Pre-Operative Sonographic Assessment of Ovarian Location and Mobility Predicts Intra-Operative Ovarian Resectability During Vaginal Hysterectomy: A Diagnostic Accuracy Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This article presents a prospective diagnostic accuracy study investigating the preoperative transvaginal ultrasound assessment of ovarian mobility and its correlation with intraoperative ovarian resectability during vaginal hysterectomy. The overall study design is reasonable, the methodology is relatively rigorous, and the study demonstrates certain clinical innovation. Below are some suggestions that require the authors' response:

1. The manuscript states that "All sonographic examinations were performed by the same physician (I.T.)." However, it does not specify the operator's level of expertise (e.g., whether they have received specialized training, years of experience, or whether they are an ultrasound specialist). The operator's experience level may influence diagnostic accuracy. It is recommended that the authors provide additional information about the operator's background (e.g., "with more than 5 years of experience in pelvic floor ultrasound").

2. Was any inter-observer or intra-observer reliability analysis conducted? It is recommended that the authors include a repeatability analysis of at least 10 cases (e.g., using Kappa statistics) to enhance the credibility of the findings.

3. The manuscript mentions that "the surgeon was not aware of the sonography results." Was the ultrasound examiner blinded to the patients' clinical background (e.g., previous surgical history, symptoms)? It is recommended that the authors clarify whether the sonographer was blinded to clinical information. If blinding was not implemented, this should be acknowledged as a limitation.

Author Response

Reviewer 1 – General comment: This article presents a prospective diagnostic accuracy study investigating the preoperative transvaginal ultrasound assessment of ovarian mobility and its correlation with intraoperative ovarian resectability during vaginal hysterectomy. The overall study design is reasonable, the methodology is relatively rigorous, and the study demonstrates certain clinical innovation. Below are some suggestions that require the authors' response:

Authors’ response: Thank you for this comment.

 

Reviewer 1- Comment 1: The manuscript states that "All sonographic examinations were performed by the same physician (I.T.)." However, it does not specify the operator's level of expertise (e.g., whether they have received specialized training, years of experience, or whether they are an ultrasound specialist). The operator's experience level may influence diagnostic accuracy. It is recommended that the authors provide additional information about the operator's background (e.g., "with more than 5 years of experience in pelvic floor ultrasound").

Authors’ response: Thank you for this constructive comment. Indeed, the ultrasound operator's experience level may influence diagnostic accuracy. In the Materials and Methods section, at the end of the third paragraph, we have now provided more information regarding the ultrasound operator’s experience. Furthermore we have discussed this issue in the penultimate and the last paragraph of the Discussion section.

 

Reviewer 1- Comment 2: Was any inter-observer or intra-observer reliability analysis conducted? It is recommended that the authors include a repeatability analysis of at least 10 cases (e.g., using Kappa statistics) to enhance the credibility of the findings.

Authors’ response: This is a plausible comment! During study design, we thought of this issue and we decided that only one operator would perform preoperative ultrasound examinations, as this would improve consistency. Therefore, inter-observer variability analysis is not feasible at this point. Regarding, intra-observer variability, this issue was not included in the study protocol, and since this is a prospective study, post hoc analysis would not be appropriate. In the first version of our manuscript we had already acknowledged this limitation in the last paragraph of the Discussion section, and now we have further discussed this issue in the same paragraph in accordance with a similar comment from another reviewer.

 

Reviewer 1- Comment 3: The manuscript mentions that "the surgeon was not aware of the sonography results." Was the ultrasound examiner blinded to the patients' clinical background (e.g., previous surgical history, symptoms)? It is recommended that the authors clarify whether the sonographer was blinded to clinical information. If blinding was not implemented, this should be acknowledged as a limitation.

Authors’ response: In the Materials and Methods section, at the end of the third paragraph, we have now clarified that the sonographer was not blinded to clinical information and we have discussed the clinical relevance of this issue in the last paragraph of the Discussion section.

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript presents a prospective diagnostic accuracy study evaluating whether preoperative transvaginal ultrasound assessment of ovarian mobility and location predicts intraoperative findings and feasibility of vaginal salpingo-oophorectomy during vaginal hysterectomy for pelvic organ prolapse.

The topic is clinically relevant because preoperative identification of adnexal accessibility could improve surgical planning and reduce unexpected intraoperative difficulties.

The study is interesting and potentially publishable; however, several methodological, statistical, and reporting issues should be addressed before acceptance.ù

 

1. Unit of analysis (ovary vs patient)
The analysis appears to be performed per ovary (99 ovaries) rather than per patient (50 patients). Since two ovaries belong to the same patient, observations are not independent. The authors should clarify this and consider statistical methods accounting for clustering or perform analysis at the patient level.

2. Definition of the reference standard
Intraoperative assessment of ovarian mobility and location is used as the reference standard, but the criteria used during surgery are not sufficiently standardized. The manuscript should clarify how these assessments were performed and confirm whether surgeons were blinded to ultrasound findings.

3. Operator dependence of ultrasound
All ultrasound examinations were performed by a single examiner. While this improves consistency, it limits generalizability. The authors should specify the examiner’s experience and acknowledge the absence of interobserver or intraobserver reliability analysis.

4. Interpretation of diagnostic performance
Some outcomes are described as having very high predictive value despite moderate diagnostic performance. For example, prediction of adhesions shows high specificity but low sensitivity. The interpretation should be more cautious and aligned with the reported metrics.

5. Clinical applicability
The manuscript suggests that ultrasound findings could guide surgical planning, but no practical clinical algorithm is proposed. The discussion would benefit from clarifying how these findings could influence the choice of surgical approach.

Author Response

Reviewer 2 – General comment: This manuscript presents a prospective diagnostic accuracy study evaluating whether preoperative transvaginal ultrasound assessment of ovarian mobility and location predicts intraoperative findings and feasibility of vaginal salpingo-oophorectomy during vaginal hysterectomy for pelvic organ prolapse. The topic is clinically relevant because preoperative identification of adnexal accessibility could improve surgical planning and reduce unexpected intraoperative difficulties. The study is interesting and potentially publishable; however, several methodological, statistical, and reporting issues should be addressed before acceptance.

Authors’ response: Thank you for this comment.

 

Reviewer 1- Comment 1. Unit of analysis (ovary vs. patient): The analysis appears to be performed per ovary (99 ovaries) rather than per patient (50 patients). Since two ovaries belong to the same patient, observations are not independent. The authors should clarify this and consider statistical methods accounting for clustering or perform analysis at the patient level.

Authors’ response: This is a plausible comment! During study design, we thought of this issue and we discussed extensively whether we should collect and analyze data per ovary or per patient. We took into account that although each patient usually has two ovaries their mobility and the surrounding and/or adherent tissues may differ considerably. Moreover, some patients may have only one ovary or one adnexum due to previous operations. Based on these considerations, we decided at the outset of the study to collect and analyze data per ovary. Since this is a prospective study, post hoc analysis at the patient level would be inappropriate, especially since as described above the mobility of an ovary is essentially independent from the contralateral ovary in the same patient. Therefore, we have now added the rationale for analyzing data at the ovary rather than the patient level in the Materials and Methods section, at the end of the third paragraph.

 

Reviewer 1- Comment 2. Definition of the reference standard: Intraoperative assessment of ovarian mobility and location is used as the reference standard, but the criteria used during surgery are not sufficiently standardized. The manuscript should clarify how these assessments were performed and confirm whether surgeons were blinded to ultrasound findings.

Authors’ response: In the first version of our manuscript we had already stated that “the surgeon was not aware of the sonography results” in the penultimate paragraph of the Discussion section and now we have added this statement in the Materials and Methods section, in subsection 2.3.

 

Reviewer 1- Comment 3. Operator dependence of ultrasound: All ultrasound examinations were performed by a single examiner. While this improves consistency, it limits generalizability. The authors should specify the examiner’s experience and acknowledge the absence of interobserver or intraobserver reliability analysis.

Authors’ response: In accordance with a similar comment from another reviewer we have now provided more information regarding the examiner’s experience in the third paragraph of the Materials and Methods section and we have discussed this issue in the last paragraph of the Discussion section.

 

Reviewer 1- Comment 4. Interpretation of diagnostic performance: Some outcomes are described as having very high predictive value despite moderate diagnostic performance. For example, prediction of adhesions shows high specificity but low sensitivity. The interpretation should be more cautious and aligned with the reported metrics.

Authors’ response: Indeed, interpretation of data should be cautious. Therefore, we have added a relevant statement in the Conclusions section.

 

Reviewer 1- Comment 5. Clinical applicability: The manuscript suggests that ultrasound findings could guide surgical planning, but no practical clinical algorithm is proposed. The discussion would benefit from clarifying how these findings could influence the choice of surgical approach.

Authors’ response: This is a reasonable comment, but existing data in this area are still scarce and thus preoperative ultrasound cannot be incorporated into a practical clinical algorithm. Therefore, we have now added a relevant comment in the Conclusions sections.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

This version is improved and we are able to accept in this form.