Reviewer ’s report  
 
Title: Lesion distribution characteristics of deep infiltrating endometriosis with ovarian  
endometrioma: An observational clinical study  
 
Version: 0 Date: 27 Jan 2020  
 
Reviewer: Diego Raimondo  
 
Reviewer's report:  
 
The Authors performed a good analysis on a very int eresting topic in endometriosis 
management. However, further details are needed in the Results and Discussion section.  
 
1. The title is clear and accurately reflects the study contents  
 
2. Introduction:  
a. The description of the background is correct.  
b. main objective: what do you mean with "When do OEM patients also develop DIE?". Please 
explain better.  
 
3. Materials and methods:     
a. Study design is well mentioned.  
b. Could you perform a sample size or power analysis calculation?  
c. Population: overa ll seems appropriate. Data about previous surgery for deep endometriosis and 
preoperative medical therapy lack. Please add;   
Why were patients operated on?  
d. Outcomes: well documented; data about ileocecal and appendiceal involvement lack. Please 
add some data about ileoceal and appendiceal endometriosis and discuss with adequate reference 
in the discussion (i.e. Mabrouk M et al. Endometriosis of the Appendi x: When to Predict and 
How to Manage -A Multivariate Analysis of 1935 Endometriosis Cases. J Minim Invasive 
Gynecol. 2020).  
e. Description: well done.  
f. Statistics: Appropriately described  
 
4. Results:  
a. Tables and figures are overall easy to underst and.  
Table  1: what do you mean with "anus bulge"? It is so frequent in your endoemtriotic patients? 
Why?  
Table 2: What do you mean with "Vaginal rectum"?  
b. I. Clarity of results: seems appropriate.  
 
ii. Reported objectives:  deep lesion distribution an d characteristics according to OMA 
presentations.  
 
iii. Clinical interpretability:  Seems appropriate  
5. Discussion:  
a. Clinical relevance: addressed.  
-Please modify the paragraph including lines 166 -171: 
" Some researchers have suggested that urinary tr act endometriosis  may occur more frequently 
than it is currently thought to, particularly in patients with DIE" Urinary tract endometriosis is a 
part of DIE, it is not? Please clarify this sentence.  
 "In this case, when there is an associated OEM, ultraso nic examination of the urogenital system 
is necessary."  
In accordance with previous study (i.e. Raimondo D et al. Severe ureteral endometriosis: 
frequency and risk factors. J Obstet Gynaecol. 2018 Feb;38(2):257 -260) the Authors found an 
association between  the presence of OMA and ureteral involvement by the disease. Please add 
some references.  
" Ureteral endometriosis should be considered when B mode ultrasound reveals ureter straitness 
and hydronephrosis. If the ureters are involved, renal function should be assessed by intravenous 
pyelography". Please modify.  
 We perform renal scintigraphy to evaluate renal function in case of hydronephrosis. Hydroureter 
and hydronephrosis are the severe forms of ureteral endometriosis (Knabben et al., 2015. Urinary 
tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, 
management, and proposal for a new clinical classification); the mild forms can be diagnosed 
also using uroCT or uroMRI and in many cases only during retroperitoneal diss ection .  
 It is better to say "stricture" or "stenosis".  
- Please explain better why monolateral endometrioma are more associated to bowel and vaginal 
endometriosis. Please remove the paragraph including lines 184 -190. It is not in line with the 
study ai m. 
b. Strengths of the study: addressed  
c. Limitations of the study: not addressed. Please add.  
d. Recommendations for further research: not addressed. Please add.  
 
6. Abstract: Seems appropriate  
 
7. Grammar, overall flow, etc comments:  
I suggest to reduce length of discussion.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported  by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please spec ify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please compl ete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of th is 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applyi ng for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is y es to any, please give details below.  
 
no competing interests to declare  
 
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