Pseudoaneurysm after Radical Prostatectomy: A Case Report and Narrative Literature Review

Round 1

Reviewer 1 Report

Authors should be congratulated for their work. The manuscript is well-written and easily readable, the methodology is robust, and tables are clear. Nevertheless, post radical prostatectomy pseudoaneurysm represents a rare condition, also demonstrated by the very scarce data in the literature, all deriving from case reports. Therefore, this paper would add nothing to the current evidences.

Author Response

Response to Reviewer 1 Comments

Dear Reviewer,

Thanks a lot for your comment. 

It is absolutely true that post radical prostatectomy pseudoaneurysm represents a rare condition, in fact literature is really poor consisting only in few case reports.

For the reasons mentioned above, we considered appropriate to write a review that included all the case reports published so far. We believe that our work can show a complete visual on the argument, offering even to the neophyte the capacity to diagnose and treat this condition, considered the variability of clinical presentations as well as the different therapeutic options. 

In addition, this is the first work where the authors raise the question of the possible functional effects,  suggesting to pay more attention during follow up of patients underwent to secondary procedure for pseudoaneurysms. Only collecting data, it will be possibile to clearly define the undesired effects of each procedure for pseudoaneurysm management. Consequently, we think that a better understanding of this problem may open new scenarios in terms of approaching and treating pseudoaneurysms: for example, if a patient does not require an immediate treatment the procedure can be modeled based on the potential secondary effects. The advent of robotic surgery and minimally invasive approaches obliges the surgeon more than ever to pursue personalized medicine during all the process of cure.

In conclusion, we would advise a reading of this work both to the urologist, to improve assessment and management of this condition, and to the general physician or the young surgeon/urologist, for a preparatory study of the topic and for a prompt recognizing in all clinical settings of cure. 

Sincerely yours

Reviewer 2 Report

Thank you for inviting me to review the article titled “ Pseudoaneurysm after radical prostatectomy: a case report and 2 narrative literature reviews”

In the review, the authors present a case of late complication of the RARP and review the available literature.

Criticisms:

The paper needs a lot of grammatical and punctuation changes.

Usually, numbers 1 to 12 are written as words but in the paper, at places, it is written and elsewhere it is numbered. Please choose one to ensure consistency. 

Line 94 – catheterism should be changed to catheterization, same for anemization can be just anemia

Line 194 – the number should be written in full

Line 340 – percutaneous is? I think its is missing the name of the procedure 

Table 2 – is missing ‘h’ in hematuria

Diagram 1 should be called figure 5

Author Response

Response to Reviewer 2 Comments

Dear Reviewer,

Many thanks for the accurate analysis and for the suggestions. 

Here we answer to all your points:

Point 1: The paper needs a lot of grammatical and punctuation changes

Response 1: An English additional revision has been done as you can see.

Point 2: Usually, numbers 1 to 12 are written as words but in the paper, at places, it is written and elsewhere it is numbered. Please choose one to ensure consistency. 

Response 2: We checked MDPI Guidelines (https://www.mdpi.com/authors/layout#_bookmark32  - Paragraph "6.1 Numbers"). We adjusted the work according to MDPI Guidelines except line 121 "6-12 months" where the use of two different forms of writing would have been worse (i.e. six-12 months).

Point 3: Line 94 – catheterism should be changed to catheterization, same for anemization can be just anemia

Response 3: We corrected the errors

Point 4: Line 194 – the number should be written in full

Response 4: Now it is correct

Point 5: Line 340 – percutaneous is? I think its is missing the name of the procedure 

Response 5: We changed "percutaneous" in "percutaneous embolization"

Point 6: Table 2 – is missing ‘h’ in hematuria

Response 6: Now it is right

Point 7: Diagram 1 should be called figure 5

Response 7: Since the paper is not a systemic review, it doesn't need diagrams according to PRISMA criteria, so we changed "diagram 1" with "figure 1". Thanks.

Best Regards

Reviewer 3 Report

Author Response

Dear Reviewer,

We really thank you for the accurate and meticulous analysis. Here we answer to all points suggested. We remain at your disposal for any additions.

Point 1: In the abstract, the authors mentioned the narrative review only searched on PubMed database (Line 19); however, the authors mentioned the data extraction on Scopus and PubMed databases in the methods and discussion part (Line 136). Please clarify and make the point consistent in your manuscript.

May I suggest the authors to follow the Evidence-based Medicine to critically review all relevant papers?  If you expand the search terms, not limited to exact wording on the topic, you will get a whole lot more recent and similar papers.  With Google Scholarship, it popped up 779.  Not 15.  And many of them are this year, not tens of years ago.

Response 1: we integrated the missing information in the abstract (line 20).

The reviewer suggests to follow the Evidence-based medicine. We pointed out in the title that this paper  is a "narrative literature review". Evidence-based medicine is generally applied in systematic reviews to eliminate bias and to provide an high-level overview of primary research on a specified and singular question, that is the best choice to answer a focused clinical dilemma. 

The aim of our study, instead, is to summarize evidences on the topic proposed offering an overview, since we do not try to answer a specific question or to support evidence-based practice. In the type of work proposed (narrative literature review) the informal or subjective methods to collect studies are recognized and validated.

Point 2: Please clearly indicate the study’s objectives in the abstract and introduction. Also, without any scientific reasoning or logical deduction, how can the study conclude this pseudoaneurysm is due to RARP, rather than general surgical risk or past smoking habit or heart-related root causes?

Response 2: we modified the sections "abstract" (line 19-20) and "introduction" (line 45-50) as suggested.

The scientific reasoning of the correlation between pseudoaneurysm and RARP is well stated in paragraph 2 "case presentation": 

<<During the robotic extended pelvic lymph node dissection before RARP, the epigastric vascular structures were partially isolated and dissected to remove lymphatic tissue around iliac arteries. In particular, electrocautery with monopolar and/or bipolar energy were used, that might cause vascular wall damage leading to pseudo-aneurysm development.>>

The RARP does not exclude the general surgical risk, since the RARP is a surgical procedure itself. 

"Past smoking habit and heart-related root causes" are not associated with pseudoaneurysms development, but they can instead indirectly lead the development of aneurysms, a disease completely different. 

In the "discussion" paragraph we offered a description of pseudoaneurysm (151-157) and we report main causes with related referring literature (154-157) where the causes hypotyzed above by the reviewer are not mentioned, since no association has been reported. 

Point 3: Comparision with previous case reports related to pseudoaneurysm after radical prostatectomy, could the author explain the uniqueness of the case report and what contribution of this report to the literature. Please elaborate on the point clearly in your manuscript.

Response 3: the case presents a patient with an anemia relapsing to transfusion of blood pockets and abdominal imaging not compatible with an active bleeding. One week after a change in clinical presentation occurred, with uneasiness, cold sweating, nausea and hypotension. Finally the diagnosis was carried out showing a pseudoaneurysm bleeding at CT-scan. 

The case is unique since it presents a difficult diagnosis with a shade presentation. The contribution to the literature is to sensitize and help recognizing this potentially dangerous complication. The case report section is didactic. 

The reading of this work can be useful both for the urologist, to perfect assessment and management, and to the general physician or the young surgeon/urologist, for a preparatory study of the topic. 

In addition, we already specified this aspect in the paragraphs:

- "introduction":

<<The following case will show a misleading presentation of delayed intermittent postoperative bleeding by a pseudoaneurysm after robotic radical prostatectomy. >> where we have added <<The clinical presentation was confusing and ambiguous, with a nuanced and intermittent course of symptoms. We hope this case could help an improvement in recognizing and assessing similar cases, which rarely occur but are easily susceptible of dangerous complication. >>

- "conclusion": 

<<We believe that our case and its management are important and to be considered for the severity and misleading appearance any time a patient undergone minimally-invasive-surgery recently shows an acute clinical presentation.>>

Point 4: I suggest the author reformat and rearrange parts of the manuscript since the heading is duplicated, and I found the paper difficult to understand. May I recommend the authors present and format the manuscript based on the CARE case report guidelines. (https://www.care-statement.org/checklist)

Response 4: we found out that the first two paragraphs were numbered the same ("1 introduction", "1 case presentation"). We have corrected. 

We rearranged the structure of the case report part following CARE case reports guidelines as proposed and we offer our thanks for the valuable suggestion. Now we believe the structure of the paper is easier to understand. 

Point 5: In terms of narrative review, may I suggest the authors to present the search terms and search strategy in the method part. The authors also need to clarify the date of search and the exclusion/ inclusion criteria in the word; for example, if authors only included the case reports or articles written in English, please indicate the inclusion criteria in detail. In addition, there are actually lots of more updated and similar cases if the authors performed an expanded search. See above 1.

Response 5: The method has been improved following the suggestion (line 21-22). We do not have enough available residual words to deepen in the abstract section.

The date of the search has been clarified in paragraph "collecting data" and we specified the exclusion/inclusion criteria and/or filters we used. 

About the search strategy, since we did not use criteria of selection, we considered the totality of works deriving from the initial search as we described <<The search terms used were “pseudoaneurysm” and “prostatectomy” using booleyan operator “AND” up to 01 June 2022. From a total of the resulting 15 works, we excluded those referring to transurethral prostatectomy or cystoprostatectomy">>. 

We hope it figures correct now. 

Point 6: When the author carried out the search strategies, which fields did the authors use to search the articles (based on the Title/ Abstract or All fields?)

Response 6:  we used default settings. We improved the section as it follows <<We used the default search strategy “all fields” and we did not select any additional filters>> in the paragraph "collecting data".

Thanks for the hint. 

Point 7: The authors did not mention of limitations of the case report. Please elaborate on the point in the manuscript.

Also, if the authors decided to pursue a systemic review, please follow EBM to critically review all updated and related papers.  It would be even better if applying artificial intelligence big data models to summarize all the research so far.

Response 7: we have added an appropriate section in the "discussion" paragraph (line 167-175)

We did not decide to pursue a systemic review so we did not apply artificial intelligence big data models as we stated in response 1. 

We thank again the Reviewer for all the inputs offered to our work, that we found precious to improve its scientific value. 

Sincerely Yours,

Round 2

Reviewer 1 Report

Authors should be congratulated for their work. The manuscript is well-written and easily readable, the methodology is robust, and tables are clear. Taking into account the authors' considerations and the purpose of the manuscript, it is suitable for publication.

Reviewer 3 Report

The paper is smoother after the English revision and modification of wording, as well as the disclosed limitations.  Ready to share to others.