Title: HEAL Africa score to predict failure of surgical repair of obstetric urethro-vaginal fistula
in the Democratic Republic of Congo
Version: 1 Date: 03 Dec 2023
Reviewer:  Phuc Nhon Nguyen
Reviewer's report:
Dear authors,
Thank you for your great work. Some risk factors and scores related to the failed rate of  surgical
repair of obstetric urethro-vaginal fistula technique (FSROUVF) in Democratic Republic of
Congo population. The interesting findings will contribute significantly to the literature. After
reading your paper, I have some constructive comments addressed as below:
- Many surgical techniques relating to this repair have been reported in the literature. Please add
it to the Introduction.
- Surgical repair of obstetric urethro-vaginal fistula technique is the most important point in this
study. Please include an illustration image or short video or some operative photos. This addition
would be more attractive.
- I suspected that 7 centers participated in this study in 5 years have a same techniques and the
operation was performed by the same team. The different hospitals and different surgeon may
be a unavoided bias in this study. Did the authors have a training curve? And the technique could
be reproducible. Particularly, the management relating to antibiotic therapy and anti-infection
methods relates directly to the surgical outcomes may be different.
- Please add the mean duration time of surgery between failed and success group.
- How the authors defined hemorrhage and infection. Please mention it in the Method section
and describe its treatment.
- How the study defined these variables fistula size (# 3 cm or > 3 cm), the presence of fibrosis
(yes or no), the status of the urethra (partial or total involvement). Please describe in detail about
the measurement tool, the standard of determination.
- Urinary incontinence is also an important variable to evaluate the outcome of intervention. The
authors referred that it is easy to determine. However, please given a gold standard. The authors
used the functional symptoms, the patient’s report, urodynamic test, or clinical examination.
Please include a reference from practical guideline recommendation:
+ Sharma N, Chakrabarti S. Clinical Evaluation of Urinary Incontinence. J Midlife Health.
2018;9(2):55-64. doi:10.4103/jmh.JMH_122_17.
+ Pope R, Beddow M. A review of surgical procedures to repair obstetric fistula. Int J Gynaecol
Obstet. 2020;148 Suppl 1(Suppl 1):22-26. doi:10.1002/ijgo.13035
- The use of intravaginal indigenous products by patients as part of traditional fistula treatment
that occurs in the community. Please detail these product’s names. The global readers cannot
imagine. Regardless of my opinion, this variable is not helpful in analysis since the study cannot
be repeated with these products worldwide although I understand that the authors only would
like to describe in their study places. However, the study should be able to apply anywhere.
- A table of population baseline characteristics consists of patient’s age, body mass index (kg/
m2), smoking, diabetes, occupation, medical record, socio-economic condition, etc should be
added. Because these factors impact on treatment ressults.
- The study flowchart with inclusion and exclusion cases should be given.
- In Table 1, the authors did not include the trauma from the assisted instruments in previous
vaginal births. May the data relating to 4 grades of peritoneal tear be added? Even, hematoma
mass of vaginal wall should be noted.
- Presentation of data in Table 1 should be changed. The percentage (%) should be given by the
column instead of row. The readers concern about the age of fistula more than 5 years along
with fibrosis presence is associated with the failed rate of fistula repair when observe the data
in the column among the subgroups. Meanwhile, the perecentage (%) in almost all variables are
greater in the success group compared to failed group. Moreover, the analysis with crude OR
is unnecessary in this Table 1.
- Perimenopausal and postmenopausal women is also affected by urinary incontinence due to the
decreased level of estrogen hormone (Ko#ody#ska G, Zalewski M, Ro#ek-Piechura K. Urinary
incontinence in postmenopausal women - causes, symptoms, treatment. Prz Menopauzalny.
2019;18(1):46-50. doi:10.5114/pm.2019.84157). The authors should include this issue although
the data related to the medical treatment may be absent in this study data.
- UCTR Predictive Score ROC Curve with AUC: 0.9375  is extremely high. Please compared to
other studies and discuss the advantage points of score level in this study. This important figure
should be only used with 3 decimal numbers following journal’s instruction.
- Please expand the discussion as suggestion: “This pathology should be managed by
multidisciplinary team including OB/GYN consultant, urogynecologist, surgeon, anesthetist.
Heath-care providers should be recognized well this complication and transfer the patient to the
tertiary referral hospitals for appropriate management. To avoid the recurrent occurrence, the
planned cesarean delivery should be informed in later pregnancy if the female patients desire
for pregnancy” (Reisenauer C, Amend B, Falch C, Abele H, Brucker SY, Andress J. Evaluation
and management of obstetric genital fistulas treated at a pelvic floor centre in Germany. BMC
Womens Health. 2021;21(1):52. Published 2021 Feb 5. doi:10.1186/s12905-021-01175-x).
- The limitations and strengths of the study needed to be described if the above comments could
not be addressed.
After revision, I believe that this paper could be published in BMC’s Women Health.
Congratulation for your work. Try your best and Good luck!
Regards,
Phuc Nhon Nguyen MD
Tu Du Clinical Research Unit (TD-CRU)
Tu Du Hospital, Ho Chi Minh City, Vietnam