Title: Long-term outcomes of transvaginal mesh surgery for pelvic organ prolapse: a
retrospective cohort study
Version: 0 Date: 15 Aug 2021
Reviewer's report:
Dear Editor and Author
Thank you for inviting me to review this paper. Retrospective study of clinical outcomes after
mesh surgery with no comparison to other surgery for prolapse repair. I find the subject is very
important. Although the vaginal mesh has been withdrawn from the market by the US authority
2019 and the Prolift mesh was withdrawn by the company 2011, there are needs for long-term
follow up after vaginal mesh surgery.
I don’t find line number through all the manuscript. However, here is my comments and I refer
to page number instead.
Abstract Page 2
Methods:
- There is no mention of anatomical outcomes, PGI-I score estimation by the POP-Q system,
(clinical examination is not specific).
- You may mention satisfaction scale 0-10 instead of long meaning and missing more important
information about POP-Q and PGI
Results:
- You included 134/247 patients from the period 2005-2010 (6 years)! Do you mean that you
operated 41 patients/year? Or did you select patients?
- Last sentence: “about recurrence”. Do you mean prolapse recurrence? If so, it would be
mentioned or POP-recurrence!
Background Page 3
-
Methods Page 3
- I don’t where the inclusion and exclusion criteria are mentioned.
- Did you included all patients operated at your hospital 247 (rate 41/year)? or did you select?
Is there is a bias of selection and why?
- Did you used the patient journal system or which system did you use to collect information
from 2005….? This should be mentioned!
- Page 4 line 1 “, and et al,”: probably something is missing!
- Try to describe surgeons and procedure in a more standard manner.
- Did some of surgeries done were hysterectomy + mesh? Or not i.e., only mesh surgery?
- Line 10 (surgical procedure): there is no description how many operated by Prolift Anterior or
Prolift Posterior. There is also lack of description if you used Gynemesh for anterior or posterior
wall? This may have very important information of possible complications,  ….
- Who examined the patients preoperative and at the follow-ups!
- Describe and explain the POP-Q system for estimation of anatomical outcomes with reference.
- Describe your single center! Is it a high-volume or low-volume surgery center?
- Page 5 line 5-7 satisfaction scale: you don’t have reference of validation of the satisfaction
scale! Please, insert a reference validating the satisfaction scale.
- Statistical analysis last sentence (page 5): you should mention the year of the SPSS version
used.
Results
- Page 6 Line 14: “We stratified the types of mesh based on the period of following-up.” What
do you mean? Did you used stratified analysis? Which type? Which variables you stratified and
why? Please explain?
- Surgery related complications: how could you catch this information? Can you illustrate direct
surgery related complications? Late complications (within 2 months after surgery)?
Discussion
- Page 7 Line 8-10: “Due to that there was rare publications about the outcomes of very long-
term follow-up, this phenomenon might be owing to the more lost to follow-up, or the formation
of peritonization leading to continuous mechanical support. With the longer-term follow up and
more similar publications, we should gain the more outcomes of mesh repairing for POP.” I
don’t understand what do you mean? I may suggest you discuss important aspects; long-term
follow up of safety/effectiveness and the decision of forbidding the vaginal mesh.
- Also in discussion part, you should mention somewhere that one the mesh used does not exist
anymore.
- It is important to indicate that Prolift was the first-generation mesh. The most studied last
generation mesh (Uphold light) does not exist since FDA decision. It is important to mention
and discuss about.
- References: you miss to refer to very important publications in the literature e.g. (Altman D,
Falconer C, Allgre.)
- Page 8 Line 14 “the first study to compare different mesh repair surgery for POP with very
long-term follow-up” I advise you not to use such terms: first, very, …
Conclusion
- “At very long-term follow up,” I advise you not to use such term (very, first …)
- It is important here in conclusion to mention if complications were minor or major! Otherwise,
it looks to be unconfident for readers not used for such surgery field to understand.
Ethics declarations
- Is the study registered at www.clinicaltrials.gov or not?
References
- You miss important references like:
Altman D, Väyrynen T, Ellström Engh M, Axelsen S, and Falconer C. for the Nordic
Transvaginal Mesh Group*. Anterior Colporrhaphy versus Transvaginal Mesh for Pelvic-Organ
Prolapse. N Engl J Med 2011; 364:1826-1836.
Gillor M, Langer S, Dietz HP (2019) A long-term comparative study of Uphold™
transvaginal mesh kit against anterior colporrhaphy. Int Urogynecol J  https://doi: 10.1007/
s00192-019-04106-5
Altman D, Falconer C (2007) Perioperative morbidity using transvaginal mesh in pelvic organ
prolapse repair. Obstet Gynecol 109(2):303-308
Table1
- Previous hysterectomy n=6 (3+3). Preserved Uterine? =19 (16+13). What does this mean?
What about the rest of patients?
- I think it is important here to show all complications in a new table!
Table 2
- 5 years n=116, 10 years n=82. There is a big drop in number of patients!
- Repeated POP surgery about 9 patients i.e., very low rate! However, the rate of repeated POP
surgery is higher in other publications in the literature. How can you explain that? How could
you catch this information? Did you used patient journal system or asked patients? You may
need to explain.
Just a comment that a language control may be needed.
Lastly, I think that you have good materials for an important study subject, but you should do
requested changes to improve your manuscript.