Urinary Diversion Can Improve the Chance of Implementing New Therapeutic Lines in Patients with Malignant Ureteral Obstruction: A Multicenter Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The topic is interesting and not well explored in literature. Therefore the manuscript is of interest. In some points is a bit confused and need improvement. However, the series is of good size. 

- Introduction is really too short. You are speaking about different type of cancers and potential therapies.. 15 lines are not enough to introduce the topic and the aim of the study. Please expand it.

- In methods, please define "urinary diversion". Nephrostomy and double J? or you also evaluated ureterocutaneostomy and others?

- Similarly, methods must be implemented. I.e. how have you evaluated the different cancers? TNM? and complications? Follow up? Please expand the methods? Antibiotic prophilaxis for the procedure (i.e. cite the EAU guidelines if you followed the standard recommended prophylaxis: Kranz J, Bartoletti R, Bruyère F, et al. European Association of Urology Guidelines on Urological Infections: Summary of the 2024 Guidelines. Eur Urol. 2024 Jul;86(1):27-41. doi: 10.1016/j.eururo.2024.03.035. Epub 2024 May 6. PMID: 38714379. )

- limitations are much more: different cancers and conditions evaluated; different centers means different diagnostics methods and surgeons, etc.

Author Response

The topic is interesting and not well explored in literature. Therefore the manuscript is of interest. In some points is a bit confused and need improvement. However, the series is of good size. 

RESPONSE: thank you. We believe it so as well.

• Introduction is really too short. You are speaking about different type of cancers and potential therapies.. 15 lines are not enough to introduce the topic and the aim of the study. Please expand it.
• response: will do.
•  
• In methods, please define "urinary diversion". Nephrostomy and double J? or you also evaluated ureterocutaneostomy and others?
• response: will do. It is explained later on the paper but I will emphasize it. only minimaly invasive procedures were studied.
• Similarly, methods must be implemented. I.e. how have you evaluated the different cancers? TNM? and complications? Follow up? Please expand the methods? Antibiotic prophilaxis for the procedure (i.e. cite the EAU guidelines if you followed the standard recommended prophylaxis: Kranz J, Bartoletti R, Bruyère F, et al. European Association of Urology Guidelines on Urological Infections: Summary of the 2024 Guidelines. Eur Urol. 2024 Jul;86(1):27-41. doi: 10.1016/j.eururo.2024.03.035. Epub 2024 May 6. PMID: 38714379. )
• response: As we stated, it is a retrospective multicentric study with different population, different groups of urologists and different ways to do the surgeries, with different protocols. Still, it should not vary very much from each other since urinary diversion most of the times is a low risk procedure.
• limitations are much more: different cancers and conditions evaluated; different centers means different diagnostics methods and surgeons, etc.
• response: yes, we acknowledge it, it is a difficult study to propose in a different scientific matter.

Reviewer 2 Report

Comments and Suggestions for Authors

It is a retrospective study evaluating the impact of urinary diversion in patients suffering from malignant ureteral obstruction. Despite the authors' excellent efforts and the topic's complexity, the manuscript has major concerns that need to be addressed.

Comment 1: There is no clear aim of the study. There is much information without determination of the purpose of the study, the main endpoints and the secondary endpoints. A clear aim of the study should be stated at the end of the introduction section

Comment 2: The prognosis differs in each cancer type, thus general outcomes of the impact of urinary diversion are biased. The outcomes should be evaluated for each cancer type separately.

Comment 3: It would be beneficial to discriminate as separate groups the patients with JJ stents and the ones with nephrostomy tubes, considering the different complications that may affect the mortality.

Comment 4: The results section is very complicated. They should be interpreted in a more efficient manner.

 

Comments on the Quality of English Language

As mentioned above.

Author Response

Comment 1: There is no clear aim of the study. There is much information without determination of the purpose of the study, the main endpoints and the secondary endpoints. A clear aim of the study should be stated at the end of the introduction section.

RESPONSE: thank you for your insites! We thoght that the aim was clear, as it is to ckeck in a very diverse and heterogenic population if urinary diversion provides an oportunity for a new therapeutic line for the primary tumor. Is to say: overall, if you put a stent you will have 75% chance to receive a new therapy for the tumor. 

Comment 2: The prognosis differs in each cancer type, thus general outcomes of the impact of urinary diversion are biased. The outcomes should be evaluated for each cancer type separately.

RESPONSE: We know that the population is very diverse and we tried to separate those in small similar groups as an intent to create a posible set of prediction factors to encourage the urinary diversion. our main goal was to see if it was posible to try to treat patients with surgery or chemo after diversion, not really look for overall survival. Most patients are metastatics but they often are managed as paliative just because, and we believe this article can help to change that point of viewm so they can live longer with better 

Comment 3: It would be beneficial to discriminate as separate groups the patients with JJ stents and the ones with nephrostomy tubes, considering the different complications that may affect the mortality. 

RESPONSE: we did separate those two groups, but the numbers were similar. the type of diversion matter less than tumor type, for ex. thats why we enphasized those other variables.

Comment 4: The results section is very complicated. They should be interpreted in a more efficient manner.

RESPONSE: We apologize for that. We had a lot of results and few words to describe them and we tried to sum up the best way we thought to be easy to understand. 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I read the edited version of the manuscript. The quality has improved.

I agree with the editing performed.

Reviewer 2 Report

Comments and Suggestions for Authors

The required revisions were performed and the manuscript is ameliorated. It may be considered for publication.