Reviewer's report 
 Hysterectomy at a Canadian Tertiary Care Facility: Results of a One-Year Retrospective Title: 
Review 
 1  19 April 2004 Version: Date: 
 James B Unger Reviewer: 
Reviewer's report: 
General 
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Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached)1. It would be very helpful if the authors would try to be more clear on what the real 
objective of this study is. Is it as they state in the abstract" to examine the circumstances in which concurrent oophorectomies were performed and to compare abdominal and vaginal hysterectomy outcomes" or is it as they state on page 3 of the paper "to audit all hysterectomies over a one-year 
period at a university teaching hospital to identify areas for improvement". These are very different 
objectives and the entire paper suffers from there not being a clear focus for the paper. 2. Although there is a lot of data presented much of it is incomplete and not really analyzed very well. For example there is no comparison of the indications for surgery between the different hysterectomy 
types. There also needs to be multivariate analysis performed for much of the data. For example, 
Table 5 shows that the hospital stay is longer for the women who had oophorectomy. Does that mean that oophorectomy in and of itself causes a longer hospital stay? That seems very unlikely, and a much more likely explanation is more oophorectomies were performed in the abdominal 
hysterectomy group than in the vaginal hysterectomy group and that is the reason for the longer 
stay. 3. Hysterectomies performed for cancer should be eliminated from this paper since it just muddies the data. 4. If the purpose of the paper is to identify areas for quality improvement, the authors need to identify those areas and critically examine them in detail. For example, the authors 
have identified that the vaginal hysterectomy rate is lower than what may be ideal. But, they have 
done very little to identify why that is other than to say obese women are less likely to have vaginal hsyterectomy. What about preoperative diagnosis/indication for surgery? What about surgeon bias towards one operation or another? Svereal studies have shown that the major determinant of the 
route of hysterectomy is the experience of the surgeon with the vaginal approach. How many 
women undergoing abdominal hysterectomy might have been candidates for the vaginal approach or 
LAVH? For example, was there a particular uterine size above which all women had abdominal 
hysterectomy? How about preoperative diagnosis and its effect on the operative route? How about 
previous cesarean section? How many underwent abdominal hysterectomy purely so the ovaries 
could be removed? These are the kind of issues the authors really need to evaluate if they want to look at quality and ways to improve it. 5. Many of the same sort of issues apply to the question of oophorectomies. How many were done for cancer prophylaxis? How many for adnexal disease? 
Was the route of hysterectomy the major determinant of whether an oophorectomy was peformed? 
What is the policy of the surgeons regarding recommending oophorectomy? Is there a particular age at which it is recommended? What do the authors think is the "correct" rate of oophorectomy? Do 
the authors believe they are removing too many or too few ovaries at their instituion? They never tell 
us. 6. The current manuscript contains information that really would be of interest only to their own 
institution and even then the information is of very limited use. With major revisions and reanalysis of 
the data using correct statisical methods there is some potential that they could generate information 
that would not only be useful to their home institution but may also to a much wider audience. 
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Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
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Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of limited interest Level of interest: 
 Acceptable Quality of written English: 
 Yes Statistical review: 
Declaration of competing interests: 
None