researched, investigated and recognized by the International Urogenital Control Association and the American Association of Gynecologic Urology and Gynecologic Surgery. The former method is simple and easy to use, but the degree of objective quantitative index is somewhat lacking; the latter method has been used in 50% of the international literature because it is objective, accurate, and has good credibility and repeatability. China has written POP-Q staging into the sixth edition of textbooks, which has contributed to the popularity of this staging system. In the anatomical and objective evaluation of POP patients, most experts believe that POP-Q stage III is an appropriate indication for surgical treatment, which means that surgical treatment can be considered regardless of the site where the most distal part of the prolapse exceeds the hymen by more than 1 cm. However, there are several issues that need attention in the specific application of the POP-Q system. One is the need to pay attention to the position of the person being examined and whether the examination is at the maximum level of prolapse. As the patient is old, she is unable to use the abdominal pressure adequately, so she can be allowed to do certain activities until she thinks her prolapse has reached the heaviest degree as usual before doing the examination, or she can be examined in a sitting or standing position with one leg slightly elevated outward. Second, attention needs to be paid to the content of the examination, the sequence and the instruments used. The parietal traps and some specific areas of vaginal defects, as well as bowel distention, high mobility of the urethra, length of the cervix, and degree of descent of the perineal body are not described in the POP-Q system, and this is something that should be noted during the preoperative examination. In fact, all areas of prolapse should be examined, including the thickness of the mucosa, folds, and the presence or absence of ulcers, if an ideal surgical outcome is to be achieved. The importance of evaluating the pelvic connective tissue and muscle support is also emphasized in the 6th edition of Ostergard’s Gynecologic Urology and Pelvic Floor Dysfunction, and although this is not an entirely objective examination, it helps the surgeon to have a preoperative understanding of the patient’s prolapse and whether there is a specific site of laceration. For those with preserved vaginal function, special attention should be paid to the length of the vaginal and pubic fissures preoperatively and postoperatively. For examination of cervical/vaginal vault prolapse, the anterior and posterior vaginal walls should be gently pressed down with a bilobed speculum under the patient’s Valsalval force and slowly moved closer to the cervical/vaginal vault, from which the support of the cervical/vaginal vault can be individually observed and evaluated. Defects around the cervix/dome, such as elongation of the primary ligament, sacral ligament, and pericervical ring, or rupture, and the presence of bowel bulge, can also be carefully observed with gentle traction of the oval forceps. To examine the vaginal wall for bulging, a single lobe vaginal pulling hook should be used. To examine the anterior wall, the hook is used to pull apart the posterior wall and the vault and vice versa. However, care should be taken not to use the unilobular hook too hard as it may cause an artifact. When examining the anterior wall, attention should be paid to the lateral sulcus of the anterior vaginal wall on both sides, which reflects the connection between the peripubic cervical ring and the pelvic fascial tendon arch, the paravaginal defect. This defect can also be identified by elevating the lateral sulci on both sides of the anterior vaginal wall using an oval forceps technique. The anterior vaginal wall examination should also be performed while observing the site of bladder bulge, whether it is central or transverse, and whether there is urethral bulge to evaluate possible stress urinary incontinence. The examination of the posterior wall bulge should be done in addition to visual inspection, with anal inspection and vaginal-anal double-handed examination to evaluate the bulge and defects of the lower or upper rectum, the presence of bowel bulge and some specific, isolated fascial defects. Recently, the observation of the perineal body has also been emphasized to evaluate the presence of bulging or prolapse. The clinical symptoms of POP are closely related to its staging, but they are not always correlated in individual patients, so in addition to the objective anatomical evaluation of POP, it is necessary to understand the patient’s resulting distress and clinical symptoms, i.e., the subjective evaluation of the patient, the latter being a key factor in the clinician’s decision to treat surgically. In other words, surgical treatment should be a measure for clinically symptomatic POP. symptoms of POP include 3 main aspects: lower urinary tract, lower genital tract, and lower gastrointestinal tract. The symptoms of lower urinary tract are mainly urinary incontinence and retention, lower genital tract is mainly vaginal mass pressure caused by uterine prolapse, lower back pain, discomfort of walking, activity and sexual intercourse, etc. The lower gastrointestinal tract is mainly manifested in fecal incontinence, difficulty in defecation, colorectal dysfunction, etc. The severity of the above symptoms can be evaluated by some special clinical tests, such as urinary pad test, urodynamics, ultrasound, MRI, anorectal manometry, electromyography, etc. However, it is now recognized that in addition to the above tests, the questionnaire approach plays a more important role in evaluating the degree of symptoms of POP. The clinician should be familiar with the content of these questionnaires and should perform a preoperative symptom score for each patient with POP to be operated on to determine the surgical approach and evaluate the surgical outcome. The choice of surgical approach, route, and repair materials There are many different reconstructive pelvic surgery (RPS) procedures for the treatment of POP, and new procedures are constantly emerging with research. In this regard, there are some principles of selection that can be used for reference. Procedures for the treatment of POP can be broadly divided into 3 categories: restoration of anatomy, compensatory replacement and closure. The first two types are for those who need to preserve vaginal function, while the latter type is for those who do not need to preserve vaginal function, depending on the patient’s wishes and the extent of the disease. The three main routes of RPS are transvaginal, transabdominal and laparoscopic, as well as combined procedures between the different routes. The choice of surgical route depends on the etiology, type, location and extent of POP; the training and experience of the surgeon; the patient’s age, fertility requirements, and the patient’s preference for the surgical route and expectations of its outcome. In most cases, RPS surgery will involve several areas, such as the anterior and posterior vaginal walls, the vault, the perineum, and even the bladder neck or anal sphincter, so several procedures are often required at once. In general, posterior vaginal wall prolapse is usually performed by a transvaginal route and occasionally by a transanal route. Surgery of the vault and anterior vaginal wall can be performed by both the transvaginal and transabdominal routes. The transvaginal route is clearly superior to the open route in terms of complications and short-term patient recovery. However, whether the transabdominal repair of POP is more effective and durable than the transvaginal route and whether laparoscopic PRS surgery is more advantageous remain controversial due to the lack of comparative data, and further studies are needed to determine this. The surgical approach can be chosen according to the different sites of prolapse such as anterior vaginal wall, posterior vaginal wall and cervical/dome. For repair of anterior vaginal wall bulge, the main options are: Kelly’s anterior vaginal wall folding suture repair, paravaginal repair (PVR), defect-guided repair, and targeted repair of transverse defects at the tip of the anterior wall. Repair of transverse defects of the anterior vaginal wall bulge has received considerable attention in recent years and is considered a key point in preventing recurrence of bladder bulge. For those with stress urinary incontinence, depending on the severity, urethral bladder junction sutures or vaginal tension-free slings are feasible. Prof. Weber recommends transvaginal surgery for POP with anterior wall repair, and transabdominal sacral vaginal suture, if PVR is not available, then anterior vaginal wall support is inadequate, and the Burch procedure with posterior pubic PVR can strengthen the mid-vaginal segment, the second level of DeLancey support. Repair of posterior vaginal wall bulge includes both posterior vaginal wall repair and repair of specific fascial defect areas. A recent literature comparing the outcomes of both types of posterior vaginal wall repair using evidence-based principles found that site-specific fascial defect repair was slightly better or equal to conventional posterior vaginal wall repair in terms of functional improvement, but had a higher anatomic recurrence rate. It was also found that anterior rectal fascial midline folding sutures with anal levator sutures were superior to site-specific defect repairs in terms of anatomic and functional improvement. In terms of repair routes, the incidence of rectal distention, bowel distention recurrence and fecal incontinence was lower with transvaginal repairs than with transanal routes. More attention has been paid to painful intercourse after posterior vaginal repair, which is often caused by vaginal stenosis, deformity, axial changes, elevation of the perineal body, or formation of raised scar bands, with anal raphe sutures being a common cause, which should be noted in young, sexually active women. Taking into account the results of current studies, traditional posterior vaginal wall repair is still the main procedure currently recommended, along with repair of specific defective areas, such as suturing of the rectovaginal connective tissue to the perineal body and folding sutures of the pararectal connective tissue in the midline. In those with old perineal muscle laceration, repair of the perineal body and suturing of the anal levator muscle should be performed at the same time. The latter can enhance the repair effect and narrow the middle and lower segments of the vagina, while the former can serve to further close the vaginal orifice, which is especially suitable for the elderly and sexually inactive. The need for repair of mild to moderate, asymptomatic posterior wall bulges that are only part of the composition of severe POP remains controversial in young, sexually active individuals, given the potential for painful intercourse associated with the procedure. The two main types of repair for cervical/vaginal vault prolapse are: restorative anatomic and closed. In the former case, the more established procedures in the last decade or so are: posterior vaultplasty by McCall, posterior vaultplasty by Mayo, sacral ligament and high sacral ligament suspension, sacrospinous ligament fixation, iliococcygeal fascial vaginal suspension, transabdominal vaginal sacral suture, transabdominal vaginal perineal sacral suture, etc. In HUS, the sacral ligament is sutured at the level of the flat sciatic spine, which allows higher suspension of the vault and preservation of the deeper vagina, thus allowing It has a complementary effect on the repair of anterior and posterior wall bulge, with a wide range of indications, and is safe, economical and has long-lasting results. When the sacral ligaments are lax and disappear, SSLF or iliocostalis fascia vaginal suspension can be used. 78% to 100% success rate of ASC for vault prolapse is considered as the gold standard procedure for vaginal vault prolapse. However, the need for open abdomen, the difficulty of operation, and the seriousness of perioperative complications have limited its wide clinical use. In limited randomized comparative trials, the success rate of open vaginal prolapse has been shown to be higher than that of the transvaginal route, but at the cost of increased near- and long-term complications, so most gynecologic urologists use this procedure in young, active patients who can better tolerate open surgery and surgical complications and who have a tendency for recurrent prolapse. The main advantages of vaginal closure are short operative time, low morbidity, safety, efficacy, minimal side effects and surgical risks.FitzGerald et al. reviewed the literature for nearly 40 years from 1966 to 2004 and found that the success rate of this procedure for POP was close to 100%. Vaginal closure can be partial or total. The results of the study showed that simultaneous hysterectomy with vaginal closure increased bleeding, prolonged surgery and hospital stay, increased postoperative morbidity and perioperative complications, but did not improve surgical outcomes, and most scholars do not favor simultaneous hysterectomy unless the uterus and cervix are pathologic. Simultaneous folding sutures of the levator muscle plus enlargement or high perineal body repair are favored by most and can achieve reduction of the pubic fissure, enhance vaginal closure and reduce recurrence of prolapse. A noteworthy complication is postoperative urinary incontinence, with an incidence of 1% to 9%, but the need for concurrent treatment remains controversial. Because older women with prolapse often have impaired detrusor muscles and overt or covert urinary retention, which can often be improved after surgery, the addition of anti-incontinence measures may reduce the benefits of surgery in this regard. If postoperative incontinence occurs, the patient may be treated with an additional antincontinence tension-free sling or a paraurethral injection. The effect of vaginal closure on bowel function and quality of life is not known. There are isolated reports of postoperative regret and this point has not been well studied. As for the application of repair materials, there is still more controversy. Biological materials are expensive, disappearing and not being absorbed long enough to be strong enough in their own tissue is one of their main concerns. The problem of erosion and exposure of synthetic materials is still unresolved and plagues physicians and patients. The erosion and exposure of synthetic materials are significantly related to their area and placement site. In addition to the material’s own characteristics, anti-incontinence sling-type procedures are mostly safe to use because of the small area of the material and the low erosion rate. The erosion rate of anterior vaginal wall bulge repair with synthetic materials is lower than that of posterior vaginal wall repair. Whether this is related to the thinner vaginal rectal fascia than the anterior vaginal fascia needs further study. Therefore, extra care should be taken when deciding to add synthetic materials during posterior wall repair. Finished synthetic materials, such as Prolift, simplify the procedure and allow for better patch placement, but the follow-up period is still short and the number of cases is small, so it is too early to draw firm conclusions. In conclusion, the application of repair materials should be cautious, especially for young and sexually active people, and the principle of its application is to use as little or as much as possible, and of course, there is a trade-off between the prevention of postoperative recurrence. Postoperative follow-up Pelvic reconstructive surgery is a new field, and like all new things, it needs to start from somewhere. Since its inception globally and in China, our work has progressed significantly from case reports to series, and randomized clinical trial studies. However, the follow-up period for most reported cases is still too short, so it is only relevant for short-term intraoperative and postoperative complications. Without follow-up reports of long-term outcomes after surgery, it does not provide useful clinical information. At a time when we are focusing on long-term success rates, trying to reduce recurrence rates, and trying to understand the superiority of new procedures, short-term follow-up reports are clearly unconvincing. In addition to the length of follow-up, the subjective healing rate of the patient is equally important in the field of RPS surgery, and this is an important criterion by which we evaluate the superiority of a procedure. There is an urgent need to strengthen the understanding of postoperative follow-up and the evaluation of postoperative subjective symptom relief, i.e., to achieve the goal of improving patients’ postoperative quality of life, because the criteria of cure for PFD have transitioned from objective cure rates to more stringent criteria of subjective cure rates that take into account the improvement of patients’ postoperative symptoms and quality of life, and many quality of life scores and questionnaires for postoperative urethral and bowel symptoms and sexual quality of life have been developed as part of the PDF postoperative survey. Many quality-of-life scores and questionnaires for postoperative urinary and bowel symptoms and sexual quality of life have been used as an important part of PDF postoperative follow-up. Because in the study, we will look more at “How is the woman’s life 5 or 10 years after surgery?” rather than “What is the success rate 5 to 10 years after surgery?” . We hope that with our efforts we will have more and better studies of clinical RPS design in the future.