Title: Postoperative urinary retention after pelvic organ prolapse surgery – influence of peri-
operative factors and trial of void protocol
Version: 1 Date: 04 Feb 2021
Reviewer's report:
The authors are commended on adding to the literature on POUR with a thoughtful retrospective
study with an impressive sample size of over 900 women who underwent pelvic floor
reconstruction. The manuscript is well-written, the tables are lengthy and seem necessary to
reflect the authors analysis. Some of my comments may be "off-base" because I had difficulty
following the exact details in the Methods about the 2 different TOV's. Adding clarity to the
methods will allow a greater number of readers to understand how this work applies to their own
clinical practice. Again, Kudos, on your study.
Results
8. How many women passed both the first and second void trial which means that only one void
trial was needed? This would actually be very helpful for other clinicians who may not have
women undergo the rigor of 2 voiding trials. At most US hospitals ERAS protocols are sending
women home the same day after all of these surgeries and a trial of void is done ~ 2 hours after
leaving the operating room. Publishing the rates of 1st trial success rates, 2nd trials success rates
in addition to 3rd trial could bring deep understanding and add to our literature.
9. The timing of when the trials were performed (hours after surgery) would help make this study
more generalizable. It sounds like the majority of these cases had void trials that were occurring
the next morning at 6 am. Is this correct?
10. Line 283 “We also examined the characteristic of women having PVR > 150 mL”. Since the
majority of women in the study had retrograde fill studies, they would have failed their TOV
with a volume > 100 mL.  Again, this reflects the confusion I have with the methods where it is
not clear how the 2nd TOV is done in women who had an initial retrograde fill.
11. If there were 2 TOV for each woman, how can there be women who passed with 1 void as
shown in table 1 “voids to pass categories 1-3”?
12. The surgeon effect in the modeling of 3.9% is reassuring and such an interesting addition to
our literature. A note, you mention 5 surgeons in the methods and 4 surgeons in the discussion.
Which is correct and please change which ever one is not correct.
Discussion:
13. The discussion to start is lovely but add into the analysis that while 10.4% more women
passed the after the 3rd TOV, xx% needlessly underwent a second TOV (meaning they passed
the first and passed the second so one trail would have been sufficient). This is just to bring
to the table a balanced discussion of when should we believe a single TOV and if it fails then
to continue.
14. Lines 385-386 Most experts would say that MUS increase urethral resistance and that
is why there is more voiding dysfunction. Which is much more sensible than “disruption of
nerve endings in the retropubic space, resulting in alteration of micturition sensation of voiding
efficiency”. This is also why women report slow urine flows after sling, increased voiding
pressures, higher urethral closure pressures and why the treatment for voiding dysfunction is to
do a sling lysis and not remove the sling from the retropubic space. Despite having a reference
that quotes this, I disagree whole-heartily with that statement.
15. Line 415: “Our study found the median number of voids to pass the protocol was 2”.  Again,
this is an issue that may be sorted out by clarification in methods, but if your protocol required
2 voids to pass the voiding trial than it is a given that it will be 2 or more voids as the median
number to pass your protocol.
16. One of the limitations of your study is that it is not generalizable to women who are being
discharged home the same day where a higher number of women may be more likely to fail their
TOV (whether the protocol is 1, 2 or 3 voids).
Conclusion:
17. I would be careful about saying that normalization of PVR takes two voids given that your
protocol required two voids. Again, if some women could pass in 1 TOV than this needs to be
better discussed in the methods, results and discussion
References
18. Reference 26 first authors last name is Elkadry (misspelt as Elkady)