Title: Effect of incision location and type of fistula on postoperative urinary retention after
radical surgery for anal fistula: A retrospective analysis
Version: 2 Date: 08 May 2024
Reviewer's report:
Dear Authors,
Thank you for providing this very well written study.
Hereinafter, I will list areas of your work which I deem in need of amendment
Methods:
Please state whether patients were advised to urinate prior to accessing the OR, or if their
bladders were drained prior to starting the surgery with an intermittent catheterisation. Did you
perform any type of assessment of bladder fullness prior to starting your surgeries?
Is a post-void residual routinely measured at your department prior to discharge to these patients?
Please also state the amount of urine drained by catheter in each patient experiencing acute
urinary retention (AUR).
"Urological disease" is a loose definition, too broad to clearly assess potential relationships to
AUR. For instance, a history of kidney cancer cannot be related to AUR, while benign prostatic
hypertrophy in males or pelvic organ prolapse in females can. Please list all the conditions you
have included under "Urological diseases" in a supplementary table.
Discussion:
Mechanistic analysis and management strategies: this is a very long paragraph, in which several
concepts are repeated throughout, I warmly suggest to revise it and synthesise it to improve flow
of text and comprehension.
The main causative mechanism for AUR in your cohort should be identified in excessive bladder
filling leading and detrusor muscle over-stretching, in turn leading to subsequent inefficient
voiding. Operative time and intraoperative fluid volume are the main parameters associated
to this. While the complexity of surgery and number of incisions have also been found to be
significant, these could possibly be due to the fact that these other parameters all concur to
increasing the length of surgery. Please comment on this. I praise your for underscoring the
importance of injuries to the local nervous plexus as a concurrent causative mechanism for AUR.
"Multivariate logistic stepwise regression analysis revealed that patients with a history of
urological diseases had a 6.048-fold greater incidence of POUR than did those without, patients
with incisions at position 1 had a 2.228-fold greater incidence of POUR than did those without
incisions at position 1, patients with high anal fistula had a 4.768-fold greater incidence of POUR
than did those with low anal fistula, patients with VAS scores # 7 had a 2.805-fold greater
incidence of POUR than did those with scores < 7, and patients with GAD-7 scores # 5 had a
2.405-fold greater incidence of POUR than did those with scores < 5. " This is a highly repetitive
paragraph, please synthesise it significantly as it is not appropriate to recall so many results in
the discussion.
"For patients with urological diseases, postoperative monitoring of bladder capacity is
recommended, and if necessary, oral administration of alpha-adrenergic antagonists such as
tamsulosin can be considered to prevent POUR [34]. " This is a divisive idea, and please be ware
that alpha-blockers prescription for AUR is off-label in  females. I would advise to change this
phrase to state that bladder capacity monitoring is recommended and if necessary, Urological
consultation should be sought.
"moreover, the study did not account for women's greater acceptance of catheterization, which
may have affected the study findings". This statement must be explained, how many males did
refuse catheter placement in your cohort? On which data do you base this statement? Please
comment in text.
"No effects of sex, age, surgery duration, or intraoperative fluid volume on the occurrence of
POUR were observed". Indeed, you did observe such effects. Please change this statement.
"the incidence of POUR and avoid persistent bladder overdistension from POUR, which can
cause irreversible damage to the patient, providing patients with a faster postoperative recovery
and increased satisfaction with the procedure.". Irreversible is an exaggeration, acute kidney
injuries with irreversible loss of renal function +/- sepsis and death may be anecdotal in a cohort
of inpatients being monitored after surgery. AUR can be bothersome for the patients, it increases
length of stay, may require catheter placement and further testing, it could rarely be dangerous
for the patients if not promptly managed. Please amend the text.
Kind Regards
Title: Effect of incision location and type of fistula on postoperative urinary retention after
radical surgery for anal fistula: A retrospective analysis
Version: 2 Date: 08 May 2024
Reviewer's report:
Dear Authors,
Thank you for providing this very well written study.
Hereinafter, I will list areas of your work which I deem in need of amendment
Methods:
Please state whether patients were advised to urinate prior to accessing the OR, or if their
bladders were drained prior to starting the surgery with an intermittent catheterisation. Did you
perform any type of assessment of bladder fullness prior to starting your surgeries?
Is a post-void residual routinely measured at your department prior to discharge to these patients?
Please also state the amount of urine drained by catheter in each patient experiencing acute
urinary retention (AUR).
"Urological disease" is a loose definition, too broad to clearly assess potential relationships to
AUR. For instance, a history of kidney cancer cannot be related to AUR, while benign prostatic
hypertrophy in males or pelvic organ prolapse in females can. Please list all the conditions you
have included under "Urological diseases" in a supplementary table.
Discussion:
Mechanistic analysis and management strategies: this is a very long paragraph, in which several
concepts are repeated throughout, I warmly suggest to revise it and synthesise it to improve flow
of text and comprehension.
The main causative mechanism for AUR in your cohort should be identified in excessive bladder
filling leading and detrusor muscle over-stretching, in turn leading to subsequent inefficient
voiding. Operative time and intraoperative fluid volume are the main parameters associated
to this. While the complexity of surgery and number of incisions have also been found to be
significant, these could possibly be due to the fact that these other parameters all concur to
increasing the length of surgery. Please comment on this. I praise your for underscoring the
importance of injuries to the local nervous plexus as a concurrent causative mechanism for AUR.
"Multivariate logistic stepwise regression analysis revealed that patients with a history of
urological diseases had a 6.048-fold greater incidence of POUR than did those without, patients
with incisions at position 1 had a 2.228-fold greater incidence of POUR than did those without
incisions at position 1, patients with high anal fistula had a 4.768-fold greater incidence of POUR
than did those with low anal fistula, patients with VAS scores # 7 had a 2.805-fold greater
incidence of POUR than did those with scores < 7, and patients with GAD-7 scores # 5 had a
2.405-fold greater incidence of POUR than did those with scores < 5. " This is a highly repetitive
paragraph, please synthesise it significantly as it is not appropriate to recall so many results in
the discussion.
"For patients with urological diseases, postoperative monitoring of bladder capacity is
recommended, and if necessary, oral administration of alpha-adrenergic antagonists such as
tamsulosin can be considered to prevent POUR [34]. " This is a divisive idea, and please be ware
that alpha-blockers prescription for AUR is off-label in  females. I would advise to change this
phrase to state that bladder capacity monitoring is recommended and if necessary, Urological
consultation should be sought.
"moreover, the study did not account for women's greater acceptance of catheterization, which
may have affected the study findings". This statement must be explained, how many males did
refuse catheter placement in your cohort? On which data do you base this statement? Please
comment in text.
"No effects of sex, age, surgery duration, or intraoperative fluid volume on the occurrence of
POUR were observed". Indeed, you did observe such effects. Please change this statement.
"the incidence of POUR and avoid persistent bladder overdistension from POUR, which can
cause irreversible damage to the patient, providing patients with a faster postoperative recovery
and increased satisfaction with the procedure.". Irreversible is an exaggeration, acute kidney
injuries with irreversible loss of renal function +/- sepsis and death may be anecdotal in a cohort
of inpatients being monitored after surgery. AUR can be bothersome for the patients, it increases
length of stay, may require catheter placement and further testing, it could rarely be dangerous
for the patients if not promptly managed. Please amend the text.
Kind Regards
Please review this paper.
user
Title: Effect of incision location and type of fistula on postoperative urinary retention after
radical surgery for anal fistula: A retrospective analysis
Version: 2 Date: 08 May 2024
Reviewer's report:
Dear Authors,
Thank you for providing this very well written study.
Hereinafter, I will list areas of your work which I deem in need of amendment
Methods:
Please state whether patients were advised to urinate prior to accessing the OR, or if their
bladders were drained prior to starting the surgery with an intermittent catheterisation. Did you
perform any type of assessment of bladder fullness prior to starting your surgeries?
Is a post-void residual routinely measured at your department prior to discharge to these patients?
Please also state the amount of urine drained by catheter in each patient experiencing acute
urinary retention (AUR).
"Urological disease" is a loose definition, too broad to clearly assess potential relationships to
AUR. For instance, a history of kidney cancer cannot be related to AUR, while benign prostatic
hypertrophy in males or pelvic organ prolapse in females can. Please list all the conditions you
have included under "Urological diseases" in a supplementary table.
Discussion:
Mechanistic analysis and management strategies: this is a very long paragraph, in which several
concepts are repeated throughout, I warmly suggest to revise it and synthesise it to improve flow
of text and comprehension.
The main causative mechanism for AUR in your cohort should be identified in excessive bladder
filling leading and detrusor muscle over-stretching, in turn leading to subsequent inefficient
voiding. Operative time and intraoperative fluid volume are the main parameters associated
to this. While the complexity of surgery and number of incisions have also been found to be
significant, these could possibly be due to the fact that these other parameters all concur to
increasing the length of surgery. Please comment on this. I praise your for underscoring the
importance of injuries to the local nervous plexus as a concurrent causative mechanism for AUR.
"Multivariate logistic stepwise regression analysis revealed that patients with a history of
urological diseases had a 6.048-fold greater incidence of POUR than did those without, patients
with incisions at position 1 had a 2.228-fold greater incidence of POUR than did those without
incisions at position 1, patients with high anal fistula had a 4.768-fold greater incidence of POUR
than did those with low anal fistula, patients with VAS scores # 7 had a 2.805-fold greater
incidence of POUR than did those with scores < 7, and patients with GAD-7 scores # 5 had a
2.405-fold greater incidence of POUR than did those with scores < 5. " This is a highly repetitive
paragraph, please synthesise it significantly as it is not appropriate to recall so many results in
the discussion.
"For patients with urological diseases, postoperative monitoring of bladder capacity is
recommended, and if necessary, oral administration of alpha-adrenergic antagonists such as
tamsulosin can be considered to prevent POUR [34]. " This is a divisive idea, and please be ware
that alpha-blockers prescription for AUR is off-label in  females. I would advise to change this
phrase to state that bladder capacity monitoring is recommended and if necessary, Urological
consultation should be sought.
"moreover, the study did not account for women's greater acceptance of catheterization, which
may have affected the study findings". This statement must be explained, how many males did
refuse catheter placement in your cohort? On which data do you base this statement? Please
comment in text.
"No effects of sex, age, surgery duration, or intraoperative fluid volume on the occurrence of
POUR were observed". Indeed, you did observe such effects. Please change this statement.
"the incidence of POUR and avoid persistent bladder overdistension from POUR, which can
cause irreversible damage to the patient, providing patients with a faster postoperative recovery
and increased satisfaction with the procedure.". Irreversible is an exaggeration, acute kidney
injuries with irreversible loss of renal function +/- sepsis and death may be anecdotal in a cohort
of inpatients being monitored after surgery. AUR can be bothersome for the patients, it increases
length of stay, may require catheter placement and further testing, it could rarely be dangerous
for the patients if not promptly managed. Please amend the text.
Kind Regards
assistant