Title: Surgical management practice of pelvic organ prolapse among Ethiopian Gynecologists,
2021: a descriptive study
Version: 3 Date: 04 Jul 2023
Reviewer's report:
Reviewer’s Feedback
Title: Surgical management practice of pelvic organ prolapse among Ethiopian Obstetricians
and Gynecologists, 2021: a descriptive study
• The title is interesting and I would like to thank the authors for attempting to do this study.
However, the authors are required to make the following revision to the manuscript.
Abstract
• Needs to be rewritten and improved
Introduction
• More literature is needed. For e.g. in the area of the existing global treatment of POP (surgical,
laparoscopic, etc.), the effectiveness of different approaches SSLF vs. SCP for instance.
• For e.g. lines 61 and 62 read as…A study comparing vaginal and abdominal approaches for the
treatment of prolapse in Ethiopia showed a 34% anatomic and 23% symptomatic failure rate in
the vaginal route while both were 0% in the abdominal route. This depends on the reference used.
Otherwise, when discussing abdominal vs. vaginal, we mainly refer to apical treatment using
Sacrocolpopexy vs. Sacrospinous ligament fixation. If this is the case there is no significant
difference b/n the two techniques. Thus, the authors need to review more literature on this before
attesting that abdominal techniques are better, which is associated with more patient morbidities
with no different outcomes than vaginal.
• In addition, a review of similar studies in the country and elsewhere is required for discussion
and comparison of the result which is not done in this manuscript.
• Line 70… the issue of mesh.. currently transvaginal mesh is not recommended due to the
complications.
Methods
• How many gynecologists were there in the country during the study? Who is the source
of data? What proportion of them have participated in the study? How many of them are
urogynecologists?
Result
Surgical management practice of anterior compartment prolapses among Ethiopian
Gynecologists
• What proportion of Obst and Gynecologists participated in the study? This could be described
in the method part.
• This section better starts with a description of the total number of OBGYNs participated and
the response rate, then their specific training like whether they are urogynecologists or took
short-term training on pelvic floor disorders management…etc. The description of surgical types
performed by the different levels of professionals would have been described.
Surgical management practice of apical compartment prolapse by Ethiopian Gynecologists
• Line 109-11 states… Vaginal hysterectomy with uterosacral ligament suspension was the
second (49.6%) and sacrospinous ligament fixation and sacrocolpopexy were performed in
32.9% and 9.3% respectively…I doubt the validity of these results. We know that almost all
the procedures like Sacrocolpopexy, and sacrospinous ligament fixations are only performed by
Urogynecologists, how can almost half of them perform these procedures which are performed
at a subspecialty level? What is the number of urogynecologists currently practicing in Ethiopia?
I don’t think it is this much high.
Surgical management practice of posterior vaginal wall prolapse by Ethiopian gynecologists
• What about perineorrhaphy? Most patients with severe stage prolapse have perineal descent
as well, which is actually the reason why they visit medical care as it results in vaginal laxity
and sexual disinterest from the husband/partner side.
Discussion
• Overall, the discussion needs a lot of improvements. I don’t see any discussion of the findings
as it is similar to the literature review/ introduction. Results must be discussed and compared
against similar studies elsewhere.
• Discussion about mesh in POP is not necessary. Firstly, it is not widely available as it is
expensive. Secondly, it is moving out of the market due to its high-risk category. Thirdly,
recommending something very expensive is not appropriate for low-income countries. Finally,
there are findings on the use of mesh in this study, and there is no point to discuss it.
• Line 139-142 ..above the ischial spine having similar success rates with sacrospinous ligament
fixation (SSLF),17 but the practice by our responders is to use the very distal end of the
uterosacral ligament which is already weakened and stretched out beyond its normal position,
so it is less effective as well as less durable.. attests the use of high Uterosacral suspension for
apical treatment. This is not currently a recommended good option because of the high risk of
ureteric injury and no good body of evidence as it is not performed widely.
• Line 142-144 the statement … Hysterectomy must also be performed to do either McCall’s
culdoplasty or uterosacral ligament suspension. Hence these two options are not preferred in
patients who need to preserve fertility.…is not generally true. It is possible to do uteropexy both
to the sacrum and sacrospinous without removing the uterus for those who need fertility. The
author has to review more articles on this. The other point is culdoplasty, which is primarily
meant for the prevention of enterocele after vaginal hysterectomy not for apical suspension
though it may support the apex somehow.
• What about sacrospinous ligament fixation (SSLF)? What is the difference in terms of the
outcome from Sacrocolpopexy? More literature comparing these two techniques is available.
SSLF is said to be the most practical one as the procedure is vaginal and is concomitantly
performed with other POP repairs and has lower morbidity and fast recovery than abdominal
SCP. The other is SCP requires intervening mesh which is less likely to be available in Low-
income countries like Ethiopia.
Conclusion
• This statement states…We found that Ethiopian gynecologists still perform the old techniques
of prolapse treatment… What is the old technique and what are the new techniques? All the
procedures have been there for decades. The reason why all OBGYNs are not doing all the
procedures for POP is that they are not urogynecologists and are not expected to do so.  Training
more urogynecologists would be an appropriate recommendation but expecting all gynecologists
to perform all POP procedures misses the distinction between the levels of training.
Strength and limitation
• It is good that the response rate is found here finally, but it would have been at the beginning
of the result. The other limitation of this study is the proportion of urogynecologists among
OBGNs is not described.