Surgical Tolerability and Frailty in Elderly Patients Undergoing Robot-Assisted Radical Prostatectomy: A Narrative Review
Round 1
Reviewer 1 Report
The definition of frail and elderly needs an improvement on. What is the criteria being used. Internationally its normally from the WHO or ECOG. Frailty is related to the ageing process. This is not very clear in the paper.
Author Response
Dear reviewer1,
Thank you very much for giving us the opportunity to submit a revised draft of the manuscript “Surgical tolerability and frailty in elderly patients undergoing robot-assisted radical prostatectomy: A narrative review” for publication in Cancers.
We thank you for the time and effort that you have dedicated to reviewing our manuscript. We are also delighted to receive your comments on our paper and we have tried our best to correct any suggestions made by the reviewers. Listed below is a point-by-point response to the reviewer’s comments and concerns. All page and line numbers refer to the revised manuscript file. Comments of the reviewers are in italics and our responses to these comments are in bold characters. The corrected parts are shown by tracked changes in the main manuscript. We hope you find our revised manuscript suitable for publication in your journal. Thank you.
Kind regards,
Yuta Yamada, MD, PhD
The comments of reviewer1:
The definition of frail and elderly needs an improvement on. What is the criteria being used. Internationally its normally from the WHO or ECOG. Frailty is related to the ageing process. This is not very clear in the paper.
→Thank you for the suggestion. The concept and definition of frailty and elderly are evolving, which made it perhaps unclear in the paper. The WHO has defined ‘elderly’ as 65 years and older and this is described on page3 lines84-85: Conventionally, the WHO used ‘65 years of age and over' as the definition of ‘elderly’ [10].
As for frailty, it is defined as the state of increased vulnerability to poor resolution of homeostasis following stress, which increases the risk of adverse outcomes including falls, delirium, and disability. We corrected the phrase to sentences below and this is described on page7 lines263-266: The definition of ‘Frailty’ is a state of increased vulnerability to poor resolution of homeostasis following stress, which increases the risk of adverse outcomes including falls, delirium, and disability [51, 52]. Although the criteria of ‘frailty’ vary, the two principal models of ‘frailty’ are the phenotype model suggested by Fried et al. known as the ‘Fried frailty criteria’ and the cumulative deficit model represented by the Canadian Study of Health and Aging (CSHA) Frailty Index [52-54].
We also added a description with respect to the relationship between frailty and sarcopenia on page8 lines294-298.: “Frailty also has close links with sarcopenia [48, 58]. Although the concepts of frailty and sarcopenia are evolving, frailty is focused on a framework to detect persons with a high risk of disability. On the other hand, sarcopenia is considered a muscle failure or muscle insufficiency that may lead to physical frailty [58]. In this context, both the concepts overlap in the physical element [58]”
Author Response File: 
Author Response.docx
Reviewer 2 Report
I was happy to read the paper "Surgical indications of robot-assisted radical prostatectomy in “Elderly” and “Frail” patients".
The authors have conducted a thorough review of the literature. There are previous reviews on the subject that have been left out, but the current paper does include more recent works and therefore adds an updated insight. In general, the authors have produced a solid manuscript.
Minor concerns:
Regarding frailty, it would have been interesting if the review had included extensive work on the correlation between iliopsoas girth and the risk of post-surgical mortality. Granted, these papers are primarily on abdominal surgery, but one can't argue that the fields are related.
Major concerns:
- The title does not match the content of the paper as no "surgical indications" are presented. This should be rewritten to match what it is the authors have done: A review! At least the phrase "review" must be added. There is in general very little focus on the "surgical indications", much more on outcomes. Hence there is a mismatch between the title/abstract and the main text.
-My main concern is concerning language—the English needs to be reviewed and, in most cases, simplified. The language is sometimes unnecessarily complex, and the manuscript is riddled with dangling modifiers. This makes it rather tough to read.
I would be happy to review the paper again providing it undergoes a major revision.
Author Response
Dear reviewer2,
Thank you very much for giving us the opportunity to submit a revised draft of the manuscript “Surgical tolerability and frailty in elderly patients undergoing robot-assisted radical prostatectomy: A narrative review” for publication in Cancers.
We appreciate the time and effort that you have dedicated to providing feedback on our manuscript. We are grateful for the insightful comments on our paper and have tried our best to incorporate most of the suggestions made by the reviewers. Listed below is a point-by-point response to the reviewers’ comments and concerns. All page numbers refer to the revised manuscript file. Comments of the reviewers are in italics and our responses to these comments are in bold characters. The corrected parts are shown by tracked changes in the main manuscript. We hope you find our revised manuscript suitable for publication in your journal. Thank you.
Kind regards,
Yuta Yamada, MD, PhD
The comments of reviewer2:
I was happy to read the paper "Surgical indications of robot-assisted radical prostatectomy in “Elderly” and “Frail” patients".
The authors have conducted a thorough review of the literature. There are previous reviews on the subject that have been left out, but the current paper does include more recent works and therefore adds an updated insight. In general, the authors have produced a solid manuscript.
Minor concerns:
Regarding frailty, it would have been interesting if the review had included extensive work on the correlation between iliopsoas girth and the risk of post-surgical mortality. Granted, these papers are primarily on abdominal surgery, but one can't argue that the fields are related.
→ Thank you for the suggestion. We added some review and a description of sarcopenia in multiple parts of the manuscript. Unfortunately, we could not find papers on iliopsoas girth in association with surgical tolerability in RARP procedures.
On page 6 lines 185-192:
Low serum testosterone level also correlates positively with lean body mass, which can be calculated by subtracting the weight of all the fat from the total weight of the body [35]. Interestingly, androgen deprivation therapy may selectively decrease lower-limb muscle function mediated by reduction of the iliopsoas and quadriceps force by 14% and 11%, respectively [36]. Another study investigating sarcopenia during ADT for PCa revealed that men of age ≥70 years had significantly greater reduction of lean body mass than that of younger men [35]. Taken together, ADT may accelerate the deterioration of mobility in elderly men undergoing ADT for PCa.
On page 7 lines 254-255:
This reduction of muscle mass and strength is known as sarcopenia, which correlates with an increased risk of frailty and falling [48].
On page8 lines295-299:
Frailty also has close links with sarcopenia [48, 58]. Although the concepts of frailty and sarcopenia are evolving, frailty is focused on a framework to detect persons with a high risk of disability. On the other hand, sarcopenia is considered a muscle failure or muscle insufficiency that may lead to physical frailty [58]. In this context, both concepts overlap in the physical element [58].
Major concerns:
- The title does not match the content of the paper as no "surgical indications" are presented. This should be rewritten to match what it is the authors have done: A review! At least the phrase "review" must be added. There is in general very little focus on the "surgical indications", much more on outcomes. Hence there is a mismatch between the title/abstract and the main text.
→ We agree with the reviewer’s suggestion and corrected the title to “Surgical tolerability and frailty in elderly patients undergoing robot-assisted radical prostatectomy: A narrative review”. The title included the phrase “review” as the reviewer pointed out.
We also corrected the summary in line with the title and the main manuscript on page1 lines14-19:
One important element to determine surgical indications is surgical tolerability. However, evidence is scarce regarding the surgical tolerability in elderlymen undergoing robot-assisted radical prostatectomy (RARP). In this review, we focused on the surgical tolerability in ‘elderly’ and/or ‘frail’ men undergoing RARP, with the intent to provide up-to-date information on this matter and to support the decision-making of therapeutic options in this spectrum of patients.
In addition, we corrected the term ‘surgical indication’ to ‘surgical tolerability’ throughout the manuscript.
-My main concern is concerning language—the English needs to be reviewed and, in most cases, simplified. The language is sometimes unnecessarily complex, and the manuscript is riddled with dangling modifiers. This makes it rather tough to read.
→ We are very sorry that our manuscript was tough to read for the reviewer. We had our manuscript read by a native English speaker and corrected grammar in the manuscript. The proofread certificate is also uploaded.
I would be happy to review the paper again providing it undergoes a major revision.
→ We thank you again for your time and effort in reviewing this manuscript.
806 WORDSAuthor Response File: Author Response.docx
Round 2
Reviewer 2 Report
I would very much like to see the certificate from the professional proof-reader. A "native" English speaker is to me not sufficient for the language standard of the journal. I am otherwise happy with the content of the revised paper and the responses to my comment, just the language remains.
The new title:
Surgical tolerability and frailty in elderly patients undergoing robot-Assisted Radical Prostatectomy: A narrative review.
The word "frailty" as it stands after "surgical tolerability" is incorrect, as there is no "surgical frailty". Indeed, patients can be more or less "frail" but "surgical frailty" is not a concept.
Indeed, the manuscript needs professional proof-reading.
