Review for 10.1186/s12876-024-03435-0 (2024)

Title: Effect of incision location and type of fistula on postoperative urinary retention after
radical surgery for anal fistula: A retrospective analysis
Version: 3 Date: 19 Jun 2024
Reviewer:  Tanan Bejrananda
Reviewer's report:
### Manuscript Review: "Effect of Incision Location and Type of Fistula on Postoperative
Urinary Retention after Radical Surgery for Anal Fistula: A Retrospective Analysis"
#### Abstract
- **Improvement Suggestions**: The abstract is clear and concise but could benefit from a
slight rephrasing for clarity and flow. The conclusion can be more specific about the practical
implications for surgeons.
#### Background
- **Improvement Suggestions**:
- Elaborate on the multifactorial nature of POUR.
- Clarify the link between surgical methods and POUR incidence with more context or
references.
- Improve flow by connecting sentences more smoothly and avoiding repetition.
#### Methods
- **Improvement Suggestions**:
- Specify the criteria for excluding patients more clearly.
- Describe the surgical procedures and post-operative care in a more structured and concise
manner.
- Provide more details on the binary logistic regression analyses used.
#### Results
- **Improvement Suggestions**:
- Clearly separate the results section into subsections (e.g., Characteristics of Participants,
Surgical Approaches, Postoperative Variables, etc.) for better readability.
- Use tables effectively but ensure all critical data are also described in the text for clarity.
#### Discussion
- **Improvement Suggestions**:
- Start with a summary of key findings before delving into detailed explanations.
- Discuss the implications of incision location in more depth, explaining why certain positions
may lead to higher POUR risk.
- Offer more detailed mechanistic insights into how pain and anxiety contribute to POUR.
- Address the limitations of the study more comprehensively and suggest specific future research
directions.
#### Conclusion
- **Improvement Suggestions**:
- Summarize the findings more concisely.
- Emphasize the practical steps that surgeons can take based on the study's findings.
- Mention potential future research directions.
#### Language and Style
- **Improvement Suggestions**:
- Ensure consistent use of medical terminology and correct any grammatical errors.
- Improve readability by breaking up long sentences and paragraphs.
- Avoid redundancy and ensure each section adds unique value to the manuscript.
### Detailed Review with Examples
#### Abstract (Revised)
**Background**: Postoperative urinary retention (POUR) is a common complication
characterized by bladder fullness without the ability to urinate. Its etiology in proctology surgery
is multifactorial. This study aims to identify the risk factors for POUR after radical surgery for
anal fistula.
**Methods**: We retrospectively reviewed clinical records of 511 patients who underwent
radical surgery for anal fistula at the China-Japan Friendship Hospital from August 2022 to
December 2023. Risk factors for POUR were analyzed using binary logistic regression.
**Results**: POUR occurred in 57 patients (11.2%) within 48 hours post-surgery,
predominantly in males (84.4%). Independent risk factors included a history of urological
disease (OR = 6.048; P < 0.001), incisions at position 1 (OR = 2.228; P = 0.046), high anal
fistula (OR = 4.768; P < 0.001), VAS score #7 (OR = 2.805; P = 0.010), and GAD-7 score #5
(OR = 2.405; P = 0.024).
**Conclusion**: POUR is a significant complication post-radical surgery for anal fistula,
particularly among patients with urological disease, high anal fistula, and incisions at position
1. Enhanced postoperative pain and anxiety management could reduce POUR incidence and
prevent long-term bladder damage.
**Keywords**: Postoperative urinary retention, radical surgery for anal fistula, risk factors,
urological disease, high anal fistula.
#### Introduction (Revised Excerpt)
Postoperative urinary retention (POUR) is defined as the inability to void urine despite a full
bladder post-surgery, often leading to increased residual urine volume and discomfort. Anal
fistula, an abnormal connection between the anorectum and perianal skin, typically results
from infection in the anal crypts. Radical surgery remains the mainstay treatment, but POUR
is a frequent complication with varying reported incidences due to different definitions and
methodologies.
#### Methods (Revised Excerpt)
Patients undergoing radical surgery for anal fistula under general anesthesia at China-Japan
Friendship Hospital from August 2022 to December 2023 were retrospectively reviewed.
Exclusion criteria included incomplete clinical records, serious systemic illnesses, psychiatric
disorders, or anorectal masses. Surgical procedures included direct incisions for low anal fistulas
and loose combined cutting setons for high anal fistulas.
#### Results (Revised Excerpt)
Out of 511 patients, 57 (11.2%) developed POUR. Significant risk factors identified included
a history of urological disease (P < 0.001), high anal fistula (P < 0.001), and incisions at
positions 1, 3, and 9. Patients with high anal fistulas required more complex surgical approaches,
contributing to increased POUR risk.
#### Discussion (Revised Excerpt)
The study confirms the multifactorial nature of POUR, with key risk factors being urological
disease history, high anal fistula, and incision location. Enhanced perioperative management,
including careful fluid administration and targeted postoperative pain and anxiety management,
may reduce POUR incidence. Future research should explore specific urological conditions
contributing to POUR and develop tailored preventive strategies.
#### Conclusion (Revised Excerpt)
Surgeons should be vigilant about POUR in patients with high anal fistulas or urological
diseases. Optimizing surgical techniques, perioperative fluid management, and postoperative
care can mitigate POUR risk, improve recovery times, and enhance patient satisfaction. Further
studies are needed to refine POUR prevention and management protocols.