Title: Fast track sacrospinous ligament fixation. Subjective and objective outcomes at six
months.
Version: 3 Date: 11 Jan 2021
Reviewer:  Omima T Taha
Reviewer's report:
Abstract:
Line 32: No need to mention the character of the studied population in the background
subheading of the abstract.
Line 35: change "is" to "was", "follow- up" to " cohort"
Line 37: " Preoperatively and six months postoperatively, objective signs of prolapse were
assessed by gynecological examination". This sentence needs rearrangement.
Line 64: keywords should be separated by semicolons and arranged in an alphabetic order.
Background:
Line 82: repeated "for" needs correction.
Line 91: "of with" needs correction.
Line 92: should not be mentioned in the introduction. Mention in the methods section.
Methods:
Line 95: use the past tense.
No inclusion and exclusion criteria
The questionnaires should be translated and validated to the native language of your country.
Questionnaires should be explained in details and referenced.
ICIQ-Vaginal Symptoms, which form was used
Line 127: Sexual Questionnaire-IR (PISQ-IR) is not written in complete. Pelvic Organ Prolapse/
Urinary Incontinence Sexual Questionnaire (PISQ-12) is the correct name. Besides, I couldn't
find the translated validated form into Danish. For women who are SA, it contains 21 items
covering six domains: arousal/orgasm, partner related, condition specific, global quality rating,
condition impact, and desire. For women who are not SA, it contains 12 items covering four
domains: condition specific, partner related, global quality, and condition impact. Each domain
receives a separate score. This was not shown in the results.
Operative technique: description of the method used for sterilization and disinfection was not
provided. Given the fact that the operation was performed in the outpatient setting and the
incision was long as well as the duration of the procedure, this is of paramount importance.
Methods are very deficient. Additional procedure performed in the same setting should be
mentioned.
How was the sample size calculated?
Line 107: the external urethral meatus should be used rather than the external ostium of the
urethra.
Results:
Table 1: is deficient. The nature of the employment is necessary. Labor work and heavy weight
lifting contributes significantly to the occurrence of POP as well as its recurrence after repair.
Previous POP surgery needs to be clarified (which compartment was operated upon).  The
menopausal state of the recruited patients needs to be mentioned.
Table 2: the points of the POP- Q system need to be illustrated in the methods sections.
Table 3: the p value should be presented using point decimal not comma. The tables should be
clear a self- explanatory.  The 20 items of the pelvic floor distress inventory 20 are not presented
in the table. The preoperative and postoperative scores are not presented. Refer to M. D. Barber,
M. D. Walters, R. C. Bump, Short forms of two condition-specific quality-of-life questionnaires
for women with pelvic floor disorders (PFDI-20 and PFIQ-7). American Journal of Obstetrics
and Gynecology (2005)193, 103–13
ICIQ-Vaginal Symptoms, the whole items of this questionnaire are not presented as well as the
scoring system.
Table 4: it should be presented in figures. This illustration should be mentioned in the results
section. Additional procedures should be mentioned in the results. Why patients had urinary
retention? It is uncommon to have urinary retention after SSLF alone.
Line 138: you can mention women with vault prolapse rather than " women had previous been
hysterectomized".
Lines 139- 140: "One woman did not attend the clinical examination at 6-months follow-up and
one woman did not answer the questionnaires". This means that you have another 2 patients lost
from the final analysis, leaving only 101 patients for the final analysis.
Line 141: you mentioned that 18 women had stage 1 prolapse while you mentioned that you
recruited women with stage 2 or more in the methods??
Lines 141- 142: the total number of the mentioned patients is 107 while you mentioned that
only 103 patients completed the study. The analysis should include the patients who completed
the study only.
Line 151: the number 102 represents what? This needs clarification in the results section.
Besides, 77 patients had prolapse less than grade 2 while 18 were recruited with a prolapse of
grade 1. This is a source of bias in the results.
Line 155: why only 24 women were offered a second operation for recurrent prolapse? What
was the management option for the remaining one?
Line 167: the number 100 represents what? Besides, the number of the sexually active women
is small compared to the study population. Either to recruit only sexually active women or at
least more than 50% of them to be sexually active. This is a major limitation of the results.
Line 169: sexually should be replaced by sexual
Line 171: "(64/84) reported improvement" this means that the questionnaire was not answered
by all the patients. This needs to be clarified regarding each questionnaire. Especially you
mentioned that only 1 patient did not answer the questionnaires.
You need regression analysis to detect significant factors contributing to recurrent POP.
Discussion:
Line 183- 185: you mentioned that the recruited women had previous surgeries for prolapse
however this was not mentioned in the methods. The type of surgery, duration of surgery, time
to recurrent prolapse after the antecedent surgery need to be mentioned. Besides, was the whole
population with history of previous prolapse surgery or not.
Line 190: you mentioned that the use of suture recapturing device avoids wide dissection of the
paravaginal space. Why did you performed a long vaginal incision " The vaginal mucosa was
opened in the midline of either the anterior or the posterior vaginal wall from the vault/cervix
to 2 cm from the external ostium of urethra or in the posterior vaginal wall to the hymen" as
mentioned in the methods.
Lines 189- 194: should be mentioned in the methods not in the discussion.
Lines 196- 201: it would be reasonable to compare the fast track technique with the traditional
SSLF in your population. This means to recruit a group who had had SSLF with the traditional
group.
Lines 214- 216: again, the nature of the previous surgery should be clarified. This would not
be applicable to justify the high recurrence rate in your population especially with 43% of your
population had previous POP surgery.  This is a small number to get conclusive results. Besides,
the suture material should not be the only cause of the increased recurrence rates of SSLF.
Why did you use absorbable suture in patients with previous POP surgery while non- absorbable
sutures are recommended in this group of patients.
Line 217: The association between the suture material and persisting buttock pain need proper
review of the literature.
Line 227: "previous" should be replaced by "previously"
Lines 220- 229: compare the results with those obtained after SSLF rather than ULS. Besides,
the high rates of anterior compartment prolapse should be justified. Also, whether it is recurrent
or denovo anterior compartment prolapse should be clarified.
Line 233: repeated "that" needs correction.
Lines 235- 237: again, the nature of the previous surgery should be clarified. This would not be
applicable to justify the high recurrence rate in your population. Besides, the suture material has
no role in the recurrence rates of SSLF
Line 253: there is a typo error in this sentence.
Line 262: the occurrence of urinary retention needs to be explained.
Lines 266- 267: although the infection rates were low, it was grave. One patient developed
sepsis. This needs to be explained in comparison to previous researches.
Lines 269- 274: use the past tense. The study has some limitations not just the sample size and
short follow up period.
The whole manuscript needs English revision.