LONGER OPERATIVE TIME AND HOSPITAL STAY ARE ASSOCIATED WITH POST-OPERATIVE CYSTECTOMY COMPLICATIONS: A MODIFIED CLAVIEN CLASSIFICATION SYSTEM ANALYSIS

Aim of the study To evaluate the applicability of the modified Clavien classification system (CCS) in grading perioperative complications of radical cys- tectomy in patients with bladder cancer. Materials and methods A consecutive series of patients with primitive or recurrent bladder cancer treated with radical cystectomy from April 2011 to March 2012 at fourteen academic centres in Europe were evaluated for complications occurring up to the end of the first postoperative month. All complications were prospectively recorded and classified according to the modified CCS. Results were presented as com- plication rates per grade. Chi-square and Kruskal Wallis tests and binary logistic regression analysis were used for statistical analysis. Results:465 patients were prospectively enrolled. Mean age was 69±9.6 years; mean BMI was 28.5±6.3 Kg/m2. Mean bladder tumors size was 4.2±2 cm, mean number of bladder lesions was 1.74±2.03. All patients underwent radical cystectomy. Urinary diversion con- sisted in orthotopic neobladder in 112 patients (24%), ileal conduit in 217 patients (46.5%) and ureterocutaneostomy in 138 patients (29.6%). Mean operative time was 277±118 minutes. Mean hos- pital stay was 15±10 days. 404 complications were recorded in 302 patients. Overall perioperative morbidity rate was 86%. Most of them were not serious and were classified as Clavien type I (109 cases; 26%) or II (220 cases, 54%). Higher grade complications were observed: Clavien type IIIa in 45 cases (11%), IIIb in 22 cases (5%); IV in 11 cases (2%) and V in 8 cases (2%). Reoperation rate was 5% (16 patients) for severe wound infection (8 patients), urinary anastomosis leakage (4 patients) and ileal perforation or occlusion (11 patients). Patients who underwent ileal conduit urinary diversion presented a higher rate of CCS type IIIa complications (27 cases, 60%) when compared to the other urinary diversions (p=0.04). No significant association between age, BMI, ASA score, anti-coagulant treatment, preoperative hydronephrosis, operative time, hospital stay and the occurrence of any type of complications were ob- served. A longer operative time and a longer hospital stay were sig- nificantly associated at an higher risk of CCS complications type III in univariate and multivariate analysis (OR: 1.005; CI: 1.002-1.007 per minute; p=0.0001 and OR: 1.117 per day; CI: 1.071-1.165; p=0.001, respectively). Discussion The modified CCS is a practical and easily applicable tool that may help urologists to classify the complications of radical cystectomy and urinary diversion in a more objective and detailed way.Conclusions In our experience, using this CCS tool, radical cystectomy is as- sociated with a significant morbidity (86%) and an acceptable reoperation rate (5%). Longer operative time and longer hospital stay are associated with a higher risk of severe post operative complications. .