Effectiveness of the mushroom technique versus morcellation in en bloc bipolar prostate enucleation for prostates over 80 mL

Zoltán Kiss; Mihály Murányi; Attila Nagy; Tibor Flaskó

doi:10.1371/journal.pone.0331142

Peer Review History

Original SubmissionMay 1, 2025
3 Jul 2025 Decision Letter - Bryan Kwun-Chung Cheng, Editor PONE-D-25-22862Effectiveness of the Mushroom Technique Versus Morcellation in En Bloc Bipolar Prostate Enucleation for Prostates over 80 mLPLOS ONE Dear Dr. Zoltán, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Aug 17 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Bryan Kwun-Chung Cheng Academic Editor PLOS ONE Journal Requirements: 1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. In the online submission form, you indicated that “The data that support the findings of this study are available upon reasonable request”. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either a. In a public repository, b. Within the manuscript itself, or c. Uploaded as supplementary information.This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 3. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process. 4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. [Note: HTML markup is below. Please do not edit.] 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: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: Yes ****** 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 ****** 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 ****** 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 study compared the mushroom technique with morcellation for en bloc transurethral bipolar prostate enucleation (TUEB) in prostate. Morcellation significantly reduced operative time and improved tissue removal efficiency, with both techniques showing similar safety. The authors conclude that morcellation is preferable for larger prostates, though both are viable options. We have the concerns as the followings: 1. Considering that both the mushroom technique and morcellation have been widely used in clinical practice for years, could the authors clarify what the key innovation or new contribution of this study is compared to the existing literature? 2. What were the specific types and rates of complications in each group, beyond the need for transfusion or conversion to TURP? For instance, were there differences in urinary incontinence, urethral strictures, or bladder injuries? 3. Bladder injury is one of the main complications of morcellation. Was bladder explosion observed during the mushroom technique? Please elaborate on this point in the discussion section. 4. Were there any criteria for selecting between the mushroom technique and morcellation in individual patients, or was allocation purely based on surgeon preference? 5. Please reorganize the tables to make more concise and clear. Reviewer #2: This study provides valuable insights into the efficacy and safety of the mushroom technique compared to morcellation in en bloc bipolar prostate enucleation for large prostates. The manuscript is well-structured and addresses an understudied aspect of anatomical endoscopic enucleation of the prostate. However, certain methodological and analytical limitations should be addressed to strengthen the conclusions: 1. Given the retrospective nature of the study, the lack of randomization and the division of cohorts based on equipment availability rather than patient characteristics may introduce potential selection bias. A discussion of how this may affect generalizability is warranted. 2. Table 1 reveals significant differences between groups in antiplatelet therapy use and urinary retention rates. Since these factors may influence operative time and blood loss, they should be accounted for in comparative analysis. 3. The reported prostate volume in Graph 1 (up to 260 mL) conflicts with the ultrasound-derived maximum volume of 125 mL in Table 1. Clarification is needed on whether specimen weights (post-enucleation) were inadvertently compared to preoperative ultrasound measurements, and any outliers should be addressed. 4. To improve clarity, consider removing non-significant outcomes from Table 2 or consolidating them into supplementary material. ****** 6. 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: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0331142.r001
Revision 1
23 Jul 2025 Author Response Reviewer #1: This study compared the mushroom technique with morcellation for en bloc transurethral bipolar prostate enucleation (TUEB) in prostate. Morcellation significantly reduced operative time and improved tissue removal efficiency, with both techniques showing similar safety. The authors conclude that morcellation is preferable for larger prostates, though both are viable options. We have the concerns as the followings: 1. Considering that both the mushroom technique and morcellation have been widely used in clinical practice for years, could the authors clarify what the key innovation or new contribution of this study is compared to the existing literature? Thank you for raising this valuable point. We fully agree that both the mushroom technique and morcellation are well-established methods for tissue removal, and are extensively documented in the current literature. Indeed, several studies have previously explored the effectiveness of various morcellators and morcellation strategies (including upwards and downwards techniques). Nonetheless, we identified only one prior study that directly compared the mushroom technique against morcellation. Our present study substantially expands upon this previous work, notably by including more than twice the number of patients, which significantly strengthens the reliability and applicability of our results. We believe that our findings provide valuable insight into a critical limitation of the mushroom technique compared to morcellation, that is, as prostate volume increases, the efficiency of the mushroom technique decreases significantly, whereas morcellation consistently maintains its effectiveness. This highlights a clear clinical implication that surgeons intending to employ the mushroom technique should carefully consider this limitation, particularly when managing larger prostates (above 80 mL), to ensure optimal surgical outcomes and operative efficiency. Based on your question, we have expanded the introduction and discussion sections of the manuscript accordingly. Lines: 60-64, 352-357 2. What were the specific types and rates of complications in each group, beyond the need for transfusion or conversion to TURP? For instance, were there differences in urinary incontinence, urethral strictures, or bladder injuries? Thank you for your insightful question regarding the complications. Our analysis showed comparable complication rates between the mushroom and morcellation groups. Regarding Clavien–Dindo grade I complications, gross hematuria was observed in nine patients (7.76%) in the mushroom cohort and in eight patients (6.78%) in the morcellation cohort. These patients were managed with prolonged bladder irrigation and tranexamic acid. For Clavien–Dindo grade II complications, fever was noted in three patients (2.59%) in the mushroom cohort and in two patients (1.69%) in the morcellation cohort, all of whom were treated with parenteral antibiotic therapy. Clot evacuation and recoagulation (Clavien–Dindo grade IIIb) were needed in two cases (1.69%) in the mushroom cohort and in one case (0.85%) in the morcellation cohort. Blood transfusions were not required in either cohort. No Clavien–Dindo grade IIIa, IV, or V complications occurred in either group. Meanwhile, we observed superficial bladder injury in one patient (0.85%) in the morcellation cohort. Bleeding from the bladder mucosa coagulated, and morcellation continued without complications. Regarding late complications, there was one case each of urethral stricture (0.86%) and bladder neck sclerosis (0.86%) in the mushroom group that was treated with urethrotomy and transurethral bladder neck resection. At 1 month postoperatively, the incidence of TSUI was 18.10% (n=21) in the mushroom cohort and 20.33% (n=24) in the morcellation cohort (p=0.666). By the 3-month follow-up, TSUI rates decreased to 8.62% (n=10) in the mushroom group and 10.16% (n=12) in the morcellation group (p=0.687), and at 6 months, it further decreased to 4.31% (n=5) in the mushroom group and 5.08% (n=6) in the morcellation group (p=0.781). We have expanded the results section of the manuscript accordingly. Lines: 238-257 3. Bladder injury is one of the main complications of morcellation. Was bladder explosion observed during the mushroom technique? Please elaborate on this point in the discussion section. Thank you for this important question. Indeed, bladder injury is a known complication of morcellation and most of these injuries are superficial mucosal lesions, whereas bladder perforation is relatively rare. Fortunately, we did not observe bladder explosion in our practice; however, following your suggestion, we have elaborated in detail on the underlying mechanisms of this complication in the discussion section, and supplemented the text with relevant additional references. Lines: 323-340 Reference numbers: 23-25 4. Were there any criteria for selecting between the mushroom technique and morcellation in individual patients, or was allocation purely based on surgeon preference? Thank you for highlighting this important methodological point. We did not apply specific selection criteria for choosing between the mushroom technique and morcellation, which represents a limitation of our study. Since March 1, 2021, after acquiring a morcellator at our institution, we have consistently employed morcellation in cases involving prostates over 80 mL to shorten the operative time and improve surgical efficiency. We acknowledge that this approach may have introduced selection bias; therefore, we explicitly addressed this limitation in the Discussion section of our manuscript. Future randomized controlled studies may help clarify the comparative effectiveness of these methods further, minimizing potential biases. Lines: 360-370 5. Please reorganize the tables to make more concise and clear. Thank you for this suggestion. The reorganization was made accordingly, resulting in improved clarity and conciseness. Reviewer #2: This study provides valuable insights into the efficacy and safety of the mushroom technique compared to morcellation in en bloc bipolar prostate enucleation for large prostates. The manuscript is well-structured and addresses an understudied aspect of anatomical endoscopic enucleation of the prostate. However, certain methodological and analytical limitations should be addressed to strengthen the conclusions: 1. Given the retrospective nature of the study, the lack of randomization and the division of cohorts based on equipment availability rather than patient characteristics may introduce potential selection bias. A discussion of how this may affect generalizability is warranted. We agree with the reviewer's comments regarding the potential selection bias arising from the retrospective design of our study, the lack of randomization, and the division of patient cohorts based primarily on equipment availability (i.e., introduction of morcellation after acquiring the morcellator) rather than patient-specific characteristics. We have expanded the discussion section to address these limitations accordingly. Lines: 360-370 2. Table 1 reveals significant differences between groups in antiplatelet therapy use and urinary retention rates. Since these factors may influence operative time and blood loss, they should be accounted for in comparative analysis. Thank you for your valuable comment. We performed a multiple robust regression analysis to account for the potential confounding effects of antiplatelet therapy use and urinary retention on operative time and blood loss, as our outcome data were not normally distributed. We have expanded the results section accordingly. Lines: 173-175, 204-218 3. The reported prostate volume in Graph 1 (up to 260 mL) conflicts with the ultrasound-derived maximum volume of 125 mL in Table 1. Clarification is needed on whether specimen weights (post-enucleation) were inadvertently compared to preoperative ultrasound measurements, and any outliers should be addressed. Thank you very much for highlighting this important point. The prostate volumes reported in Table 1 are median values with interquartile ranges (IQR), due to the non-normal distribution of the data from our study population. Specifically, the 125 mL mentioned in Table 1 reflects the upper quartile (75th percentile) of prostate volume, not the maximum measured value. In fact, the largest prostate volume measured preoperatively by ultrasound in our cohort was 260 mL, consistent with the maximum value illustrated in Graph 1. To clarify this, we have explicitly stated as follows: Graph 1 reflects the full range of prostate volumes measured, including the maximum observed value. Lines: 232-233 4. To improve clarity, consider removing non-significant outcomes from Table 2 or consolidating them into supplementary material. Thank you very much for your suggestion. Considering that we observed statistically significant difference only in the maximum flow rate (Qmax) at 1 month, we have decided to highlight this result explicitly within the Results section of our manuscript. Consequently, we have removed the entire Table 2 from the main document and included it as a supplementary material, to improve clarity of the manuscript (Table S1). Lines: 257-262 Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0331142.r002
12 Aug 2025 Decision Letter - Bryan Kwun-Chung Cheng, Editor Effectiveness of the Mushroom Technique Versus Morcellation in En Bloc Bipolar Prostate Enucleation for Prostates over 80 mL PONE-D-25-22862R1 Dear Dr.Kiss Zoltán, 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Bryan Kwun-Chung Cheng 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 #2: All comments have been addressed ******** 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: 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 #2: Yes ****** 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 #2: 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 #2: (No Response) ****** 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 #2: No ******** https://doi.org/10.1371/journal.pone.0331142.r003
Formally Accepted
Acceptance Letter - Bryan Kwun-Chung Cheng, Editor PONE-D-25-22862R1 PLOS ONE Dear Dr. Zoltán, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Bryan Kwun-Chung Cheng Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0331142.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .