Title: A retrospective analysis of the incidence and risk factors of perioperative urinary tract
infections after total hysterectomy
Version: 1 Date: 24 Feb 2024
Reviewer's report:
Summary: this interesting study investigates the incidence of PUTI of patients having a TH in
the NIS database from 2010 to 2019 and associated factors as determined by a case control
type of analysis. Among the interesting findings of the analysis were that the median length of
stay in days for PUTI patients was 5 compared 2 in those without. Furthermore, patients with
PUTI had significantly higher hospital charges. Factors strongly associated with PUTI were
advanced age and multiple comorbidities. Among the comorbidities studied, fluid/electrolyte
disorders, weight loss, paralysis, and lymphoma were strongly associated with the PUTI group.
These findings are interesting and worth reporting. I recommend major revisions however prior
to consideration for acceptance.
Major revisions recommended:
- The stated conclusion of 'PUTIs in patients undergoing TH are associated with increased
morbidity and mortality. Counseling should be done prior to surgery to reduce the incidence
of PUTIs.' does not seem adequate to the study or the findings and the authors should consider
revising this statement. This conflicts with the authors' statement that: "This study's goals were
to find out what percentage of women have PUTIs after TH surgery and what factors make them
more likely to get them." I recommend using the latter and modifying the former to answer the
reasonable study question.
- The first sentence of the introduction is a nearly verbatim quote from reference #2. I suggest
paraphrasing or using quotation marks ensure appropriate attribution.
- The authors' assert "In the United States, urinary tract infections (UTIs) are prevalent and a
major cause of high healthcare expenses; in 2010, direct costs from UTIs exceeded $5 billion."
without a corresponding reference.
- The authors assert "Women experience higher rates of UTIs than men do due to anatomical
and physiological variations[3].", however,  this is a reference to a paper about UTI after
hysterectomy, it does not substantiate the difference in rates of UTI due to anatomical and
physiological variations between males and females.
- The authors assert: "absence of risk factors that have been discovered and may be utilized to
calculate the incidence of PUTIs[5, 6]." This is a confusing statement that does not make sense
at first glance, please revise.
- Use the Discussion section to expand on the findings and reserve the Results section for
reporting them.
- Several instances in the Results section where the author could condense information and allow
the figures to speak for themselves. The figures are great as is and easy to interpret.
- Association is not the same thing as causation. This mistake is present in the section of 'Adverse
effects of PUTIs after TH,' furthermore, such an interpretation would belong in the Discussion
section instead of the 'Results' section.
- The explanation of elective hospitalization versus non-elective needs better description in both
the Methods and Results sections.
- The authors description of possible limitations that would be expected from such a case
control study, such as confounding variables, spurious associations, etc., are incomplete in the
discussion section. Furthermore, the study is over-powered and the measure of 'significance'
is questionable as a result. I've listed above factors that appeared to be strongly associated,
some of which may be confounded by factors such as malignancy or renal failure, for example.
Nonetheless, the findings are interesting. The authors just need to completely outline potential
limitations and refrain from overstating the impact of the findings.
- Overall, I think the authors should stick to the stated aim of: "This study's goals were to find
out what percentage of women have PUTIs after TH surgery and what factors make them more
likely to get them." In doing so, I recommend making both the Introduction and Discussion
sections more concise, dropping unnecessary statements/commentary on items extraneous to
that aim. Furthermore, the phrasing of that aim could be reworded to more appropriately express
the aforementioned limitations of such a study.