Title: Learning Curve Analysis of Transvaginal Natural Orifice Transluminal Endoscopic
Surgery in Treating Ovarian Cysts: A Retrospective Cohort Study
Version: 1 Date: 12 May 2024
Reviewer's report:
In the present paper, the authors tried to report their learning curve analysis of transvaginal
natural orifice transluminal endoscopic surgery in treating ovarian cysts. The manuscript is well-
written. I do however see some crucial problems.
Background:
1. Line 91-92, there are 20% of postmenopausal women suffering from ovarian tumors. Is the
incidence too high?
2. Line 96, please clarify the adverse outcomes other than rupture.
3. Line 102, please provides the reference of 1st report of vOTES for ovarian cyst surgery in
2012.
4. Relevant papers have been published in the literature. The author should explain or describe
why we need this study. Is it to supplement the shortcomings of previous research?
Methods:
1. The youngest surgeon in this study has 10 years of working experience and conducted more
than 200 cases of TU-LESS, so the surgeons in this study should be considered as skilled hands.
It is unreasonable for the authors to make such a distinction.
2. Line 152, please clarify "shows preference for vNOTES over other surgical options".
3. Line 155 &156, since rectovaginal endometriosis and severe pelvic adhesion have been
excluded, why chocolate cystectomy and cases with relatively severe pelvic adhesion were
enrolled in this study.
4. Line 162 &163, should general anesthesia first then follow by positioning.
5. Line 167-173, The figure provided by the author is Figure 1, not the supplementary figure.
The order of Figures later in the article must be revised accordingly.
6. Line 174, about the retractor and surgical platform, please provide the names and
manufacturers.
7. Line 187 & 191, please provide the name, size, manufacturer of the sutured material.
Results:
1. Table 1 & table 2 can merge into one table
2. Table 3 can be deleted
3. Table 4, please compare endometriotic tumor and non-endometriotic tumors. But, the
endometriotic tumor was supposed not to exist in this study.
4. Surgeons in this study are all experienced hands. Therefore, influencing factors can only
be considered as individual differences rather than experiences. All results need to be revised
accordingly.
Discussions:
1. Line 345, vNOTES through posterior colpotomy should rarely cause urinary bladder injury.
2. Line 395, reference 11 discusses nephrectomy, the author quoted it incorrectly.
3. I agree with the author's opinions that vNOTES ovarian surgery is less difficult than vNOTES
hysterectomy, and inexperienced surgeon can be able to do it after learning. However, the
surgeons in this study are all experienced hands, so the discussion in this study about whether
experience will affect the learning curve should be revised.
4. Endometriomas are often combined with other pelvic diseases, such as pelvic adhesion,
fallopian tubal obstruction, and infertility. Therefore, the purpose of surgery for endometriosis
is not only to remove the tumor (endometrioma), but also to fix associated disorders. In order
to achieve the purpose of enhancing nature conception after surgery. vNOTES surgery may be
difficult to achieve the above goals, that is why endometrioma is excluded by published study.
Overall:
1. The author should pay attention to inclusion and exclusion criteria. Don't contradict each other
2. Surgeons in this study are all experienced hands and the results should be revised accordingly.
3. The tables need to be revised.
4. Of course, the Abstract will also need to be revised accordingly.