Effect of Preoperative Pelvic Floor Muscle Training on Erectile Dysfunction After Radical Prostatectomy—A Systematic Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

properly performed systematic review on the PFMT before ED - the least invasive treatment alternative for post-RP ED

row 139 - no trials after 2020? typo? - Minor

row 227-228 - unclear Sentence - Minor

row 239 - 299 - should be omitted - those are PFMT post-operatively, irrelevant to the question - MAJOR

 

Author Response

Comment 1: row 139 - no trials after 2020? typo? - Minor

Response:  Agreed. We thank the reviewer for identifying this typographical error. The text in the Eligibility Criteria section has been corrected to read “on or after 2018.”

Comment2: row 227-228 - unclear Sentence - Minor

Response: Agree. We appreciate this observation. The sentence in the Discussion section (lines 335-338) has been revised for clarity as follows:

“The major limitation of the studies lies in its limited no. of studies include and inadequate description of the PPFMT intervention. Key details necessary for understanding the protocol were not provided, including – number and duration of sessions, intervals, intensity, utilization of biofeedback or physiotherapy guidance, and the specific timing of the intervention.”

Comment 3: row 239 - 299 - should be omitted - those are PFMT post-operatively, irrelevant to the question - MAJOR

Response:  Agree. The above comment has been acknowledged by omitting the mentioned rows.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

I read with great interest this systematic review on the effect of preoperative pelvic floor exercises on postprostatectomy erectlie function. The systematic review is in line with the PRISMA statement and almost all the guidelines have been followed. Comments for the authors:

1) The title must me renamed as mini review. The inclusion of only three studies is a very important limiting factor that must be recognized in both the title and in the limitations section of the discussion.

2) The authors shuld report the PICO Framework when they describe inclusion and exclusion criteria.

3) Did the authors include congress abstracts? Were references of included studies carefully considered? Was manually search acceptable? 

4) The authors should discuss on the nerve-sparing technique that was followed in included studies. If different technique was used, this could be a serious confounding factor. 

5) The number of patients on postoperative PDE5 inhibitors must be reported, because this could also be a serious limitation and confounding factor.

6) The effect of preoperative Kegel exercises on other aspects of radical prostatectomy outcomes (such as continence) must be discussed in the paper. Moreover, the pentafecta concept should be mentioned. 

Author Response

Comment1: The title must me renamed as mini review. The inclusion of only three studies is a very important limiting factor that must be recognized in both the title and in the limitations section of the discussion.

Response: The title of the review has been changed to Mini-review. In addition, the inclusion of 3 studies has been added as a limitation in the discussion section as recommended on page no.9 (line 289). Thank you for pointing this out. 

Comment 2: The authors shuld report the PICO Framework when they describe inclusion and exclusion criteria

Response:  thank you for your recommendation. We agree to the above comment. The PICO framework has been added to the eligibility criteria under material and methods on page 3, line 104 to 112. The text reads as:

 

      "In accordance with the PRISMA 2020 guidelines, the eligibility criteria were structured using the PICO framework (Population, Intervention, Comparator, and Outcome).

• Population (P): Adult men scheduled to undergo radical prostatectomy (RP) for prostate cancer.
• Intervention (I): PPFMT programs, with or without adjacent modalities such as biofeedback or physiotherapy
• Comparator (C): Standard care or control group that didn’t receive pre-operative pelvic floor training prior to RP.
• Outcome (O): Post-operative ED, assessed using validated tools such as IIEF-5"

 Comment 3: Did the authors include congress abstracts? Were references of included studies carefully considered? Was manually search acceptable?

Response:No congress abstracts weren’t included as they only included the abstract and not the full details of the study. Yes, references for included studies were carefully considered by 2 reviewers. Yes, Manual search was acceptable.

Comment 4:The authors should discuss on the nerve-sparing technique that was followed in included studies. If different technique was used, this could be a serious confounding factor

Response:Thank you for you feedback. We agree on the above comment and details of it has been added under the title results of included studies  and reads as follow:

"In the included RCT conducted by Milios et al.[15], majority of the patients in the control and case group underwent robotic RP with nerve sparing technique" (page 7, line 183)

"In the other RCT study by de Lira et al. [14] all patients underwent open RP with nerve sparing technique. In terms of pelvic floor exercise regimen" (page7, line 202)

Under discussion section: "To add more, the surgical techniques reported were heterogeneous among all included studies, with perez et.al [16] didn’t reported it at all " (page 9, line 341-343)

Comment 5: The number of patients on postoperative PDE5 inhibitors must be reported, because this could also be a serious limitation and confounding factor.

Response: We agree to the above comment. and we have added the following to the discussion section:

"The studies by De Lirea et.al [14] and Perez at.al[16] also didn’t mentioned about use of PDE-5 inhibitors while Milos et.al [15] reported it as positive post RP" (page 9, line 344-345)

Comment 6: The effect of preoperative Kegel exercises on other aspects of radical prostatectomy outcomes (such as continence) must be discussed in the paper. Moreover, the pentafecta concept should be mentioned.

Response: We agree to the above comments and following details were added to the manuscript:

In the Milos et. al study : "ANOVA test was conducted to report the continence score using expanded prostate Cancer Index Composite for clinical practice (EPIC_CP Qol) questionnaire, which showed a significant difference in between the group at 2-week point (P<0.005) but not at 6 and 12 week interval. At last,Milios et al.[15] also reported routine use of post-operative PDE-5 –I in all patients as a part of RP protocol." (page: 7, line 231-236)

For Perez et.al study "The continence score was reported using ICIQ-SF questionnaire, which showed no significant difference between 2 groups (P=0.97)" page 7, line 274, 275

The perez et. al study didn't report any results on incontinence.

In addition, "Also, the Pentfecta outcomes were not reported by any of the included studies" which was added  under the discussion section on page 9, line 343.

 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

the authors has taken sufficiently into consideration all of this reviewer`s points 

Author Response

Thank you for considering and taking time to review this systematic review. 

Reviewer 2 Report

Comments and Suggestions for Authors

The authors' responses to the reviewer's comments have nay grammatical and linguistic errors that must be fixed. The revised version must be carefully reviewed by a fluent English speaker before re-submission. Moreover. the authors didn't answer to the comment regarding the nerve-sparing technique that was used (intrafascial, interfascial, extrafascial, veil of Aphrodite, etc). 

Author Response

Comment 1; The authors' responses to the reviewer's comments have nay grammatical and linguistic errors that must be fixed. The revised version must be carefully reviewed by a fluent English speaker before re-submission. Moreover. the authors didn't answer to the comment regarding the nerve-sparing technique that was used (intrafascial, interfascial, extrafascial, veil of Aphrodite, etc). 

Response: Thank you for your feedback. In regards to nerve sparing technique the follow has been updated under the manuscript  section 4.4 results : included studies and synthesis (line 187 - 214):

"In the included RCT conducted by Milios et al. [15], majority of the patients in the control and case group underwent robotic RP with cavernosal nerve sparing technique."

"In the other RCT study by de Lira et al. [14] all patients underwent open retropubic RP with no mentioning of nerve sparing technique."

"In the non-RCT study conducted by Perez et al. [16] all participants underwent open RP with pudendal nerve sparing technique."

In accordance we have appropriately reviewed the grammatical and linguistic errors accordingly. 

Thank you for all revisions and feedback, for improving our manuscript.