Reviewer’s report
Title: 
Pelvic organ prolapse and uterine preservation: A cohort study (POP-UP
study)
Version: 
0 
Date: 
14 Oct 2020
Reviewer's report:
Thank you to the authors for performing this study and adding to the literature
regarding sacrocolpopexy (SCP) with and without uterine preservation as a
technique. While I do think this work merits publication given the large number
of patients included, I have a few concerns and recommended edits.
1) Title and design: The two groups of patients (uterine preservation or no) were
defined by their intervention and not outcome. As such, the proper title and
methodology is a cohort study.
2) Other literature: While this study does add to the literature, there have been
other studies looking at uterine preservation, cervical preservation, and total hyst
with SCP that should be included and referenced in this work. 
Please see more granular suggestions/edits as below:
Title: As above, correct this to be a cohort study
Abstract:
1) Lines 25-27: "the preferred option" is very strong wording given that native
tissue repair is still an excellent option. 
Consider "is considered the standard
surgical option" or that is the authors preferred surgical management.
2) Line 38 (and throughout manuscript): The word rates is used incorrectly here.
It should be "incidence" throughout as rates are incidents over time.
3) Lines 46-48: The second part of this sentence is incomplete. Consider:
"nevertheless, uterine preservation with LSC was associated with increased
incidence of anterior compartment failures and suboptimal mesh placement
based on postoperative imaging techniques."
Background:
1) Lines 69-70: It is unclear what the authors are referring to regarding "this
option". Perhaps they mean, "The choice of route of apical surgical correction is
one of the most challenging..."
2) Line 73: outcome is missing an s-- should read as "outcomes"
3) Lines 74-78: Consider rephrasing to "In women who have their uterus and
who desire a laparoscopic procedure with mesh..." 
The reason to make this more
specific there are a number of other options here not including sacrocolpopexy --
one option is to perform a laparoscopic native tissue suspension. This has been
compared to LSC sacrocolpopexy and this data should be included in the
manuscript at least in the discussion.. Davidson ERW, Casas-Puig V, Paraiso
MFR, Ridgeway B, Ferrando CA. Pelvic Organ Prolapse Recurrence and
Patient-Centered Outcomes Following Minimally Invasive Abdominal
Uterosacral Ligament and Mesh-Augmented Sacrohysteropexy. Female Pelvic
Med Reconstr Surg. 2019 Mar 6. PMID: 30845072.
4) Lines 88-91: There is actually a decent amount of data here, both cited by the
authors and a few other studies I recommend adding. In addition, multiple
studies do describe the differences in techniques with hysterectomy and SCP. I
would consider rephrasing to say that the data is evolving. 
This study does also
add the additional imaging and this may be worth mentioning here. 
Other studies re: SCP and hysterectomy
Cardenas-Trowers O, Stewart JR, Meriwether KV, Francis SL, Gupta A.
Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route
of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical
Quality Improvement Program Database. J Minim Invasive Gynecol. 2019.
Davidson ERW, Thomas TN, Lampert EJ, Paraiso MFR, Ferrando CA. Route of
hysterectomy during minimally invasive sacrocolpopexy does not affect
postoperative outcomes. International Urogynecology Journal. 2019;30(4):649-
655.
Methods:
1) Line 99: As above, this is actually a cohort study.
2) Lines 103-104: 
As this is a cohort study, define the two cohorts as LSH
(uterine preservation) vs non-uterine preservation (TLH+LSC, LSCH+LSC). 
3) Lines 135-142: Could the authors further elaborate if this is a part of routine
postop care for their practice? I am curious about the cost to patients here. 
I also
recommend defining what clearly what optimal vs suboptimal mesh placement
was -- did they need to meet all these criteria for optimal postoperative mesh
location?
4) For the C point, consider adding a parenthetical explanation of C >/= -TVL/2
cm such as "apical descent less than half of the vaginal length" for those not as
familiar with the POPQ. 
5) Line 147: Consider stating that this was "Very Much" or "Much Better" here.
6) Could the authors comment on anticipated power, even if it is a post-hoc
calculation of power? 
7) Line 150: again, this should be cohort comparisons. 
8) Were the subanalyses planned a priori?
9) While the authors have published their surgical technique, I recommend
briefly reviewing the procedures here, especially where mesh was placed for the
hysteropexy group.
Results:
1) Lines 166-167: I recommend listing the important differences between the
cohorts here.
2) Line 176: "rates" should be incidence.
3) Lines 177-179: Please clarify -- I believe that the authors mean that "When
looking at subgroups, however, operating time was only longer for LSCH vs
TLH+LSC subgroup (p=0.048), not the LSH-LSC group. In addition, TLH
appeared to be associated with increased blood loss compared to the LSH and
LSCH (insert p-values)."
4) Lines 189-190: "Not" instead of "neither". This failure to see significance is
likely due to power with smaller numbers. 
Since the primary outcome was to
look at the two groups, not the subgroups. 
I would leave this in the supplemental
outcomes.
5) Consider putting the mesh details in another paragraph. 
Again, the "optimal
mesh placement" should be defined clearer in the methods.
6) Lines 160-161: Recommend summarizing how many were in each group as
defined by your cohorts and then clarifying how many in each type of hyst.
7) Throughout the results section, recommend putting in the actual values and
not just p-values (especially when significant). Actual difference in blood loss
and OR time is important to see not just in tables. A difference in EBL of 150mL
and OR time of only 15 minutes is very little and likely not clinically relevant.
This really shapes the conclusions.
Discussion: 
1) I recommend stating that this is AMONG the first studies to discuss. You
cited the Iliano study and there are many studies that include the different routes
of hysterectomy (cited above) at time of SCP.
2) Recommend discussion the clinical relevance in the benefits of uterine-
preservation at time of SCP -- worse POP and mesh outcomes and OR "savings"
including EBL and OR time are minimal.
3) Lines 274-277: As above, I do not think that this is the first to report this
comparison. However, it does add the novelty of imaging.
Conclusion:
1) Line 280-281: Consider limiting this to your population or say "many women"
-- this is not universally true.
2) Lines 282-283: Similar to the abstract, this last phrase is not a complete
sentence.
3) Consider, "LSCH+LSC appears to have the best balance between limiting
operative time and blood loss with balancing recurrence."
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes