Inguinal Hernia Containing the Bladder and Postoperative Appearance: A Multimodality Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is an interesting and educational case report demonstrating a bladder-containing inguinal hernia identified on bone scintigraphy with CT urographic confirmation and subsequent postoperative appearance on PSMA PET/CT. The multimodality imaging correlation is a strength of the manuscript.

Minor Revision

1. The prostate cancer pathology description should be reviewed for consistency. The manuscript states Gleason 4+4 (Grade Group 2), which appears incorrect, as Gleason 4+4 corresponds to Grade Group 4. Please clarify the pathology and staging details.
2. The section describing the postoperative mesh findings is interesting. Please provide additional support or references regarding the CT appearance of polypropylene versus ePTFE mesh and clarify whether the observed soft-tissue density represents the mesh itself, surrounding fibrosis, or both.
3. There are several minor grammatical issues throughout the manuscript (e.g., “more common that” should be “more common than”; “may patients” should be “many patients”). A careful editorial review is recommended.

Overall, this is a worthwhile teaching case with good image quality and a clear educational message. After addressing the points above, the manuscript would be suitable for publication.

Author Response

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below. References are given to location of changes in the manuscript.

1. Comment 1: The prostate cancer pathology description should be reviewed for consistency. The manuscript states Gleason 4+4 (Grade Group 2), which appears incorrect, as Gleason 4+4 corresponds to Grade Group 4. Please clarify the pathology and staging details. The grade group was incorrect and has been changed in the manuscript at page 2, line 16. Gleason 4+4 (grade group 4) was the highest grade disease on systematic biopsy. The bone scan was the only pre-operative imaging done for staging purposes and a statement has been added that “[t]he decision was made to proceed with radical prostatectomy after a negative bone scan” at page 2, lines 16-17.
2. The section describing the postoperative mesh findings is interesting. Please provide additional support or references regarding the CT appearance of polypropylene versus ePTFE mesh and clarify whether the observed soft-tissue density represents the mesh itself, surrounding fibrosis, or both. The soft tissue density at site of the polypropylene mesh repair represents a combination of fibrosis and mesh material. We state “[t]he appearance is caused by a combination of connective tissue and the mesh material itself” at page 4, lines 13-14. Page 4, lines 19-20 has been edited to read, “Polypropylene mesh is isoattenuating and may produce an inflammatory response that appears as a rounded density.” References are provided on page 4, lines 14 and 17.
3. There are several minor grammatical issues throughout the manuscript (e.g., “more common that” should be “more common than”; “may patients” should be “many patients”). A careful editorial review is recommended. The manuscript was scrutinized to typographical errors. The first noted error was in a section of text that was removed to shorten the introduction. The second note error was corrected at page 2, line 2. Other small typographical changes were made, as reflected in the tracked edits.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript is well writtend and systematic, with various imaging diagnostic results presented clearly. 
The figures are informative and effectively support the key educational content.
In particular, the emphasis on the importance of lateral scintigraphy images and recognizing postoperative findings related to mesh will be highly useful for radiologists and nuclear medicine specialists.

I believe this case report is suitable for publication as it possesses sufficient originality and educational value.
However, a few editorial corrections are required.

Minor Comments:

1. Please carefully review for typos and grammatical errors, such as "Intitial" or "may patients."

2. Please verify the accuracy of the explanations regarding the Gleason score and classification. The part in the text where a Gleason score of 4+4 is labeled as Classification 2 appears inconsistent.

3. Please review the reference numbers in the discussion section, particularly any previous studies cited with the same reference numbers.

4. Since the introduction is quite long, it would be better to reduce its length and make it more concise so that the focus can be on the key imaging findings and educational points of the case.

Author Response

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below. References are given to location of changes in the manuscript.

1. Please carefully review for typos and grammatical errors, such as "Intitial" or "may patients." The manuscript was scrutinized to typographical errors. The noted typos were corrected at page 2, lines 2 and 34. Other small typographical changes were made, as reflected in the tracked edits.
2. Please verify the accuracy of the explanations regarding the Gleason score and classification. The part in the text where a Gleason score of 4+4 is labeled as Classification 2 appears inconsistent. The grade group was incorrect and has been changed in the manuscript at page 2, line 16. Gleason 4+4 (grade group 4) was the highest grade disease on systematic biopsy.
3. Please review the reference numbers in the discussion section, particularly any previous studies cited with the same reference numbers. We manually reviewed reference numbers in the discussion section and found that reference number for the study by Ilgan et al. was incorrect. It is updated on page 5, line 9.
4. Since the introduction is quite long, it would be better to reduce its length and make it more concise so that the focus can be on the key imaging findings and educational points of the case. The introduction was significantly shortened by removal of background information not directly relevant to the case. Specifically, the previous 2^nd and 3^rd paragraphs of the introduction have been removed, and the final paragraph has been shortened to focus on the different types of mesh material.

Reviewer 3 Report

Comments and Suggestions for Authors

In this case report, the authors should shorten their Introduction. The reader may find many details that are not relevant to the report and are not analyzed in the remaining part of the report.

In the second section, it would be helpful to provide a brief overview of the Gleason score.

From the descriptions of the scans presented here, it is not clear what the advantages and limitations of the imaging techniques used in this case (SPECT, CT/PET, and CT) are. Reading this part of the case report, one cannot find this information, except for some general statements from previously published papers.

In the last part of the case report, the authors should explain what is important in this case and what is meaningful for the scientific community, beyond general statements about the significance of accurate diagnostic information from images obtained in nuclear medicine and radiology. More precisely, they mentioned that other papers so far published lead to the same conclusion (see the second paragraph in section 3). Please, after analysing other papers in detail, we need to know what is interesting here and what is different from the others.

Author Response

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below. References are given to location of changes in the manuscript.

1. In this case report, the authors should shorten their Introduction. The reader may find many details that are not relevant to the report and are not analyzed in the remaining part of the report. The introduction was significantly shortened by removal of background information not directly relevant to the case. Specifically, the previous 2^nd and 3^rdparagraphs of the introduction have been removed, and the final paragraph has been shortened to focus on the different types of mesh material.
2. In the second section, it would be helpful to provide a brief overview of the Gleason score. The initially noted grade group was incorrect and has been changed in the manuscript at page 2, line 16. Gleason 4+4 (grade group 4) was the highest grade disease on systematic biopsy.
3. From the descriptions of the scans presented here, it is not clear what the advantages and limitations of the imaging techniques used in this case (SPECT, CT/PET, and CT) are. Reading this part of the case report, one cannot find this information, except for some general statements from previously published papers. Several statements are made about the strengths and weaknesses of the different imaging modalities. We added the text “CT urography allows evaluation of fine anatomic details and assessment of the urinary tract with excreted contrast. Patients may be repositioned to assess nonopacified portions of the urinary tract in typical supine positioning” at page 3, lines 12-14. The PSMA PET/CT subsection now includes the text “[i]nclusion of a localizer CT allows superior assessment of anatomy compared to planar bone scintigraphy” at page 4, lines 9-10. A statement on bone scintigraphy’s limitations in assessing anatomy is made at page 2, line 37-40.
4. In the last part of the case report, the authors should explain what is important in this case and what is meaningful for the scientific community, beyond general statements about the significance of accurate diagnostic information from images obtained in nuclear medicine and radiology. More precisely, they mentioned that other papers so far published lead to the same conclusion (see the second paragraph in section 3). Please, after analysing other papers in detail, we need to know what is interesting here and what is different from the others. Our case has unique teaching potential by demonstrating longitudinal imaging from a single patient with a rare bladder-containing hernia who subsequently gets surgical repair with two mesh materials that show different appearances on CT. The following statement was added to the conclusion: Our case provides a unique teaching opportunity to highlight the challenge posed by atypical bladder configuration on planar imaging with radiopharmaceuticals excreted in the urine and the expected postoperative appearance following hernia repair with different types of mesh.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

no more comments.