Title: Effect of annualized surgeon volume on major surgical complications for abdominal and
laparoscopic radical hysterectomy for cervical cancer in China, 2004-2016: A retrospective
cohort study
Version: 2 Date: 28 Dec 2022
Reviewer's report:
First of all, I would like to congratulate the authors for this great effort to carry out a review
with great data on this topic, however, I consider it prudent to make some comments that could
perhaps contribute to the strengthening of the manuscript.
Regarding the title, I suggest modifying the title because there seems to be no standardized
objective way of measuring the effect and/or quality of a surgeon and its inherence in surgical
complications of surgery. I also suggest deleting the phrase "cervical cancer" because radical
hysterectomy is a procedure that is only performed on patients with cervical cancer.
Introduction.
Line 54 - 55: Authors should add that open surgery for cervical cancer is today the gold standard
according to FIGO, ESGO, NCCN and NICE.
Line 56 - 58: I suggest briefly describing which are the factors and characteristics on which what
is described in this sentence depends for a better reading comprehension.
Line 58: What do the authors mean by "received attention", paraphrase. I suggest modifying this
line in a more objective sense.
Line 61 – 67: I suggest considering reviewing and adding other articles related to this topic and
gynecologic oncology, which could help to improve the development of the manuscript as .......
Matsuo K, Shimada M, Yamaguchi S, et al. Association of Radical Hysterectomy Surgical
Volume and Survival for Early-Stage Cervical Cancer. Obstet Gynecol. 2019;133:1086–1098.
[PubMed: 31135722]
Wright JD, Huang Y, Ananth CV. Influence of treatment center and hospital volume on survival
for locally advanced cervical cancer. Gynecol Oncol. 2015;139:506–512. [PubMed: 26177552]
Matsuo K, Matsuzaki S, Mandelbaum RS, Matsushima K, Klar M, Grubbs BH, Roman
LD, Wright JD. Association between hospital surgical volume and perioperative outcomes
of fertility-sparing trachelectomy for cervical cancer: A national study in the United States.
Gynecol Oncol. 2020 Apr;157(1):173-180. doi: 10.1016/j.ygyno.2020.01.015. Epub 2020 Jan
22. PMID: 31982179; PMCID: PMC7526700.
Hollenbeck BK, Dunn RL, Miller DC, Daignault S, Taub DA, Wei JT, Volume-based referral
for cancer surgery: informing the debate, J. Clin. Oncol. Off. J. Am. Soc. Clin. Oncol 25 (2007)
91– 96.
Ruiz MP, Chen L, Hou JY, Tergas AI, St Clair CM, Ananth CV, et al., Effect of minimum-
volume standards on patient outcomes and surgical practice patterns for hysterectomy, Obstet.
Gynecol 132 (2018) 1229–1237. [PubMed: 30303921]
Line 75 – 77: These lines seem to describe more than one variable to be evaluated, it seems that
there are more than two main objectives, please define the second objective, or if there is more
than one, paraphrase the text.
Line 85 – 87: The authors should describe whether the hospitals that were not oncology
centers had trained and qualified surgeons, whether they were oncology gynecologists, oncology
surgeons, or obstetrician-gynecologists, for this type of surgery.
Line 103: I suggest justifying why ST IIB patients were included in this cohort when the fact of
having compromised parametria is an independent risk factor for greater surgical complications,
and surgery is not the gold standard because they are ST considered locally advanced, and should
go to definitive chemoradiation therapy.
line 124 - 127: Was this surgeon volume calculation validated or is it the same for all institutions?
How do you define a high-medium and low-volume surgeon?
This number of procedures was for radical hysterectomies only, and if so, can you define the
types of radical hysterectomies?  And if so, can you define the types of radical hysterectomies
you did for your learning curve and stratify the "surgeon volume"?
I think the authors should describe this.
Line 160 – 161: These results are too heterogeneous to make a comparison between two types
of methods that require a specific skill and learning curve, and one of the arms to be evaluated
could be biased. Have you ever considered doing a Propensity Score Match to have a more
objective assessment?
Line 178 – 192: The fact that this group of patients was treated by the group considered to have
the greatest surgical skill generates a bias that may be irreversible due to the retrospective nature
of the data, also the authors should describe who operated on the ST IIB tumors and which
received neoadjuvant chemotherapy, this could contribute to more objective results.
Line 202 - 205: How can the authors justify that lower volume surgeons had a lower or similar
percentage of ureterovaginal fistula type complications, even than high volume surgeons?
Line 207: authors should define what complications they are referring to.
Line 218: What the authors mean by the term “had little effect”, is not scientifically measurable,
and consider relating the first paragraph of the discussion to the primary and secondary outcome.
Line 234 - 239: I consider that the authors could use the references that I suggested in
previous lines, with the objective of adjusting the discussion to the topic of cervical cancer
and gynecologic oncology, because there is a great difference in the complexity of surgery for
endometrial cancer and cervical cancer. And thus, to have a more robust and related evidence
described.
Line 241: In this aspect what do the authors mean by "complex" when they talk about the
association between surgeon volume and complications? authors should describe it.
Line 243 - 252:
This seems contradictory to what has been stated throughout the manuscript, authors have any
explanation for a better surgical outcome in less experienced surgeons?
Line 256 - 258:
This could be defined in materials and methods, and this bias could justify some of the results,
however, it would be ideal if the authors in materials and methods described the criteria for
surgeries in locally advanced cervical cancer as STIIB.
Line 262 - 263: What do the authors mean by “paying more attention”?
Authors describe that the rise of MIS use in cervical cancer before the LACC trial could be
related to a considerable decrease in open surgery for cervical cancer, and their complication
rates were similar in low and high-volume surgeons, can this result be explained in the context
of the main objective of their manuscript?
line 273 - 277: The authors should consider using articles more related to gynecologic oncology
because the learning and training curves differ markedly from other specialties.
Finally, I believe that the authors could improve the wording of the English in the manuscript for
a better interpretation by the readers, and thus obtain the best scientific benefit from the research.