Comparison of Prognosis between Minimally Invasive and Abdominal Radical Hysterectomy for Patients with Early-Stage Cervical Cancer

Round 1

Reviewer 1 Report

Overall very appropriate representation of the work and description of the validity and use of the data presented. The author's very appropriately identified the limitations of this otherwise very valuable work and did not try to draw conclusions beyond the scope of the paper. Given that one of the conclusions that was found related to the surgical technique of vaginal closure, I would recommend elaborating in the methods the approach to vaginal closure - things that would be of interest would be: 1. was the colpotomy made under active insufflation 2. Was the colpotomy made vaginally or from the laparoscopic route. 3. Was the vaginal vault closed vaginally (without insufflation), or with the robotic cases was it closed via the robot. Specifics to the procedure will help others in the future emulate these potentially harm reducing measures.

Minor typos to be corrected below. Otherwise excellent.

Line 213 – typo- please reword “because MIS had been increasing for their minimal invasiveness in the last decade “

Line 275 – correct “forth” meant to read “fourth”

 

In a perfect world a logistic regression analysis to attempt to statistically correct for the differences in the groups in tumour size, duration of follow up, stromal invasion, histology, stage on 3 year PFS would be very helpful (but this would be nice to have, but not need to have given the discussion of limitations). 

Author Response

We appreciate the time and effort of the editor and referees in reviewing our manuscript. We have addressed all the issues indicated in the review report and hope that the revised version meets the journal’s requirements for publication.

Response to Comments from Reviewer 1:

Comment 1:

Overall very appropriate representation of the work and description of the validity and use of the data presented. The author's very appropriately identified the limitations of this otherwise very valuable work and did not try to draw conclusions beyond the scope of the paper. Given that one of the conclusions that was found related to the surgical technique of vaginal closure, I would recommend elaborating in the methods the approach to vaginal closure - things that would be of interest would be: 1. was the colpotomy made under active insufflation 2. Was the colpotomy made vaginally or from the laparoscopic route. 3. Was the vaginal vault closed vaginally (without insufflation), or with the robotic cases was it closed via the robot. Specifics to the procedure will help others in the future emulate these potentially harm reducing measures.

Response:

Vaginal closure was performed transvaginally, without insufflation. Colpotomy and closure of the vaginal vault were performed under insufflation using a laparoscope or robot. According to your suggestions, we have added the procedures for vaginal closure along with the figures. (page 3, line 86-99)

Comment 2:

Minor typos to be corrected below. Otherwise excellent.

Line 213 – typo- please reword “because MIS had been increasing for their minimal invasiveness in the last decade “

Line 275 – correct “forth” meant to read “fourth”

 Response:

We apologize for our typos. We have revised them. (page 9, line 243-247; page 10, line 309)

Comment 3:

In a perfect world, a logistic regression analysis to attempt to statistically correct for the differences in the groups in tumour size, duration of follow up, stromal invasion, histology, stage on 3 year PFS would be very helpful (but this would be nice to have, but not need to have given the discussion of limitations). 

 Response:

We performed a logistic regression analysis as you mentioned; however, the parameters, including the relative risk and odds ratio, were not calculated because of the small sample size. We then performed a propensity score-matching analysis. The results are presented in the “Results” section. (page 8, line 225-236, figure 7)

Author Response File: Author Response.docx

Reviewer 2 Report

Dear authors, In this study titled “ Comparison of prognosis between minimally invasive (MIS) and abdominal radical hysterectomy (ARH) for patients with early stage cervical cancer”, the authors aimed to evaluate the prognosis of patients who underwent MIS with vaginal closure vs ARH. I strongly recommend to be assessed by native translator assistant. In line 43 it is said “long term follow-up”; however, interquartile range of follow-up in MIS group is 36 months. I do not consider 36 months as “long follow-up”. Besides, the number of patients at risk in each period of time in Figure 3 and Figure 4 should be shown. Line 58: “FIGO staging 2008”. The past edition of FIGO staging for cervical cancer was 2009. In addition, the authors used numeric staging as “1A2, 1B1, or 2A1“. Those should be replaced by IA2, IB1 or IIA1. The authors should explain in detail, how the vaginal closure was performed. Was at the beginning of the surgery by vaginal approach? Was prior to colpotomy with some device…?? The main limitation of this study is that both groups (MIS vs ARH) are not comparable. In Table 1 patients in MIS group had: higher rates of IIA1 stage, higher rates of adenocarcinoma histology, lower tumor size, lower deep stromal invasion, higher rates of conization, and a 30% higher rate of adjuvant treatment. This study requires a propensity score match analysis in order to make both groups homogenous and comparable. Otherwise, results of this study can not be take into consideration and this conclusion wrote in line 282: “MIS with vaginal closure did not have a poorer prognosis than ARH”; cannot be deduced. Thank you

Author Response

We appreciate the time and effort of the editor and referees in reviewing our manuscript. We have addressed all the issues indicated in the review report and hope that the revised version meets the journal’s requirements for publication.

Response to Comments from Reviewer 2:

Comment 1:

Dear authors, In this study titled “Comparison of prognosis between minimally invasive (MIS) and abdominal radical hysterectomy (ARH) for patients with early stage cervical cancer”, the authors aimed to evaluate the prognosis of patients who underwent MIS with vaginal closure vs ARH. I strongly recommend to be assessed by native translator assistant.

 Response:

The manuscript was assessed by a native translator assistant prior to submission. As you mentioned, we have reordered the English correction.

Comment 2:

In line 43 it is said “long term follow-up”; however, interquartile range of follow-up in MIS group is 36 months. I do not consider 36 months as “long follow-up”. Besides, the number of patients at risk in each period of time in Figure 3 and Figure 4 should be shown.

 Response:

According to your suggestions, we deleted “long-term”. (page 1, line 17 and 43)

We also added the number of patients at risk in the figures as you mentioned. (Figure 4-7)

Comment 3:

Line 58: “FIGO staging 2008”. The past edition of FIGO staging for cervical cancer was 2009. In addition, the authors used numeric staging as “1A2, 1B1, or 2A1“. Those should be replaced by IA2, IB1 or IIA1.

 Response:

According to your suggestions, we revised them. (page 2, line 59)

Comment 4:

The authors should explain in detail how the vaginal closure was performed. Was at the beginning of the surgery by vaginal approach? Was prior to colpotomy with some device…??

 Response:

Vaginal closure was performed vaginally after the uterine ligaments were cut. Colpotomy was performed with a laparoscope or robot under active insufflation using monopolar scissors. Based on your suggestion, we have added the procedure for vaginal closure. (page 3, line 86-99)

Comment 5:

The main limitation of this study is that both groups (MIS vs ARH) are not comparable. In Table 1 patients in MIS group had: higher rates of IIA1 stage, higher rates of adenocarcinoma histology, lower tumor size, lower deep stromal invasion, higher rates of conization, and a 30% higher rate of adjuvant treatment. This study requires a propensity score match analysis in order to make both groups homogenous and comparable. Otherwise, results of this study can not be take into consideration and this conclusion wrote in line 282: “MIS with vaginal closure did not have a poorer prognosis than ARH”; cannot be deduced.

 Response:

Based on your suggestions, we performed a propensity score-matching analysis. We have added the figures for PFS and OS after the analysis. 8page 8, line 225-236, figure 7)

 

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Dear authors,

After major revisions, this article has improved statistically. The authors performed a propensity score, as a result: 43 v 43 patients were compared. Characteristics os these 43 and 43 patients shuld be shown as a descriptive table in the main text.

Finally, I would recomment to not be so emphatic in their conclusions: line 395  "did not have a poorer prognosis". Due to retrospective nature of this study, verbs like "did not show, might have..." are preferable. 

 

Thank you

Author Response

We appreciate the time and effort of the editor and referees in reviewing our manuscript. We have addressed all the issues indicated in the review report and hope that the revised version meets the journal’s requirements for publication.

 

Response to Comments from Reviewer 1:

Comment 1:

After major revisions, this article has improved statistically. The authors performed a propensity score, as a result: 43 v 43 patients were compared. Characteristics os these 43 and 43 patients shuld be shown as a descriptive table in the main text.

 

Response:

According to your suggestion, we added the table for characteristics of patients after propensity score-matching. (page 8, table 4)

 

Comment 2:

Finally, I would recomment to not be so emphatic in their conclusions: line 395  "did not have a poorer prognosis". Due to retrospective nature of this study, verbs like "did not show, might have..." are preferable. 

 

Response:

According to your suggestion, we revised the sentences in conclusions. (page 11, line 315)

Author Response File: Author Response.docx