Title: A retrospective analysis of the incidence and risk factors of perioperative urinary tract
infections after total hysterectomy
Version: 1 Date: 26 Feb 2024
Reviewer:  Jason M. Clark
Reviewer's report:
This retrospective review, using the NIS database, attempted to look at the incidence of
perioperative urinary tract infections and risk factors associated with total hysterectomies. The
authors found a total incidence of 2% (1.7% - 2.3%) between 2010 - 2019.  They noted increased
length of hospital stay, medical cost, complications and death. They found age, number of pre-
existing comorbidities, size of the hospital, teaching hospitals, and region to also a play a role
in the risk of UTI's.
Strengths: Strengths of the study include the large sample size and the included economic
analyses.
Weakness:  The retrospective nature of the database. The database can be prone to sampling
error and possible reporting bias. There is no way to determine if patients had pre-existing UTI's
prior surgery. Due to the size of the population, small changes will make a significant difference
that may be of no clinical relevance.
Discussion points not addressed: Why were there increased risk associated with "teaching"
hospitals, large centers, and their locations? Why was black race found to be protective?
No line numbering was provided. All further comments will be from continuous line numbering
performed on Word:
Page 2, line 74: Citation need for statement "In 17 - 23% of cases".
Page 2, line 77: Citation need for "2010, direct cost sfro UTIs exceeded $5 billion".
Page 3, line 86: The line, "The study used multivariate logistics" should be removed as it part
of the methods section.
Page 3, line 94: "NIS" anacronym needs to be spelled out the first time within the manuscript.
Page 3, line 97: "TH" anacronym needs to be spelled out the first time within the manuscript.
Page 3, line 110: "there were almost no" is confusing. Was there missing data or not? Please
either state 0 or provide the low number.
Page 4, line 150:"The fact that PUTI ... is not surprising". Authors should remain objective here
and reword..
Page 4, lines 157 - 195: Including all the OR and ranges makes these paragraphs difficult read.
I would remove this as it also included in Figure 3 which is much easier to see.
Page 4, line167 - 169: The authors' figure shows Black race being protective. This is not
mentioned in your paragraph. This needs to be listed as well and the authors need to discuss it
later in the paper, as most studies find the opposite finding.
Page 5, lines 186 - 190: All risk factors were associated with UTI's except cardiac arrest. This
not mentioned and not discussed late either.
Page 5, lines 201-202: "Hysterectomy is a procedure...." This is confusing and I am not sure what
the authors are implying. Is this hysterectomy different from the reported TH above? Is there
another name for surgeries performed for oncological disease? Please reword, better explain or
remove.
Page 5, lines 202 - 210: I am not sure what is "noteworthy" about this. Some fluctuance
is to be expected. The authors make no good argument for this either. The explanation for
increasing knowledge is completely conjecture and has no supporting evidence from the authors.
Why would increase knowledge of coding change the percentage and then lower it? Are the
authors implying that the hospitals did not know how to code or that they now know how to
avoid coding? Was their a change in guidelines that changed  practice like "Surviving sepsis
campaign"? This would have been 2016 but maybe something else came out at that time. The
authors speak of 2015 and change over antibiotics use and cystoscopy, this would be a better
argument but no citations are made for this.
Page 5, lines 211 - 213: The authors make mention of POP and urinary incontinence surgery are
at higher risk of UTI's. Are the authors implying that more of the elderly patients in their dataset
have had the surgery? Is there a way to determine this or is this a guess?
Page 5, lines 215 - 221: The authors make references to increasing age leading to increasing risk
of UTI. Did the authors compare year to year to determine if age was a cause of their changes
in infection rates? I cannot see the relevance to this article and dataset. This either needs be
rewritten to make more sense or removed.
Page 6, line 218 - 220: This statement needs citation.
Page 6, line 220 - 222: This citation is wrong. This study compared 50% dextrose fluid versus
saline for cystoscopy with risk of UTI. This citation brings questions of the rest of the citations.
Page 6, lines 222 - 229: This should be a completely new paragraph as it discusses  a  different
subject.
Page 6, lines 229 -231: This is a new subject and should be a new paragraph. Also, further
discussion about this should be done by citing the other articles and showing the comparisons.
Page 6, lines 232 - 250: This argues that if you have these comorbidities, that maybe a pre-
existing infection is present. Was this checked for the study? This seems to be weakness.
Page 6,  lines 257 -259: Grammer. should read, "These studies were small and retrospective,
and the analysis of the complications was incomplete. One of this study's "
Page 7, line 272 - 273: Why is not excluding cancers a limitation. The authors mention this but
provide no argument or citation to explain why?
Page 7, line 296: "Based on 2.0%....". This line should be removed as the article provides no
data to support that conclusion.