EVALUATION OF POSTOPERATIVE RADICAL CYSTECTOMY COMPLICATIONS: A MODIFIED CLAVIEN CLASSIFICATION SYSTEM ANALYSIS

Introduction: The modified Clavien classification system has been proposed to classify and grade complications in general surgery and in the last years it is increasingly becoming a popular method in urology. Aim of our study was to evaluate the applicability of the modified Clavien classification system (CCS). Patients and Methods: A consecutive series of patients with primitive or recurrent bladder cancer treated with radical cystectomy from April 2011 to August 2011 at eleven academic centres in Europe were evaluated for complications occurring up to the end of the first postoperative month. Variables analyzed for each patient were: age, sex, asa score, anticoagulation therapy, type of diversion, operation time, preoperative hydronefrosis and BMI All complications were prospectively recorded and classified according to the modified CCS. Results were presented as complication rates per grade. Chi-square and Kruskal Wallis tests and binary logistic regression analysis were used for statistical analysis. Results: 194 patients were prospectively enrolled. Mean age was 57.8±12.7 years; mean BMI was 21.5±2.3 Kg/m2. Mean bladder tumors size was 3.6±3.7 cm, mean number of bladder lesions was 2±2. All patients underwent radical cystectomy. Urinary diversion consisted in orthotopic neobladder in 44 patients (23%), ileal conduit in 89 patients (46%) and ureterocutaneostomy in 61 patients (31%). Mean operative time was 307±55 minutes. Mean hospital stay was 14.5±2.4 days. 185 complications were recorded in 123 patients. Overall perioperative morbidity rate was 63%. Most of them were not serious and were classified as Clavien type I (51 cases; 27.5%) or II (91 cases, 49%). Higher grade complications were observed: Clavien type IIIa in 15 cases (8%), IIIb in 18 cases (10%); IVa in 5 cases (3%), IVb in 2 cases (1%) and V in 3 cases (1.5%). Reoperation rate was 8% (16 patients) for severe wound infection (4 patients), urinary anastomosis leakage (4 patients) and ileal perforation or occlusion (7 patients). Patients who underwent ileal conduit urinary diversion presented a higher rate of CCS type I complications (58%) when compared to other urinary diversions (p=0.034). No significant association was found between Age, BMI, ASA score, anti-coagulant treatment, preoperative hydronephrosis, operative time, hospital stay and CCS type I or ≥IIIb complications. Patients with CCS complications type II and IIIa presented a significant longer operative time and hospital stay in univariate and multivariate analysis (p=0.01) Discussion and Conclusion: The modified CCS represents 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. In our experience, using this CCS tool, radical cystectomy is associated with a higher morbidity (63%), an 8% reoperation rate and a 1.5% of mortality. Ileal conduit urinary diversion has a higher rate of type I complications. Longer operative time and longer hospital stay are associated with a higher risk of post operative complications.