Title: Clinical and Pelvic Floor Ultrasound Characteristics of Pelvic Organ Prolapse Recurrence
after Transvaginal Mesh Pelvic Reconstruction
Version: 1 Date: 18 Dec 2021
Reviewer:  Hans Peter Dietz
Reviewer's report:
Thanks for letting me referee this manuscript. It’s very interesting and original and deserves
publication. The authors determined risk factors for recurrence in over 100 women after prolapse
surgery with mesh, at a median follow-up of 2.5 years which in my view is optimal. The technical
sophistication of the follow-up is matched by very few other studies in this field.
I've tried to edit the text in order to improve clarity of expression. Editing for remaining issues
of vocabulary, grammar and syntax could be handled at the copy-editing stage. There are many
incorrect articles such as ‘the’ instead of ‘a’.
General comments:
Abstract:
1.) Please include the n=  and mean length of follow-up in your abstract.
2.) The statement ‘The patients with cystocele, enterocele or rectocele diagnosed by PFUS were
selected as case group’ is misleading. I’d say ‘ Patients with prolapse recurrence on postoperative
follow-up…’
Intro:
1.) line 59: I’d remove ‘prolapsed contents’
2.) line 69: The words ‘was observed’ are redundant.
3.) line 70: The word ‘And’ is redundant.
Methods:
1.) line 84: The words ‘or so’ are redundant.
2.) line 85: why not simply say ‘prolapse recurrence in any compartment’?
3.) line 87: better say ‘constituted the control group'.
4.) line 94: better say ‘mild POP’.
5.) line 96: better say ‘as the interval between surgery and first ultrasound showing prolapse
recurrence (cases) and the interval between surgery and last scan (controls).'
6.) line 103: better say ‘midsagittal’
7.) line 108: better say ‘during maximal pelvic floor contraction.’
Results:
1.) line 140: ‘6 were in combination with…’
2.) line 142f: Please change ‘We can observe the anterior vaginal wall meshes and their moving
during Valsalva maneuver’ to Anterior vaginal wall meshes could in all cases be observed, and
mesh movement was recorded on Valsalva.’
3.) line 144: change ‘supposed’ to ‘suspected’.
4.) line 151:  ‘with P < 0.10 in the POP or incontinence surgery history (20.4% vs. 8.3%).’ is
difficult to understand.  I assume you mean ‘while a history of prior POP or incontinence surgery
was also a risk factor (20.4% vs. 8.3%, P < 0.10).'
5.) line 152: The sentence ‘Levator avulsion, HA and POP or incontinence surgery history
entered into Logistic regression analysis. ‘ properly belongs to the next paragraph.
6.) Please tell us how many patients had such surgery during the inclusion period, and how many
of those you were able to see.
Discussion:
1.) line 159: you mean ‘a number of clinical…’
2.) line 165: ‘As the loss of follow-up could be more likely occur in control group patients, these
number cannot reflect the true failure rate of TVM surgery. ‘ I don’t understand. Did you not
invite everybody for follow-up appointments?
3.) line 173: better change ‘increased by 0.202 times’ to ‘increased by 20%.
4.) line 174: ‘The AUC for HA diagnosis of prolapse recurrence’- better say ‘prediction of…’
5.) line 175: You assume that surgery does not change the hiatus. This may not be true and
needs to bed discussed. I suggest you read Andrew B, Shek KL, Chantarasorn V, Dietz HP.
Enlargement of the levator hiatus in female pelvic organ prolapse: cause or effect? ANZJOG
2013; 53: 74–78
6.) line 182 ‘protective’
7.) line 189: ‘As our speculation, it may be attributed to different race, ‘ please change to ‘This
may be due to differences between the populations or due to our smaller sample size, that is,
power issues.'
8.) line 201: ‘In this retrospective study our study, HA is’ better change to ‘In this retrospecyive
study, hiatal area on Valsalva was the only independent risk factor for recurrence at a mean
follow-up length of 2.5 years after TVM prolapse surgery.’
Tables:
I’d suggest changing case group and control group to ‘recurrence’ and ‘no recurrence’
Figure:
Figure 1 is not credible as B could be a sling, and A is rather unusual. And why introduce
a contested concept such as ‘contraction’ here? How do you know this mesh was not folded
from the moment of skin closure? Please find a better, more typical mesh image at rest and
on Valsalva. I’d recommend using the 3 plane methodology given by the IUGA cookbook
or a recent review (Shek KL, Dietz HP. Ultrasound Imaging of Slings and Meshes in
Urogynaecology. Ultrasound Obstet Gynecol. 2021 Apr;57(4):526-538).
Best wishes
HP Dietz
Sydney