Reviewer’s report
Title: Recurrent apical prolapse after high uterosacral ligament suspension – in a heterogenous cohort  
characterised by a high prevalence of previous pelvic operations.
Version: 1 Date: 07 May 2019
Reviewer: Abraham Morse
Reviewer's report:
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Unfortunately, at this point in the evolution of USLS, this relatively small, retrospective study with  
short clinical follow-up does not contribute new information and runs the risk of providing inaccurate  
and incompletely characterized outcomes to the body of clinical studies on USLS.  I am not in favor of  
publishing it.  
145 ：I am not aware of any system of prolapse documentation referred  to as the "ICS-Q".  I suspect  
that the authors are using the POP-Q system.  The authors need to describe the system of prolapse  
assessment they used and indicate whether or not it is equivalent to the POP-Q.  
185:  Rather than include a few women with primary apical prolapse, I would recommend limiting  
report to cohort with previous surgery.  Exclude the 16%of women with no previous surgery.
 
189:  The authors state that 19% had a stage 2 or greater recurrence at 6 months but over the ensuing 4  
or more years "this number did not increase".  It is extremely unlikely that no other women in the  
cohort developed recurrent prolapse after 6 months.  This suggests very significant selection bias in the  
information gleaned from the chart reviews - notwithstanding the authors suggestion that the patients  
had not other option for their care.  
219:  In the discussion the authors cite recurrence rates from many studies with different subjects (e.g.  
primary vs. recurrent), different  surgeries, different  definitions  of failure  and  different lengths  of  
follow-up.  It is impossible to draw any conclusions by comparing their experience with this very  
heterogeneous group of studies. The authors should remove any inferences based on comparisons of  
their experience with other studies.  There is no reliable basis for comparison.  There cohort is small,  
retrospective and short term.  The validity of the follow up after 6 months is highly questionable.  
306:Due to size of your study, adverse event rates are not reliable enough to try and compare with other  
studies.  I would remove this from the discussion 
357:  Justification for not making data available is weak.  No databank would accept data which  
contained information that identified subjects.  Recommend anonymizing and submitting data.
Are the methods appropriate and well described?
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No
Does the work include the necessary controls?
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Unable to assess
Are the conclusions drawn adequately supported by the data shown?
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No
Are you able to assess any statistics in the manuscript or would you recommend an additional  
statistical review?
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assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
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Acceptable
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