Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This narrative review provides a comprehensive overview of iatrogenic nerve injuries in urological surgery. It addresses an important yet underappreciated complication that can significantly impact patients' quality of life. However, some parts of the manuscript can be improved.

1. While the manuscript provides a thorough review, it lacks a certain degree of originality. It is better offer more in-depth analysis or novel insights into the mechanisms of nerve injuries or innovative treatment strategies.
2. The discussion of a multidisciplinary approach could be expanded with specific examples of how different specialties can collaborate in the prevention and management of nerve injuries.
3. The authors are suggested to add some figures to summarize the key information, such as the classification of nerve injuries, anatomical pathways, or surgical techniques.

Author Response

Reply to Reviewers’ Comments

 

 

Dear Editor and Reviewers,

We would like to express our sincere gratitude to the reviewers for their constructive feedback and for the opportunity to revise and resubmit our manuscript. We greatly appreciate the insightful comments and suggestions provided during the review process.

We are pleased to confirm that we have thoroughly and carefully addressed all recommendations and have implemented the necessary revisions accordingly. All changes have been clearly marked in dark red font to distinguish our modifications from the original version.

Please find below our detailed responses to each of the reviewers' comments.

 

Reviewer 1

 

We wish to express our sincere appreciation for your positive assessment and for the time and effort invested in reviewing our manuscript. We are grateful for your valuable comments and thoughtful suggestions, which have contributed significantly to the refinement of the work.

 

R1 Comment #1

“This narrative review provides a comprehensive overview of iatrogenic nerve injuries in urological surgery. It addresses an important yet underappreciated complication that can significantly impact patients' quality of life. However, some parts of the manuscript can be improved.

1. While the manuscript provides a thorough review, it lacks a certain degree of originality. It is better to offer more in-depth analysis or novel insights into the mechanisms of nerve injuries or innovative treatment strategies.

2.The discussion of a multidisciplinary approach could be expanded with specific examples of how different specialties can collaborate in the prevention and management of nerve injuries.

3. The authors are suggested to add some figures to summarize the key information, such as the classification of nerve injuries, anatomical pathways, or surgical techniques.”

 

 

 

 

Response to R1 Comment #1:

We sincerely appreciate the reviewer’s thoughtful and constructive feedback, which has significantly contributed to the improvement of our manuscript.

1. In response to the suggestion regarding the need for greater originality and depth, we have incorporated a new paragraph that offers a more detailed analysis of the mechanisms underlying nerve injuries. Additionally, we have explored emerging and innovative treatment strategies, supported by recent literature. This content can now be found in the revised manuscript under the section “Analysis of available literature on the mechanisms of nerve damage and innovative treatment strategies.”
   
   
2. We agree that the discussion of a multidisciplinary approach could be further developed. Accordingly, we have expanded this section by including specific examples illustrating how collaboration among urologists, neurologists, physiotherapists, and pain specialists may contribute to both the prevention and management of iatrogenic nerve injuries. This expanded discussion is presented in Paragraphs 4 and 5 of the revised section.
   
   
3. In response to the suggestion to include visual elements, we have added two figures: Figure 1 illustrates the classification and anatomical pathways of nerves relevant to urological surgery, while Figure 2 summarises surgical techniques with associated risks of nerve injury.

Once again, we are grateful for your valuable comments and hope that the revisions adequately address your concerns.

 

Reviewer 2

 

We wish to express our sincere appreciation for your positive assessment and for the time and effort invested in reviewing our manuscript. We are grateful for your valuable comments and thoughtful suggestions, which have contributed significantly to the refinement of the work.

 

R2 Comment #1-6

“This narrative review brings together current knowledge on iatrogenic nerve injuries in urological surgery, specifically focusing on commonly affected peripheral nerves. It discusses the mechanisms of injury, associated procedures, preventative strategies, and treatment options related to urological interventions, such as radical prostatectomy and cystectomy. The review emphasizes the importance of early identification, careful dissection, and tension-free epineural repair as essential principles. It organizes fragmented data into a clear and structured summary to support intraoperative prevention and evidence-based treatment strategies. It is an interesting review on a very important and complex topic which is associated with a significant postoperative complication.

However, there are several issues that must be addressed. The limitations section needs to be improved and expanded.

1. The basic limitation of this review is its methodology, which lacks clearly defined search criteria and a transparent study selection. Both issues raise concerns about selection bias and the reproducibility of the review.
2. Likewise, the absence of a transparent evidence synthesis is an important concern that should be stated in the limitations.
3. The study also lacks a critical approach to the gathered literature. This limitation should also be clearly stated.
4. It becomes obvious that the concluding remark “A major strength of this work…a model for other specialties” must be removed.
5. A figure illustrating the relevant anatomical pathways of the peripheral nerves commonly affected during urological surgeries could be helpful.
6. The authors could add a Column in Table 1 summarising the clinical manifestation / presentation associated with the respective nerve injury.

The anticipated changes are going to change the manuscript draft significantly. Therefore, I recommend a major revision.”

 

 

Response to R2 Comment #1-6:

We thank the reviewer for the detailed and constructive feedback.

1. The Methods section (pages 2–3) has been revised to include explicit search criteria and a transparent study selection process. This addition aims to address concerns regarding selection bias and reproducibility.
2. The Limitations section has been expanded (Paragraph 4, page 3) to acknowledge the absence of formal evidence synthesis and the limited critical appraisal of the included literature.

1. A statement addressing the absence of formal evidence synthesis and the limited critical appraisal of the literature has been added to Paragraph 4, page 3, within the revised Limitations section.
2. The sentence stating “a major strength of this work… a model for other specialties” has been removed as suggested.
3. A new figure (Figure 2) illustrating the peripheral nerves commonly affected in urological surgeries has been added.
4. Table 1 (page 8) has been updated to include a new column summarising the clinical manifestations associated with each respective nerve injury (Column 5).
   
   

We trust these revisions address the concerns raised and improve the clarity and scientific rigour of the manuscript.

 

 

Reviewer 3

 

We wish to express our sincere appreciation for your positive assessment and for the time and effort invested in reviewing our manuscript. We are grateful for your valuable comments and thoughtful suggestions, which have contributed significantly to the refinement of the work.

 

R3 Comment #1-3

“A  useful narrative review .

1. I think that adding a comment regarding the impact on the nerves during ESWL would be interesting.
2. The authors have reviewed nerve injuries secondary to various urological interventions, but I believe it would be useful to specify their incidence in the various studies, for each pathology listed.
3. The authors also note the various nerve repair methods, I think it would be useful that the outcome related to each intervention should also be specified, by referring to the various studies in the literature.”

 

Response to R3 Comment #1-3

We thank the reviewer for the helpful observations and suggestions.

1. We have added a comment on the potential impact of ESWL on peripheral nerves. This addition has been included in the section “Types and Management of Intraoperative and Positional Nerve Injuries in Urological Surgery”.
2. The incidence of nerve injuries has now been specified, where available, for each relevant pathology within the respective nerve sections.
3. We agree that information regarding the outcomes of nerve repair methods is essential. We have therefore revised the manuscript to include outcome data associated with the different nerve repair techniques, as reported in the literature. Additional references have been integrated into the Discussion section (lines 524–541), including:
   
   

• Georgiou M, Bunting SC, Davies HA, et al. Engineered neural tissue for peripheral nerve repair. Biomaterials. 2013;34(30):7335–7343.
  
  
• Siemionow M, Brzezicki G. Current techniques and concepts in peripheral nerve repair. Int Rev Neurobiol. 2011;109:27–46.
  
  

The manuscript structure has also been revised in accordance with feedback from all reviewers to enhance coherence and completeness.

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Editor,

Please find below my review of the manuscript draft titled "Nerve at Risk: A Narrative Review of Surgical Nerve Injuries in Urological Practice", which has been submitted to the Surgeries Journal.

 

This narrative review brings together current knowledge on iatrogenic nerve injuries in urological surgery, specifically focusing on commonly affected peripheral nerves. It discusses the mechanisms of injury, associated procedures, preventative strategies, and treatment options related to urological interventions, such as radical prostatectomy and cystectomy. The review emphasizes the importance of early identification, careful dissection, and tension-free epineural repair as essential principles. It organizes fragmented data into a clear and structured summary to support intraoperative prevention and evidence-based treatment strategies.

 

It is an interesting review on a very important and complex topic which is associated with a significant postoperative complicaton.

 

However, there are several issues that are must be addressed.

 

1. The limitations section needs to be improved and expanded.
2. The basic limitation of this review is its methodology, which lacks clearly defined search criteria and a transparent study selection. Both issues raise concerns about selection bias and the reproducibility of the review.
3. Likewise, the absence of a transparent evidence synthesis is an important concern that should be stated in the limitations.
4. The study also lacks a critical approach to the gathered literature. This limitation should also be clearly stated.
5. It becomes obvious that the concluding remark “A major strength of this work…a model for other specialties” must be removed.
6. A figure illustrating the relevant anatomical pathways of the peripheral nerves commonly affected during urological surgeries could be helpful.
7. The authors could add a Column in Table 1 summarising the clinical manifestation / presentation associated with the respective nerve injury.

The anticipated changes are going to change the manuscript draft significantly. Therefore, I recommend for a major revision.

Best regards

Author Response

Reply to Reviewers’ Comments

 

 

Dear Editor and Reviewers,

We would like to express our sincere gratitude to the reviewers for their constructive feedback and for the opportunity to revise and resubmit our manuscript. We greatly appreciate the insightful comments and suggestions provided during the review process.

We are pleased to confirm that we have thoroughly and carefully addressed all recommendations and have implemented the necessary revisions accordingly. All changes have been clearly marked in dark red font to distinguish our modifications from the original version.

Please find below our detailed responses to each of the reviewers' comments.

 

Reviewer 1

 

We wish to express our sincere appreciation for your positive assessment and for the time and effort invested in reviewing our manuscript. We are grateful for your valuable comments and thoughtful suggestions, which have contributed significantly to the refinement of the work.

 

R1 Comment #1

“This narrative review provides a comprehensive overview of iatrogenic nerve injuries in urological surgery. It addresses an important yet underappreciated complication that can significantly impact patients' quality of life. However, some parts of the manuscript can be improved.

1. While the manuscript provides a thorough review, it lacks a certain degree of originality. It is better to offer more in-depth analysis or novel insights into the mechanisms of nerve injuries or innovative treatment strategies.

2.The discussion of a multidisciplinary approach could be expanded with specific examples of how different specialties can collaborate in the prevention and management of nerve injuries.

3. The authors are suggested to add some figures to summarize the key information, such as the classification of nerve injuries, anatomical pathways, or surgical techniques.”

 

 

 

 

Response to R1 Comment #1:

We sincerely appreciate the reviewer’s thoughtful and constructive feedback, which has significantly contributed to the improvement of our manuscript.

1. In response to the suggestion regarding the need for greater originality and depth, we have incorporated a new paragraph that offers a more detailed analysis of the mechanisms underlying nerve injuries. Additionally, we have explored emerging and innovative treatment strategies, supported by recent literature. This content can now be found in the revised manuscript under the section “Analysis of available literature on the mechanisms of nerve damage and innovative treatment strategies.”
   
   
2. We agree that the discussion of a multidisciplinary approach could be further developed. Accordingly, we have expanded this section by including specific examples illustrating how collaboration among urologists, neurologists, physiotherapists, and pain specialists may contribute to both the prevention and management of iatrogenic nerve injuries. This expanded discussion is presented in Paragraphs 4 and 5 of the revised section.
   
   
3. In response to the suggestion to include visual elements, we have added two figures: Figure 1 illustrates the classification and anatomical pathways of nerves relevant to urological surgery, while Figure 2 summarises surgical techniques with associated risks of nerve injury.

Once again, we are grateful for your valuable comments and hope that the revisions adequately address your concerns.

 

Reviewer 2

 

We wish to express our sincere appreciation for your positive assessment and for the time and effort invested in reviewing our manuscript. We are grateful for your valuable comments and thoughtful suggestions, which have contributed significantly to the refinement of the work.

 

R2 Comment #1-6

“This narrative review brings together current knowledge on iatrogenic nerve injuries in urological surgery, specifically focusing on commonly affected peripheral nerves. It discusses the mechanisms of injury, associated procedures, preventative strategies, and treatment options related to urological interventions, such as radical prostatectomy and cystectomy. The review emphasizes the importance of early identification, careful dissection, and tension-free epineural repair as essential principles. It organizes fragmented data into a clear and structured summary to support intraoperative prevention and evidence-based treatment strategies. It is an interesting review on a very important and complex topic which is associated with a significant postoperative complication.

However, there are several issues that must be addressed. The limitations section needs to be improved and expanded.

1. The basic limitation of this review is its methodology, which lacks clearly defined search criteria and a transparent study selection. Both issues raise concerns about selection bias and the reproducibility of the review.
2. Likewise, the absence of a transparent evidence synthesis is an important concern that should be stated in the limitations.
3. The study also lacks a critical approach to the gathered literature. This limitation should also be clearly stated.
4. It becomes obvious that the concluding remark “A major strength of this work…a model for other specialties” must be removed.
5. A figure illustrating the relevant anatomical pathways of the peripheral nerves commonly affected during urological surgeries could be helpful.
6. The authors could add a Column in Table 1 summarising the clinical manifestation / presentation associated with the respective nerve injury.

The anticipated changes are going to change the manuscript draft significantly. Therefore, I recommend a major revision.”

 

 

Response to R2 Comment #1-6:

We thank the reviewer for the detailed and constructive feedback.

1. The Methods section (pages 2–3) has been revised to include explicit search criteria and a transparent study selection process. This addition aims to address concerns regarding selection bias and reproducibility.
2. The Limitations section has been expanded (Paragraph 4, page 3) to acknowledge the absence of formal evidence synthesis and the limited critical appraisal of the included literature.

1. A statement addressing the absence of formal evidence synthesis and the limited critical appraisal of the literature has been added to Paragraph 4, page 3, within the revised Limitations section.
2. The sentence stating “a major strength of this work… a model for other specialties” has been removed as suggested.
3. A new figure (Figure 2) illustrating the peripheral nerves commonly affected in urological surgeries has been added.
4. Table 1 (page 8) has been updated to include a new column summarising the clinical manifestations associated with each respective nerve injury (Column 5).
   
   

We trust these revisions address the concerns raised and improve the clarity and scientific rigour of the manuscript.

 

 

Reviewer 3

 

We wish to express our sincere appreciation for your positive assessment and for the time and effort invested in reviewing our manuscript. We are grateful for your valuable comments and thoughtful suggestions, which have contributed significantly to the refinement of the work.

 

R3 Comment #1-3

“A  useful narrative review .

1. I think that adding a comment regarding the impact on the nerves during ESWL would be interesting.
2. The authors have reviewed nerve injuries secondary to various urological interventions, but I believe it would be useful to specify their incidence in the various studies, for each pathology listed.
3. The authors also note the various nerve repair methods, I think it would be useful that the outcome related to each intervention should also be specified, by referring to the various studies in the literature.”

 

Response to R3 Comment #1-3

We thank the reviewer for the helpful observations and suggestions.

1. We have added a comment on the potential impact of ESWL on peripheral nerves. This addition has been included in the section “Types and Management of Intraoperative and Positional Nerve Injuries in Urological Surgery”.
2. The incidence of nerve injuries has now been specified, where available, for each relevant pathology within the respective nerve sections.
3. We agree that information regarding the outcomes of nerve repair methods is essential. We have therefore revised the manuscript to include outcome data associated with the different nerve repair techniques, as reported in the literature. Additional references have been integrated into the Discussion section (lines 524–541), including:
   
   

• Georgiou M, Bunting SC, Davies HA, et al. Engineered neural tissue for peripheral nerve repair. Biomaterials. 2013;34(30):7335–7343.
  
  
• Siemionow M, Brzezicki G. Current techniques and concepts in peripheral nerve repair. Int Rev Neurobiol. 2011;109:27–46.
  
  

The manuscript structure has also been revised in accordance with feedback from all reviewers to enhance coherence and completeness.

 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

A  useful  narative review .

I think that adding a comment regarding the impact on the nerves during ESWL it would be interesting.

The authors have reviewed nerve injuries secondary to various urological interventions, but I believe it would be useful to specify their incidence in the various studies, for each pathology listed.

 

The authors also note the various nerve repair methods, I think it be would useful that the outcome related to each intervention should also be specified, by referring to the various studies in the literature.

Author Response

Reply to Reviewers’ Comments

 

 

Dear Editor and Reviewers,

We would like to express our sincere gratitude to the reviewers for their constructive feedback and for the opportunity to revise and resubmit our manuscript. We greatly appreciate the insightful comments and suggestions provided during the review process.

We are pleased to confirm that we have thoroughly and carefully addressed all recommendations and have implemented the necessary revisions accordingly. All changes have been clearly marked in dark red font to distinguish our modifications from the original version.

Please find below our detailed responses to each of the reviewers' comments.

 

Reviewer 1

 

We wish to express our sincere appreciation for your positive assessment and for the time and effort invested in reviewing our manuscript. We are grateful for your valuable comments and thoughtful suggestions, which have contributed significantly to the refinement of the work.

 

R1 Comment #1

“This narrative review provides a comprehensive overview of iatrogenic nerve injuries in urological surgery. It addresses an important yet underappreciated complication that can significantly impact patients' quality of life. However, some parts of the manuscript can be improved.

1. While the manuscript provides a thorough review, it lacks a certain degree of originality. It is better to offer more in-depth analysis or novel insights into the mechanisms of nerve injuries or innovative treatment strategies.

2.The discussion of a multidisciplinary approach could be expanded with specific examples of how different specialties can collaborate in the prevention and management of nerve injuries.

3. The authors are suggested to add some figures to summarize the key information, such as the classification of nerve injuries, anatomical pathways, or surgical techniques.”

 

 

 

 

Response to R1 Comment #1:

We sincerely appreciate the reviewer’s thoughtful and constructive feedback, which has significantly contributed to the improvement of our manuscript.

1. In response to the suggestion regarding the need for greater originality and depth, we have incorporated a new paragraph that offers a more detailed analysis of the mechanisms underlying nerve injuries. Additionally, we have explored emerging and innovative treatment strategies, supported by recent literature. This content can now be found in the revised manuscript under the section “Analysis of available literature on the mechanisms of nerve damage and innovative treatment strategies.”
   
   
2. We agree that the discussion of a multidisciplinary approach could be further developed. Accordingly, we have expanded this section by including specific examples illustrating how collaboration among urologists, neurologists, physiotherapists, and pain specialists may contribute to both the prevention and management of iatrogenic nerve injuries. This expanded discussion is presented in Paragraphs 4 and 5 of the revised section.
   
   
3. In response to the suggestion to include visual elements, we have added two figures: Figure 1 illustrates the classification and anatomical pathways of nerves relevant to urological surgery, while Figure 2 summarises surgical techniques with associated risks of nerve injury.

Once again, we are grateful for your valuable comments and hope that the revisions adequately address your concerns.

 

Reviewer 2

 

We wish to express our sincere appreciation for your positive assessment and for the time and effort invested in reviewing our manuscript. We are grateful for your valuable comments and thoughtful suggestions, which have contributed significantly to the refinement of the work.

 

R2 Comment #1-6

“This narrative review brings together current knowledge on iatrogenic nerve injuries in urological surgery, specifically focusing on commonly affected peripheral nerves. It discusses the mechanisms of injury, associated procedures, preventative strategies, and treatment options related to urological interventions, such as radical prostatectomy and cystectomy. The review emphasizes the importance of early identification, careful dissection, and tension-free epineural repair as essential principles. It organizes fragmented data into a clear and structured summary to support intraoperative prevention and evidence-based treatment strategies. It is an interesting review on a very important and complex topic which is associated with a significant postoperative complication.

However, there are several issues that must be addressed. The limitations section needs to be improved and expanded.

1. The basic limitation of this review is its methodology, which lacks clearly defined search criteria and a transparent study selection. Both issues raise concerns about selection bias and the reproducibility of the review.
2. Likewise, the absence of a transparent evidence synthesis is an important concern that should be stated in the limitations.
3. The study also lacks a critical approach to the gathered literature. This limitation should also be clearly stated.
4. It becomes obvious that the concluding remark “A major strength of this work…a model for other specialties” must be removed.
5. A figure illustrating the relevant anatomical pathways of the peripheral nerves commonly affected during urological surgeries could be helpful.
6. The authors could add a Column in Table 1 summarising the clinical manifestation / presentation associated with the respective nerve injury.

The anticipated changes are going to change the manuscript draft significantly. Therefore, I recommend a major revision.”

 

 

Response to R2 Comment #1-6:

We thank the reviewer for the detailed and constructive feedback.

1. The Methods section (pages 2–3) has been revised to include explicit search criteria and a transparent study selection process. This addition aims to address concerns regarding selection bias and reproducibility.
2. The Limitations section has been expanded (Paragraph 4, page 3) to acknowledge the absence of formal evidence synthesis and the limited critical appraisal of the included literature.

1. A statement addressing the absence of formal evidence synthesis and the limited critical appraisal of the literature has been added to Paragraph 4, page 3, within the revised Limitations section.
2. The sentence stating “a major strength of this work… a model for other specialties” has been removed as suggested.
3. A new figure (Figure 2) illustrating the peripheral nerves commonly affected in urological surgeries has been added.
4. Table 1 (page 8) has been updated to include a new column summarising the clinical manifestations associated with each respective nerve injury (Column 5).
   
   

We trust these revisions address the concerns raised and improve the clarity and scientific rigour of the manuscript.

 

 

Reviewer 3

 

We wish to express our sincere appreciation for your positive assessment and for the time and effort invested in reviewing our manuscript. We are grateful for your valuable comments and thoughtful suggestions, which have contributed significantly to the refinement of the work.

 

R3 Comment #1-3

“A  useful narrative review .

1. I think that adding a comment regarding the impact on the nerves during ESWL would be interesting.
2. The authors have reviewed nerve injuries secondary to various urological interventions, but I believe it would be useful to specify their incidence in the various studies, for each pathology listed.
3. The authors also note the various nerve repair methods, I think it would be useful that the outcome related to each intervention should also be specified, by referring to the various studies in the literature.”

 

Response to R3 Comment #1-3

We thank the reviewer for the helpful observations and suggestions.

1. We have added a comment on the potential impact of ESWL on peripheral nerves. This addition has been included in the section “Types and Management of Intraoperative and Positional Nerve Injuries in Urological Surgery”.
2. The incidence of nerve injuries has now been specified, where available, for each relevant pathology within the respective nerve sections.
3. We agree that information regarding the outcomes of nerve repair methods is essential. We have therefore revised the manuscript to include outcome data associated with the different nerve repair techniques, as reported in the literature. Additional references have been integrated into the Discussion section (lines 524–541), including:
   
   

• Georgiou M, Bunting SC, Davies HA, et al. Engineered neural tissue for peripheral nerve repair. Biomaterials. 2013;34(30):7335–7343.
  
  
• Siemionow M, Brzezicki G. Current techniques and concepts in peripheral nerve repair. Int Rev Neurobiol. 2011;109:27–46.
  
  

The manuscript structure has also been revised in accordance with feedback from all reviewers to enhance coherence and completeness.

 

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors addressed all concerns adequately.

Author Response

Thank you for your comments!

Author Response File: Author Response.docx