Title: Development and validation of a prediction model for postoperative urinary retention
after prolapse surgery: A retrospective cohort study
Version: 2 Date: 18 May 2024
Reviewer's report:
The authors have chosen a topic of great importance. In their work, they aim to identify risk
factors for the development of postoperative urinary retention. Since POUR can cause some
complications, it is of the utmost importance to identify the individual risk factors for this
condition so that these complications can be eliminated. Although I consider this topic to be
important and the work of the authors to be beneficial, I would like to make a few comments
regarding the manuscript.
Abstract: no comment
Background: no comment
Methods:
Line 60: Please specify the number of patients in each excluded group.
Line 77: It would be beneficial to explain the rationale behind the decision to
remove the catheter on the first or second day. It would also be helpful to ascertain whether
there were any discernible differences between the two groups of patients, namely those where
the catheter was removed on the first versus the second day. These differences could include
postoperative edema or epidural anesthesia.
Line 81: As there is no clear definition for POUR, the authors should state their basis for defining
normal postoperative voiding as two consecutive voids # 150 mL with a PVR # 150 mL. Is this
based on local guidelines or previous studies? If previous studies, please provide a reference.
Line 85: It would be helpful to include other demographic characteristics, such as menopausal
status, race, and history of previous POP or SUI surgery.
The authors should also consider adding other perioperative characteristics such as Kelly
plication and type of anesthesia. According to the Hakvoort (1) study, Kelly plication was found
to be an independent predictor of POUR. Also, neuraxial anesthesia is considered a risk factor
(2, 3).
Line 92: The authors should gain further clarification regarding the type of uterosacral ligament
suspension (McCaul Culdoplasty, HUSLS, or else) and the approach employed (vaginal or
laparoscopic/abdominal).
Results: no comment here
Discussion:
Line 139: Since two of the predictors in the proposed model are concomitant hysterectomy and
type of apical prolapse repair, it is recommended that the authors provide a detailed explanation
of the SCP procedure.
Could you provide information on whether any patients underwent concomitant hysterectomy
with SCP? If so, it would be helpful to know the type of hysterectomy performed. It would
also be valuable to know if the concomitant hysterectomies were total or if any of them were
performed as supracervical. It would be interesting to know if there was a difference in outcomes
between the sacrocolpopexy and sacrocervicopexy groups.
143: The published online model includes a category labeled ICG and SSLF, which lacks a
clear definition. What distinguishes these two categories? According to Table 1, these two types
of surgery were grouped in the same category. Additionally, in Table 2 and manuscript lines
156-157, both surgeries are considered to be in the same category with the same risk. Upon
inputting the identical data into the online model, the results for both types of surgery (ICG
and SSLF) were identical. Please explain this discrepancy between the online calculator and the
manuscript.
Line 146: Further discussion of the models presented in other published studies is required, along
with an explanation of why the model presented here is considered superior.
Line 164: „We avoided levator ani plication as much as possible except for women receiving
extraperitoneal native tissue apical suspension, which may explain why PR was not included as
a predictor in the model. “
It is important to determine whether all extraperitoneal NTR procedures were performed with
levator ani plication. If this was not the case, the authors must consider identifying patients with
concomitant plication in the NTR group. According to a study published by Hakvoort (2) levator
plication was identified as an independent risk factor for POUR. It is therefore necessary to
clarify whether the risk of POUR is caused by the plication of LAM or by extraperitoneal NTR.
Line 187-189: The authors discuss the lower incidence of UTI in women following the early
removal of the catheter. Could you please comment on the UTI rate in women with early and
later catheter removal in your cohort? Was any antibiotic surgical prophylaxis administered?
Line 206: I would recommend rephrasing the sentence:
„The current study has several strengths. Our model covers all types of prolapse surgery…. “
to: The current study has several strengths. Our model covers most types of prolapse surgery.
It should be noted that the Menchester-Fothergil, HUSLS (not specified in the manuscript), POP
surgeries using vaginal mesh, and some other types of POP surgery are not included in the study.
Line 220: Please provide a detailed description of the baseline characteristics of the population
under study, as outlined in the Methods section (line 85).
Conclusion: no comment
1. Hakvoort, R.A., Dijkgraaf, M.G., Burger, M.P., Emanuel, M.H. and Roovers, J.P.W.R.
(2009), Predicting Short-Term Urinary Retention After Vaginal Prolapse Surgery†‡. Neurourol.
Urodyn., 28: 225-228. https://doi.org/10.1002/nau.20636
2. Geller EJ. Prevention and management of postoperative urinary retention after urogynecologic
surgery. Int J Womens Health. 2014; 6:829-838.
3. Choi S, Mahon P, Awad IT. Neuraxial anesthesia and bladder dysfunction in the perioperative
period: a systematic review. Can J Anaesth. 2012;59(7):681–703.