Improving Estimates of Perioperative Morbidity After Radical Cystectomy Using the European Association of Urology Quality Criteria for Standardized Reporting and Introducing the Comprehensive Complication Index

Abstract

Background: No procedure-specific definitions in complication reporting have been universally accepted in urological surgery, and conventional classification systems do not reflect cumulative morbidity.

Objective: To conduct a rigorous assessment of 30-d complications after radical cystectomy and improve morbidity estimates by introducing the novel Comprehensive Complication Index (CCI).

Design, setting, and participants: A retrospective proof-of-concept study of 506 patients with bladder cancer between 2009 and 2017.

Intervention: Radical cystectomy with pelvic lymph node dissection.

Outcome measurements and statistical analyses: Thirty-day complications were extracted from digital charts based on a procedure-specific catalog. Each complication was graded by the Clavien-Dindo classification (CDC), and each individual CCI was calculated. We evaluated traditional morbidity endpoints and tested the ability of both classification tools to mirror cumulative morbidity. Multivariable regression analyses were employed for risk modeling using conventional and novel endpoints. The study fulfilled all the European Association of Urology (EAU) criteria of standardized reporting. Limitations include restricted follow-up of 30 d.

Results and limitations: Of 506 patients, 503 (99%) experienced a total of 2485 complications, of which the majority was classified as "minor" (CDC grade ≤ IIIa; 89%). Overall, 29 (5.7%), 20 (4.0%), and 12 (2.4%) patients were reoperated, readmitted, and died within 30 d, respectively. When using the CCI to capture cumulative morbidity, the proportion of patients with most severe complication burden (CDC grade ≥ IIIb or corresponding CCI > 33.7) increased to 31% as compared with 11% when considering only the highest-grade complication according to the CDC. Age-adjusted comorbidity and delta hemoglobin were the main drivers of perioperative complications for all outcomes in multivariable models.

Conclusions: The assessment of short-term morbidity after radical cystectomy may be refined and optimized by employing the EAU criteria of standardized reporting and using the CCI to capture cumulative morbidity. These are the cornerstones of urgently needed procedure-tailored benchmarking to improve comparability and quality control.

Patient summary: Characterization of short-term morbidity after radical cystectomy was improved by using several validated assessment tools and adhering to existing guidelines for reporting surgical complications.

Keywords: Clavien-Dindo classification; Comorbidity; Postoperative complications; Quality improvement; Urinary bladder neoplasms.