PONE-D-20-39174

Severe urinary tract damage secondary to primary bladder neck obstruction in women

PLOS ONE

Dear Cristiano

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Israel Franco, M.D.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a retrospective review of case series including a small number of women (6) presenting primary bladder neck obstruction and treated by bladder neck incision at one institution.

ABSTRACT: Abstract is well written and points out the most important results.

INTRODUCTION: Introduction is fine. The authors report important findings previously described on the subject and point out the gap in the literature as well as their objective with their study

METHODS: I believe that due to the retrospective aspect of the study the authors may have found in their database review only the most severe cases, that needed BNI, which may be a bias to the study.

What were the reasons to chose one or two bladder neck incision?

RESULTS: What do the authors attribute to be the reason for such a long period between the onset of symptoms and the diagnosis? It took more than 3 decades in one patient.

Do the authors did EMG analysis during uroflowmetry or UDS? That could have shortened the time between the onset of symptoms and the diagnosis.

Tables and figures are fine

DISCUSSION: The results on bladder outlet obstruction index (BOOI) should be described in the RESULTS section. Otherwise, discussion is fine.

After reading the paper I would suggest the authors to review the title, since they included only severe bladder neck obstruction, and that is what the paper is about. It would be more accurate if the title was something like this: Urinary tract damage secondary to SEVERE primary bladder neck obstruction in women

Reviewer #2: The authors present a well written and compelling argument for pnbd.

As some one who sees many young patients and adolescents with this problem and believes that it is a problems that persists into adulthood it would have been beneficial if there was some data regarding these women and their symptoms as children or adolescents to tie this condition to a long standing problem to further be able to increase awareness of this insidious problem.

if there are free flow stats on all patients it would be very useful to present this data as well so that the reader has a baseline from which to work prior to moving to invasive urodynamics. similarly what are the free flow numbers post incision.

We know from the pediatric literature that bn dysfunction is commonly associated with frontal lobe dysfunction and autonomic dysregulation. can you provide us with information regarding psychiatric diagnosis or disorders that the patients had and also if they were on any medications that would result in norepinephrine levels being elevated such as NERI, SSRI/NERI, sympathomimetics, Tricyclic antidepressants since these medications can exaggerate the response of the bn and create significant voiding issues.

Reviewer #3: This is a report of women with severe bladder neck dysfunction who underwent bladder neck incision. The authors found this procedure to be effective for patients with severe lower urinary tract dysfunction secondary to PBNO. It is clinically useful to know that although PBNO can lead to severe bladder damage, BNI is an effective treatment.

It is not clear in the introduction what is the authors' scientific hypothesis and research question. I understand that severe bladder changes have been poorly described for primary bladder neck dysfunction. However, the authors presented only two cystographic images with diverticulum and one MRI showing detrusor thickened. No image from the urodynamic study is presented. The CT image does not show thickened bladder. The hydronephrosis represented is mainly pelvis dilation.

As there are few cases presented by the authors it is important that more details of the cases are provided, such as the evolution of symptoms to urinary retention, history of urinary infection, urodynamics pictures and types of treatment before BNI.

The authors suggest hydronephrosis as an important finding of the study. However, in patients with urinary retention, bilateral renal dilation is the rule and not the exception. This is probably why this finding is not described extensively in the literature. Because it is an expected finding.

The authors comment that “Our findings, however, demonstrate that female PBNO may result in severe and irreversible damage to the bladder and the upper urinary tract.” However, although structural changes suggest severity, urodynamic is the most important finding for lower urinary tract evaluation. Video-urodynamic study is more important for the BNO diagnosis and for assessing vesicoureteral reflux than for diagnosing diverticulum, since its presence shouldn’t change the treatment.

How did the maximum detrusor pressure evolve after the procedure?

Was sacral stigma a diagnosis of exclusion? How has spina bifida occulta been ruled out?

In table 1 is creatinine at baseline or after CIC or after foley catheter placement? If it was at baseline, how many normalized with Foley?

How many used alpha blockers and for how long? Was standard urotherapy used and for how long? How about any type of electrical neuromodulation?

When there is no control group, as much information as possible before surgery should be given.

There is no indication where the discussion begins.

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Reviewer #1: Yes: Jose Murillo B. Netto

Reviewer #2: Yes: israel franco

Reviewer #3: Yes: Ubirajara Barroso

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Severe urinary tract damage secondary to primary bladder neck obstruction in women

PONE-D-20-39174R1

Dear Dr. Gomes,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Israel Franco, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed all suggestions properly.

I still believe that the title should be revised.

Reviewer #2: no additional comments are necessary, all the questions were appropitely answered.

excellent study

Reviewer #3: The authors answered nicely all questions. The retrospective nature of the study is the main limitation, but do not invalidate the main findings.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Israel Franco, MD

Reviewer #3: Yes: Ubirajara Barroso Jr.