Reviewer’s report
Title: Recurrent apical prolapse after high uterosacral ligament suspension – in a heterogenous cohort  
characterised by a high prevalence of previous pelvic operations.
Version: 0 Date: 26 Mar 2019
Reviewer: Maria Bortolini
Reviewer's report:
The manuscript entitled "Rate of recurrent apical prolapse after high uterosacral ligament suspension"  
by Pedersen et al presents a retrospective descriptive analysis of the outcomes of the HUSLS technique  
performed  in  a  cohort  of  95  women  with  apical  prolapse  regarding  mainly  to  recurrence  and  
reoperation rates at 6-month follow-up.
The authors based primarily on the publication of Shull et al (2000) to compare and discuss their  
results, but also on other relevant literature of high quality scientific content.
This reviewer concerns about important limitations of the paper of the study: small sample size, short-
term follow-up, retrospective chart review methodology (even though the authors acknowledged those  
in the text). Those limitations obviously influence the scientific quality of the study. On the other hand,  
the  population  studied  seems  of  a  high  risk  for  recurrence  (previous  hysterectomy,  previous  
reconstructive surgeries, advanced POP), which reflects the high rates of POP recurrence in the short-
term and reoperation of the different compartments. Perhaps the important end message to the readers  
is that HUSLS might not be the best option to that population.
1-Can the authors clarify if the procedures were performed by trainees (fellows or residents); Is it  
a teaching hospital? Can that have influenced the results?
2-Could  the  authors  discuss  about  the  role  of  HUSLS  for  apical  prolapse  after  previous  
hysterectomy? Were they able to easily identify USL on those cases?
3-Could the authors discuss about the role of HUSLS for apical prolapse overall? What would be  
the ideal patient for this procedure? Who should we avoid this?
4-Stage 2 apical POP was predominant preoperatively (71%): can the authors mention how many  
presented prolapse beyond the hymen? We know that stage 2 ranges from -1 to +1 (POP-Q) and  
patients usually are symptomatic when POP is beyond the level of the hymen or outside the  
vagina. Also, this stratification may affect the interpretation of the results and conclusion.
5-The authors should list the concomitant procedures performed with HUSLS: anterior repair?  
Posterior  repair?  Hysterectomy?  Those  information  also  might  be  confronted  with  the  
recurrence of anterior and posterior prolapse and reoperation of multiple compartments as  
potential cofounder variables.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
No
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you recommend an additional  
statistical review?
If  an  additional  statistical  review  is  recommended,  please  specify  what  aspects  require  further  
assessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
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