Clavien-Dindo System Research Articles

Comparison of minimal access and traditional anterior spinal surgery in managing infectious spondylitis: a minimum 2-year follow-up

Background contextTraditional anterior spinal surgery (TASS) for the thoracolumbar spine is associated with significant morbidities. To avoid excessive tissue damage, minimal access spinal surgery (MASS) has been developed to treat a variety of anterior spinal disorders at the authors' institution. No previous reports comparing the outcomes of MASS and TASS for the treatment of infectious spondylitis were noted in the literature, to our knowledge. PurposeThe aim of this study was to investigate the outcomes of MASS in managing infectious spondylitis and compare the results to TASS with a minimum follow-up of 2 years. Study designA retrospective comparative cohort study in a single center. Patient sampleForty patients with thoracic or lumbar infectious spondylitis who underwent anterior spinal surgery were enrolled. Outcome measuresPerioperative data including operative time, estimated blood loss, packed red blood cell transfusion, postoperative tube drainage, need for intensive care, and length of hospital stay. Postoperative complications were classified according to the Clavien-Dindo system. Fusion grade was assessed by plain radiographs on the basis of Burkus criteria. MethodsBetween January 2002 and June 2010, all enrolled patients were collected via the Spine Operation Registry of the authors' institution. There were 23 MASS patients and 17 TASS patients. The average follow-up was 4.2 years (range, 2–9 years). ResultsThe mean estimated blood loss in MASS and TASS groups was 521.7 versus 979.4 mL (p=.007), intraoperative transfusion of packed red blood cells was 0.9 versus 2.7 units (p=.019), the amount of postoperative tube drainage was 235.2 versus 454.3 mL (p=.005), the number of patients requiring postoperative intensive care was 2 versus 7 (p=.023), and length of hospital stay was 15.4 versus 22.9, respectively (p=.043). The overall complication rate in the MASS group was 17% and 59% in the TASS group (p=.007). No major complications occurred in the MASS group, whereas four occurred in the TASS group (p=.026). Bone graft union was achieved in 38 of 39 survival patients (97%), with no difference between the groups. One patient in TASS had a pseudarthrosis and needed a posterior instrumented fusion. ConclusionsMinimal access spinal surgery has been suggested to be an effective and safe technique in treating thoracic and lumbar infectious spondylitis. Minimal access spinal surgery did not need endoscopic equipments or complex surgical instruments. Furthermore, in comparison to TASS, MASS resulted in a reduced blood transfusion amount, decreased intensive care unit stay, reduced overall length of stay, and reduced surgical complication rate. Nevertheless, the risks may be increased in performing MASS on patients with multilevel involvement, which could be associated with high vascularity, alternated vascular anatomy, increased soft-tissue edema, and adhesion.

Zonal NePhRO Scoring System: A Superior Renal Tumor Complexity Classification Model

BackgroundSince the advent of the first standardized renal tumor complexity system, many subsequent scoring systems have been introduced, many of which are complicated and can make it difficult to accurately measure data end points. In light of these limitations, we introduce the new zonal NePhRO scoring system. Patients and MethodsThe zonal NePhRO score is based on 4 anatomical components that are assigned a score of 1, 2, or 3, and their sum is used to classify renal tumors. The zonal NePhRO scoring system is made up of the (Ne)arness to collecting system, (Ph)ysical location of the tumor in the kidney, (R)adius of the tumor, and (O)rganization of the tumor. In this retrospective study, we evaluated patients exhibiting clinical stage T1a or T1b who underwent open partial nephrectomy performed by 2 genitourinary surgeons. Each renal unit was assigned both a zonal NePhRO score and a RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, location relative to polar lines) score, and a blinded reviewer used the same preoperative imaging study to obtain both scores. Additional data points gathered included age, clamp time, complication rate, urine leak rate, intraoperative blood loss, and pathologic tumor size. ResultsOne hundred sixty-six patients underwent open partial nephrectomy. There were 37 perioperative complications quantitated using the validated Clavien-Dindo system; their occurrence was predicted by the NePhRO score on both univariate and multivariate analyses (P = .0008). Clinical stage, intraoperative blood loss, and tumor diameter were all correlated with the zonal NePhRO score on univariate analysis only. ConclusionThe zonal NePhRO scoring system is a simpler tool that accurately predicts the surgical complexity of a renal lesion.

Fatores preditivos de complicações graves em cirurgia neonatal

To investigate the incidence and severity of early postoperative complications and to identify their risk factors in newborns undergoing surgery under general anesthesia. We conducted a retrospective analysis of data from 437 critically ill newborns undergoing surgery in a tertiary pediatric surgical center, between January 2000 and December 2010. Complications that occurred within the first 30 days after surgery were classified using the Clavien-Dindo system, for which grades III to V were considered severe. We used univariate and multivariate analysis to evaluate pre- and intraoperative variables potentially predictive of severe postoperative complications. The incidence of at least one serious complication was 23%, with a median of one complication per patient 1:3. Altogether, there were 121 serious complications. Of these, 86 required surgical, endoscopic or radiological interventions (grade III), 25 endangered life, with uni or multi-organ failure (grade IV) and ten resulted in death (grade V). The most common complications were technical (25%), gastrointestinal (22%) and respiratory (21%). We identified four independent risk factors for severe postoperative complications: reoperation, operation for congenital diaphragmatic hernia, preterm birth less than 32 weeks of gestational age and abdominal surgery. The incidence of severe postoperative complications after neonatal surgeries under general anesthesia remains high. The conditions considered independent risk factors for those can guide interventions to improve results.

Impact of a Low-Volume Laparoscopic Radical Prostatectomy Learning Curve on Perioperative Outcomes: Is It Acceptable?

The reproducibility of high-volume published series of laparoscopic radical prostatectomy (LRP) is still debatable. Many questions about its implementation, safety, and number of procedures required to achieve competence and improvement of outcomes with the technique remain unclear, and a learning curve study is crucial to investigate the acceptable performance of this advanced, minimally invasive procedure. Between 2004 and 2011, 240 consecutive patients underwent an LRP performed by a single surgeon and were divided into the first, second, and third groups of 80 patients each. Perioperative and oncologic outcomes were compared across the groups to assess the impact of the learning curve for LRP. All surgical complications were classified using the Clavien-Dindo system (CDS). Mean (range) patient age was 61 (43-78) years. The mean (range) level of prostate-specific antigen was 6.47 (3-18) ng/mL. The mean (range) Gleason sum was 6 (5-9). There was a significant reduction in the mean operative time (P<.001), mean anastomosis time (P<.001), mean blood loss (P<.001), mean hospital stay (P<.001), and mean minor CDS complications (P<.01) among the three groups as the series progressed. The D'Amico tumor stage was an independent factor for positive surgical margin across the learning curve (P<.001). Our study demonstrated safety and low morbidity of the LRP technique since the beginning of a learning curve development, in which up to 80 cases were necessary to create a plateau to improve faster perioperative parameters, although, from the plateau created, it requires a very large number of surgeries for slightly better, additional overall benefits. In spite of its complexity and steep learning curve, new surgeons can be encouraged in the LRP technique with mentorship training without compromising overall outcomes, permitting the wide spread of an alternative minimally invasive procedure in low-volume centers.

Beyond the Learning Curve of the Retzius-sparing Approach for Robot-assisted Laparoscopic Radical Prostatectomy: Oncologic and Functional Results of the First 200 Patients with ≥1 Year of Follow-up

BackgroundRobot-assisted laparoscopic radical prostatectomy (RARP) has become the main surgical option for localized prostate cancer. We recently developed a new approach for RARP, passing through the pouch of Douglas and avoiding all the Retzius structures involved in continence and potency preservation. ObjectiveTo report the functional and oncologic results of our first 200 patients operated on using this new approach. Design, setting, and participantsThis was a prospective, noncontrolled case series including the first 200 consecutive patients undergoing this kind of surgery (January the 1st, 2010 to December the 31st, 2011). Surgical procedureRetzius-sparing RARP. Outcome measurements and statistical analysisAll perioperative, oncologic, and functional data were prospectively recorded. Potency was defined as an International Index of Erectile Function-5 questionnaire score >17; continence was defined as use of no pad or of one safety liner. Oncologic results were reported as positive surgical margins (PSM) and 1-yr biochemical disease-free survival (1y-bDFS). Recurrence was defined as a repeated prostate-specific antigen >0.2 ng/ml. Complications were graded according to the Clavien-Dindo system. The first 100 patients (group 1) were compared with the second 100 (group 2) to evaluate the learning curve effects. Results and limitationsThe median patient age was 65 yr. Comparing the two groups, transfusions were needed in 8% versus 4% of cases in groups 1 and 2, respectively (p=0.02). There was one Clavien-Dindo grade 3b in group 1 versus one grade 3a complication in group 2. In patients with pT2 disease, PSMs were recorded in 22.4% of those in group 1 versus 10.1% in group 2 (p=0.045). 1y-bDFS was 89% in group 1 versus 92% in group 2. For groups 1 and 2, respectively, immediate continence was reached in 92% versus 90% of patients, and the 1-yr continence rate was 96% versus 96%. Considering the 77 potent patients aged <65 yr who underwent bilateral intrafascial nerve-sparing surgery, 40.4% of those in group 1 versus 40% of those in group 2 reached their first intercourse within 1 mo; at 1 yr of follow-up, these figures had increased to 81% versus 71%, respectively (p=0.162). The main limitation of this study is its noncontrolled nature. ConclusionsWe demonstrated Retzius-sparing RARP to be oncologically safe and to result in high early continence and potency rates. Long-term, prospective, comparative, and possibly randomized studies are needed.

Oncologic, Functional, and Complications Outcomes of Robot-assisted Radical Cystectomy with Totally Intracorporeal Neobladder Diversion

BackgroundRobot-assisted radical cystectomy (RARC) with totally intracorporeal neobladder diversion is a complex procedure that has been reported with good outcomes in small series. ObjectiveTo present complications and oncologic and functional outcomes of this procedure. Design, setting, and participantsBetween 2003 and 2012 in a tertiary referral center, 70 patients were operated on by two experienced robotic surgeons. Data were collected prospectively and reviewed retrospectively. InterventionRARC with totally intracorporeal modified Studer ileal neobladder formation. Outcome measurements and statistical analysisThe overall outcome of RARC with a totally intracorporeal neobladder was presented by assessing (1) surgical margins, (2) recurrence or cancer-specific death at 24 mo, (3) 30-d and 90-d complications graded according to the modified Clavien-Dindo system, (4) daytime and nighttime continence (no or one pad per day) at 6 and 12 mo, and (5) satisfactory sexual activity or potency at 6 mo and 12 mo. Survival rates were estimated by Kaplan-Meier plots. Results and limitationsMedian follow-up of the cohort was 30.3 mo (interquartile range: 12.7–35.6). We recorded negative margins in 69 of 70 patients (98.6%). Clavien 3–5 complications occurred in 22 of 70 patients (31.4%) at 30 d and 13 of 70 (18.6%) at >30 d. At 90 d, the overall complication rate was 58.5%. Clavien <3 and Clavien ≥3 complications were recorded in 15 of 70 patients (21.4%) and 26 of 70 (37.1%), respectively. Kaplan-Meier estimates for recurrence-free, cancer-specific, and overall survival at 24 mo were 80.7%, 88.9%, and 88.9%, respectively. Daytime continence and satisfactory sexual function or potency at 12 mo ranged between 70% and 90% in both men and women. Limitations of this study include its retrospective design, selection bias due to the learning curve phase, and missing data. ConclusionsIn this expert center for RARC, outcomes after RARC with totally intracorporeal neobladder diversion appear satisfactory and in line with contemporary open series.

Postoperative complications after major head and neck surgery with free flap repair—prevalence, patterns, and determinants: a prospective cohort study

This study aims to give a better understanding of the prevalence, patterns, and determinants of postoperative complications, to evaluate the Clavien–Dindo classification of surgical complications, and to set out a protocol to improve postoperative recovery. Over a period of 27 months we studied 192 patients who had had major head and neck operations with free flaps. Data on complications were gathered prospectively along with patients’ details, comorbidities, factors indicative of the magnitude of the surgical insult, and variations in perioperative care. Complications were classified according to the Clavien–Dindo system. Outcomes analysed comprised any complication, major complications (Clavien–Dindo III and above), wound complications, and pulmonary complications. A total of 64% of patients had complications, and in around one third they were serious; wound and pulmonary complications were the most common. Factors significantly associated with complications reflected an interaction between coexisting conditions of the patient at operation and the magnitude of the surgery. Perioperative interventions to ensure preoperative optimisation of patients, and to lessen the systemic inflammatory response that results from operation offer the best prospect of reducing the burden of surgical complications. A protocol to improve recovery after operation would be appropriate. The Clavien–Dindo classification of surgical complications is useful in this group.

1922 CONTEMPORARY MORBIDITY RELATED OUTCOMES OF NEPHRECTOMY AND IVC THROMBECTOMY FOR RCC USING A VALIDATED COMPLICATION TOOL

You have accessJournal of UrologyKidney Cancer: Advanced (II)1 Apr 20131922 CONTEMPORARY MORBIDITY RELATED OUTCOMES OF NEPHRECTOMY AND IVC THROMBECTOMY FOR RCC USING A VALIDATED COMPLICATION TOOL Tony Kurian, Patrick N Espiritu, Timothy J Kim, Yin Zheng, Wade J Sexton, Julio M Pow-Sang, Devanand Mangar, Paul Armstrong, and Philippe E Spiess Tony KurianTony Kurian Tampa, FL More articles by this author , Patrick N EspirituPatrick N Espiritu Tampa, FL More articles by this author , Timothy J KimTimothy J Kim Tampa, FL More articles by this author , Yin ZhengYin Zheng Tampa, FL More articles by this author , Wade J SextonWade J Sexton Tampa, FL More articles by this author , Julio M Pow-SangJulio M Pow-Sang Tampa, FL More articles by this author , Devanand MangarDevanand Mangar Tampa, FL More articles by this author , Paul ArmstrongPaul Armstrong Tampa, FL More articles by this author , and Philippe E SpiessPhilippe E Spiess Tampa, FL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2341AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal cell carcinoma (RCC) associated with venous tumor thrombus often requires a multidisciplinary surgical approach for higher level inferior vena cava (IVC) tumor thrombi. Although potentially curative, very little has been reported on the outcomes of patients undergoing such procedures using valid complication tools such as the Clavien-Dindo system. The aim of the present study is to assess this clinical question within our patient cohort. METHODS A retrospective IRB protocol was approved prior to conducting the present study. A total of 125 consecutive patients underwent nephrectomy and IVC thrombectomy in the context of RCC at our respective center from 11/1989 to 5/2012, and they are the basis of this report. We categorized all perioperative complications using the validated prognostic Clavien-Dindo system. For patients who experienced multiple complications, we report the highest grade of complication. Events occurring within 30 days of the date of surgery were considered peri-operative complications. For the purposes of this study, we defined grade I and II complications as minor complications as they required no interventional procedure(s) whereas complications grade III or higher were considered major complications. RESULTS The patient cohort consisted of 125 patients, with a median age at presentation of 64 years. The male to female preponderance of cases were 89 (71%) and 36 (29%), respectively. The level of thrombus was I in 37 patients, II in 41 patients, III in 26 patients, and IV in 21 patients. Sixty-four patients (51%) experienced 83 complications. Of these, 34 (53%) were minor complications and 30 (47%) were major complications. The incidence of peri-operative complications for patients presenting with level I, II, III, and IV tumor thrombus were 51%, 44%, 58%, and 57%, respectively. Complication rates were not associated with the level of IVC tumor thrombus (p = 0.66). Overall peri-operative mortality rate was 9% (11 patients). Mortality rates were 5%, 15%, 4%, and 10% for patients with level I, level II, level III, and level IV thrombus, respectively. Mortality was not associated with level of thrombus (p = 0.38). Median follow-up was 16 months. CONCLUSIONS Significant morbidity and mortality is associated with nephrectomy with IVC thrombectomy. Importantly, neither mortality nor complications were associated with the proximal level of the IVC tumor thrombus. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e788 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tony Kurian Tampa, FL More articles by this author Patrick N Espiritu Tampa, FL More articles by this author Timothy J Kim Tampa, FL More articles by this author Yin Zheng Tampa, FL More articles by this author Wade J Sexton Tampa, FL More articles by this author Julio M Pow-Sang Tampa, FL More articles by this author Devanand Mangar Tampa, FL More articles by this author Paul Armstrong Tampa, FL More articles by this author Philippe E Spiess Tampa, FL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Reporting and grading of complications after urologic surgical procedures: An ad hoc EAU guidelines panel assessment and recommendations

ContextThe incidence of postoperative complications is still the most frequently used surrogate marker of quality in surgery, but no standard guidelines or criteria exist for reporting surgical complications in the area of urology. ObjectiveTo review the available reporting systems used for urologic surgical complications, to establish a possible change in attitude towards reporting of complications using standardised systems, to assess systematically the Clavien–Dindo system when used for the reporting of complications related to urologic surgical procedures, to identify shortcomings in reporting complications, and to propose recommendations for the development and implementation of future reporting systems that are focused on patient-centred outcomes. Evidence acquisitionStandardised systems for reporting and classification of surgical complications were identified through a systematic review of the literature. To establish a possible change in attitude towards reporting of complications related to urologic procedures, we performed a systematic literature search of all papers reporting complications after urologic surgery published in European Urology, Journal of Urology, Urology, BJU International, and World Journal of Urology in 1999–2000 and 2009–2010. Data identification for the systematic assessment of the Clavien–Dindo system currently used for the reporting of complications related to urologic surgical interventions involved a Medline/Embase search and the search engines of individual urologic journals and publishers using Clavien, urology, and complications as keywords. All selected papers were full-text retrieved and assessed; analysis was done based on structured forms. Evidence synthesisThe systematic review of the literature for standardised systems used for reporting and classification of surgical complications revealed five such systems. As far as the attitude of urologists towards reporting of complications, a shift could be seen in the number of studies using most of the Martin criteria, as well as in the number of studies using either standardised criteria or the Clavien–Dindo system. The latter system was not properly used in 72 papers (35.3%). ConclusionsUniformed reporting of complications after urologic procedures will aid all those involved in patient care and scientific publishing (authors, reviewers, and editors). It will also contribute to the improvement of the scientific quality of papers published in the field of urologic surgery. When reporting the outcomes of urologic procedures, the committee proposes a series of quality criteria.

Robot-Assisted Laparoscopic Prostatectomy: Nodal Dissection Results During the First 440 Cases by Two Surgeons

Although many studies address the learning curve for robot-assisted laparoscopic prostatectomy (RALP), little is known concerning the results for pelvic lymph node dissection (LND) during RALP. Between 2006 and 2011, two surgeons performed 904 RALP procedures. LND was performed in 440 (48.6%) cases based on the European Association of Urology guidelines. Both surgeons had extensive experience with open LND for both prostate and bladder cancer. Clinical data were prospectively recorded into an online database. Complications were reported using the Clavien-Dindo system and documented prospectively. For both surgeons, the operative time for LND decreased over time during the first 150 LND procedures. After that, a mean plateau of operative time of 49 minutes for LND was reached. Nodal yield increased from a mean of 10 nodes for the first 50 cases to 14 for cases 351 to 400. The percentage of positive nodes increased significantly in these intervals from 4% to 23.1% (P<0.001, Mann Whitney U test). Overall complications by grade were not significantly different between RALP with or without LND. In 440 LND cases, 5 (1.5%) grade IIIb complications occurred. All were infection related with bowel perforation in one. Symptomatic lymphoceles necessitating drainage were present in five (1.5%) men. Thromboembolic events (0% vs 1.5%) and anastomosis dehiscence (0.2% vs 1.1%) were more common in men with LND. During the learning curve, the incidence of Clavien grade I and II but not grade III and IV complications decreased. An improvement pattern for LND during RALP is observed for operative time, nodal yield node positivity rate, and complication rate during the first 400 cases of LND.

Comparison Between Living Donor Liver Transplantation Recipients Who Met the Milan and UCSF Criteria After Successful Downstaging Therapies

Background and AimsVarious downstaging therapies were introduced to liver recipients who could not meet the relative criteria for liver transplantation, and many endpoints were reported. The most common criteria used were the Milan criteria and the University of California, San Francisco (UCSF) criteria. However, no comparison was made between them, and we attempted to find possible differences between the living donor liver transplantation (LDLT) patients who met the Milan criteria and those who met the UCSF criteria after accepting preoperative downstaging therapies. Materials and MethodsWe performed a retrospective study of all 72 patients at our center from January 2003 to March 2009 who were diagnosed with advanced hepatocellular carcinoma but accepted various downstaging therapies. Some patients met the Milan criteria (group 1), and some met the UCSF criteria (group 2) but not the Milan criteria. We collected the data from the two groups and then compared the preoperative demographic data, downstaging therapies, intraoperative data from LDLT, and the recovery and complications after LDLT. Survival rates were compared using Kaplan–Meier analysis. ResultsOnly 44 patients (61.1 %) met the criteria for liver transplantation, 21 cases met the Milan criteria (group 1), and 23 cases met the UCSF criteria (group 2) but not the Milan criteria. All of the 44 patients accepted right lobe living liver donor liver transplantation in our center. The difference in the baseline characteristics between the two groups did not reach statistical significance. The mean number of downstaging treatments per patient was 1.81±0.35 in group 1 and 1.83±0.41 in group 2 (P = 0.928). Most of the patients received only one downstaging treatment, and transcatheter arterial chemoembolization (TACE) was the most common downstaging therapy. Four patients suffered complications after downstaging therapies: intra-abdominal hemorrhage after right hepatectomy, upper gastrointestinal hemorrhage after TACE, biliary fistula after resection, and hand–foot syndrome after taking sorafenib. All complications after LDLT, classified according to the Clavien–Dindo system, were compared within the two groups, and the calculated score of the complications in group 1 was 1.48 ± 1.63, which was greater than that of group 2 (1.39 ± 1.64), but this difference did not reach statistical significance (P = 0.865). The 1-, 3-, and 5-year survival rates were 90.4, 76.2, and 71.4 % in group 1 and 91.3, 73.9, and 69.6 % in group 2, respectively (P > 0.05). Seven patients (three in group 1 and four in group 2) had tumor recurrence after a median follow-up period of 72 months. The pathology findings were not different between the two groups. ConclusionRecipients who meet the Milan or UCSF criteria after accepting successful preoperative downstaging therapy in LDLT can achieve the same result.

Eraser Laser Enucleation of the Prostate: Technique and Results

BackgroundEraser, a 1318-nm diode laser, has been used for 15 yr for resection of lung metastases. It was recently introduced in urology for small kidney tumors and for the treatment of benign prostatic obstruction. ObjectiveTo demonstrate on video our technique of Eraser laser enucleation of the prostate (ELEP) and report our experience. Design, setting, and participantsFrom June 2010 to October 2011, 43 consecutive patients were prospectively evaluated. All of them had lower urinary tract symptoms suggestive of benign prostatic obstruction and a mean prostate size of 59.9ml (range: 34–89ml) on transrectal ultrasound. Their mean prostate-specific antigen value was 3.4 ng/ml (range: 0.8–5.0 ng/ml); mean maximum flow rate (Qmax), 6.9ml/s (range: 2–11ml/s); mean International Prostate Symptom Score (IPSS), 25.9 (range: 18–32); and mean postvoid residual (PVR), 170.5ml (range: 60–330ml). Surgical procedureThe details of the technique are shown on video. Outcome measurements and statistical analysisSuccess was defined as patients being able to void with improved IPSS, Qmax, PVR volume, and ameliorated quality of life. Results and limitationsThe mean operating time was 67.0±11.43min. Mean serum hemoglobin was 15.1±0.87g/l before, and 14.39±0.94g/l after surgery. Mean blood loss was 115.90±98.12ml. No blood transfusions were required. All patients had their catheters removed within 2 d and were able to void spontaneously after this time. Significant improvements were noted in Qmax, quality of life, IPSS, and PVR volume from baseline to each follow-up time point.Based on the validated Clavien-Dindo system, we observed one grade 1d complication, one grade 2 complication, and one grade 3b complication. ConclusionsELEP is a safe and reproducible method for relieving bladder outflow obstruction and lower urinary tract symptoms. Its advantages include minimal blood loss, short catheterization time, and a brief hospital stay.

Notificación y clasificación de complicaciones después de procedimientos quirúrgicos urológicos: una evaluación y recomendaciones del panel de guías clínicas de la EAU

ContextThe incidence of postoperative complications is still the most frequently used surrogate marker of quality in surgery, but no standard guidelines or criteria exist for reporting surgical complications in the area of urology. ObjectiveTo review the available reporting systems used for urologic surgical complications, to establish a possible change in attitude towards reporting of complications using standardised systems, to assess systematically the Clavien-Dindo system when used for the reporting of complications related to urologic surgical procedures, to identify shortcomings in reporting complications, and to propose recommendations for the development and implementation of future reporting systems that are focused on patient-centred outcomes. Evidence acquisitionStandardised systems for reporting and classification of surgical complications were identified through a systematic review of the literature. To establish a possible change in attitude towards reporting of complications related to urologic procedures, we performed a systematic literature search of all papers reporting complications after urologic surgery published in European Urology, Journal of Urology, Urology, BJU International, and World Journal of Urology in 1999–2000 and 2009–2010. Data identification for the systematic assessment of the Clavien-Dindo system currently used for the reporting of complications related to urologic surgical interventions involved a Medline/Embase search and the search engines of individual urologic journals and publishers using Clavien, urology, and complications as keywords. All selected papers were full-text retrieved and assessed; analysis was done based on structured forms. Evidence synthesisThe systematic review of the literature for standardised systems used for reporting and classification of surgical complications revealed five such systems. As far as the attitude of urologists towards reporting of complications, a shift could be seen in the number of studies using most of the Martin criteria, as well as in the number of studies using either standardised criteria or the Clavien-Dindo system. The latter system was not properly used in 72 papers (35.3%). ConclusionsUniformed reporting of complications after urologic procedures will aid all those involved in patient care and scientific publishing (authors, reviewers, and editors). It will also contribute to the improvement of the scientific quality of papers published in the field of urologic surgery. When reporting the outcomes of urologic procedures, the committee proposes a series of quality criteria.

Totally laparoscopic resection of the splenic flexure for tumor

Colonic tumors located at the splenic flexure are rare and show a higher occlusive risk than other colorectal cancers. The totally laparoscopic segmental resection of splenic flexure represents a challenging procedure that requires adequate technical skills and for this reason it is still not widespread and validated. Between October 2010 and March 2012, a consecutive unselected series of eight (N = 8) patients underwent totally laparoscopic splenic flexure resection at our Institute. Data on patients' demographics, disease features, operative details and short-term follow-up were prospectively recorded in a specific database and retrospectively analyzed. All the operations were performed or supervised by the same surgeon (I.S.). We used a four-port medial-to-lateral standardized technique with intracorporeal anastomosis. A selective vascular ligation was performed in all cases and the specimens were extracted through a protected incision. Perioperative care plan and surgical instrumentations were standardized. Complications were classified using the Clavien-Dindo classification system. No conversion to open surgery was registered. All cases achieved an adequate number of lymph nodes harvested (22.9 ± 5.2) and an oncologically correct resection of the tumor (proximal margin 7.0 ± 2.4 cm, distal margin 7.1 ± 2.8 cm). The mean hospital stay was 6.1 ± 1.3 days. Postoperative complication rate according to the Clavien-Dindo system was 37.5 %, but all the complications reported were grade I. We did not observe any reoperation or readmission within 60 days after discharge. Totally laparoscopic splenic flexure resection is a feasible and reproducible technique. A correct surgical indication and a standardized technique allow to perform an oncologically safe and functionally effective treatment.

Reply

Over the past decade, interest in and use of radiofrequency ablation (RFA) for treatment of renal tumors has increased substantially. RFA can be achieved by either a laparoscopic or a percutaneous approach. There are no published guidelines for choosing between the laparoscopic and percutaneous approaches. Each approach has theoretical and proven advantages and disadvantages, which can lead to confusion and inefficiencies in the referral process for patients with renal masses. We present a retrospective, single-center comparison of complications between patients undergoing laparoscopic RFA (LRFA) and percutaneous RFA (PRFA) because of a renal mass. The complication rate is not significantly different between LRFA and PRFA. Although we do not focus on oncological outcomes in this study, our previous studies suggest that there is a slightly higher rate of primary treatment failure in the percutaneous group than in the laparoscopic group. 1 Ji C. Li X. Zhang S. et al. Laparoscopic radiofrequency ablation of renal tumors: 32-month mean follow-up results of 106 patients. Urology. 2011; 77: 798-802 Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar , 2 Zhang S. Li X. Zhang G. et al. Treatment of renal tumors with ultrasound-guided percutaneous radiofrequency ablation. Jiangsu Med J. 2010; 36: 2243-2245 Google Scholar Imprecise targeting of renal masses may result in collateral damage or imperfect ablations, which lead to most ablation-related complications and/or failures. The laparoscopic approach allows aggressive mobilization of renal tumors and placement of the probe under direct vision, which leads to more accurate tumor targeting than the percutaneous approach. 3 Vricella G.J. Ponsky L.E. Cadeddu J.A. Ablative technologies for urologic cancers. Urol Clin North Am. 2009; 36: 163-169 Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In the laparoscopic approach, especially for exophytic and parenchymal tumors, the surgeon can observe the change of the developing thermal damage directly, and extra cycles of RFA can be performed easily if ablation is considered incomplete. Furthermore, in some cases where the ureter, ureteropelvic junction, or colon is near the tumor, the increased exposure and visualization of the kidney would prevent adjacent organ injury during ablation. Editorial CommentUrologyVol. 80Issue 1PreviewThe authors present a descriptive analysis of complications from laparoscopic and percutaneous radiofrequency ablation (RFA) using the Clavien-Dindo system.1 The groups are well matched in terms of medical comorbidities and tumor characteristics (ASA class, and RENAL nephrometry score, respectively).2,3 Although their findings do not demonstrate any significant differences in complication rates between the two approaches, their study is nonetheless limited by sample size, which may explain why length of ablation time was found as the only factor associated with complications on multivariable analysis. Full-Text PDF

1427 R.E.N.A.L. NEPHROMETRY SCORE CAN PREDICT FOR COMPLICATIONS AND URINARY FISTULA FOLLOWING PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized III1 Apr 20121427 R.E.N.A.L. NEPHROMETRY SCORE CAN PREDICT FOR COMPLICATIONS AND URINARY FISTULA FOLLOWING PARTIAL NEPHRECTOMY Michael Knox, Tyler Poston, Kristin Broderick, Rizk El-Galley, and J. Erik Busby Michael KnoxMichael Knox Birmingham, AL More articles by this author , Tyler PostonTyler Poston Birmingham, AL More articles by this author , Kristin BroderickKristin Broderick Birmingham, AL More articles by this author , Rizk El-GalleyRizk El-Galley Birmingham, AL More articles by this author , and J. Erik BusbyJ. Erik Busby Birmingham, AL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1900AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES R.E.N.A.L. nephrometry score is a qualitative system that assigns a score based on the complexity of the mass. Emerging evidence demonstrates that the R.E.N.A.L. score can affect perioperative outcomes. Our objective was to examine our partial nephrectomy experience with respect to the ability of the R.E.N.A.L. nephrometry score to predict outcomes, specifically complication and urinary fistula. METHODS Data from 198 consecutive partial nephrectomies was evaluated from 2008-2010. Pre-operative imaging data was available for 163 patients. Imaging was reviewed and a R.E.N.A.L. score was assigned. R.E.N.A.L. score was statistically analyzed both individually and stratified into three groups (4-5, 6-8, > 9). RESULTS An increasing R.E.N.A.L. score individually predicted for complications based on the Clavien-Dindo system, (p=0.024). R.E.N.A.L. scores 9 and 10 predicted the highest complication rate of 48% and 35%, respectively. Patients who developed a urinary leak had an increased R.E.N.A.L. score 8.8 vs. 6.7, (p=0.05). When evaluating based on three groups, an increasing R.E.N.A.L. score predicted for longer duration of fistula (p=0.002). Specifically, a score of > 9 compared to 6-8 predicted for longer duration of urinary leak, 31 days vs. 22 days (p=0.003). On multivariate analysis, we evaluated risk factors for complications and found that R.E.N.A.L. score predicted for complications (p=0.013). Finally, when the R.E.N.A.L. score was stratified into three groups it also predicted for complications (p=0.003). CONCLUSIONS Increasing R.E.N.A.L. scores predicted for complications following partial nephrectomy including urinary fistula formation and duration of fistula. In particular, R.E.N.A.L. score of > 9, predicted for increased duration of urinary fistula. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e579 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Knox Birmingham, AL More articles by this author Tyler Poston Birmingham, AL More articles by this author Kristin Broderick Birmingham, AL More articles by this author Rizk El-Galley Birmingham, AL More articles by this author J. Erik Busby Birmingham, AL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

2180 ERASER LASER ENUCLEATION OF THE PROSTATE (ELEP) VERSUS BIPOLAR TURP

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy and New Technology III1 Apr 20122180 ERASER LASER ENUCLEATION OF THE PROSTATE (ELEP) VERSUS BIPOLAR TURP Lukas Lusuardi, Tobias Schätz, Stephan Hruby, Manuela Sieberer, Reinhold Zimmermann, and Günter Janetschek Lukas LusuardiLukas Lusuardi Salzburg, Austria More articles by this author , Tobias SchätzTobias Schätz Salzburg, Austria More articles by this author , Stephan HrubyStephan Hruby Salzburg, Austria More articles by this author , Manuela SiebererManuela Sieberer Salzburg, Austria More articles by this author , Reinhold ZimmermannReinhold Zimmermann Salzburg, Austria More articles by this author , and Günter JanetschekGünter Janetschek Salzburg, Austria More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2353AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Goal of the present study was to ascertain safety and efficacy of a 1,318-nm diode laser for transurethral enucleation of the prostate comparing it to the “gold standard” bipolar transurethral resection of the prostate (TURP). The Eraser laser has been successfully used to resect lung metastasis. It has been recognized to cut and coagulate vascular rich tissue safely and effectively. We describe a prospective randomized trial of Eraser enucleation (ELEP) of the prostate versus TURP. METHODS A total of 100 patients with lower urinary tract symptoms suggestive of bladder outlet obstruction and a mean prostate size of 61.3 ml on transrectal ultrasound were randomized to ELEP or bipolar TURP. Patients were assessed preoperatively and at 1 and 6 months postoperatively. RESULTS ELEP was equivalent to bipolar TURP in terms of improvement in IPSS, maximal flow rates and quality of life. ELEP was significantly superior to bipolar TURP for measured blood loss (114.54 ± 95.02 vs 389.80 ± 138.60ml, p<0.05), catheter time (31.70 ± 7.79 vs 63.74 ± 13.72 hours, p<0.05) and hospital time (43.15 ± 14.56 vs 89.10 ± 10.73 hours, p<0.05). Using the validated Clavien-Dindo system there were 3 grade Id complications and 1 grade II complication. CONCLUSIONS ELEP and bipolar TURP were equally safe and effective for relieving bladder outflow obstruction and lower urinary tract symptoms. ELEP has the advantage of less blood loss, shorter catheter time and hospital stay. Table 1. Perioperative data Mean ELEP+/− SD Mean TURP+/− SD p Value Operative time (min) 68.00 +/− 10.22 59.41 +/− 4.4 <0.05 Enucleation/resection time (min) 45.60 +/− 6.45 59.42 +/− 4.4 <0.05 Morcellation (min) 20.90 +/− 6.51 Resected wt (gm) 32.10 +/− 9.34 32.16 +/− 8.74 0.989 Retrieval rate (gm/min) 0.44 +/− 0.07 0.43 +/− 0.08 0.674 Hemoglobin postop.(gm/dl) 14.69 +/− 0.97 13.122 +/− 0.75 <0.05 Blood loss (ml) 114.54 +/− 95.02 389.80 +/− 138.60 <0.05 HB loss (gm/dl) 0.24 +/− 0.16 0.61 +/− 0.71 <0.05 Blood loss/resected tissue (ml/gm) 6.05 +/− 3.86 10.90 +/− 3.37 <0.05 Bleeding velocity (ml/min) 2.89 +/− 1.41 5.39 +/− 0.76 <0.05 Catheter time (hours) 31.70 +/− 7.79 63.74 +/− 13.72 <0.05 Hospital time (hours) 43.15 +/− 14.56 89.10 +/− 10.73 <0.05 Intraoperative irrigation volume (l) 21.17 +/− 2.84 14.07 +/− 1.60 <0.05 © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e879 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lukas Lusuardi Salzburg, Austria More articles by this author Tobias Schätz Salzburg, Austria More articles by this author Stephan Hruby Salzburg, Austria More articles by this author Manuela Sieberer Salzburg, Austria More articles by this author Reinhold Zimmermann Salzburg, Austria More articles by this author Günter Janetschek Salzburg, Austria More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Developing a Laparoscopic Radical Prostatectomy Service: Defining the Learning Curve

Laparoscopic radical prostatectomy (LRP) is an established treatment for patients with prostate cancer in selected centers with appropriate expertise. We studied our single-center experience of developing a LRP service and subsequent training of two additional surgeons by the initial surgeon. We assessed the learning curve of the three surgeons with regard to perioperative outcomes and oncologic results. Three hundred consecutive patients underwent a LRP between January 2005 and April 2011. Patients were divided into three equal groups (1-100 group 1], 101-200 [group 2], and 201-300 [group 3]). Age, American Society of Anesthesiologists score, preoperative comorbidities, and indications for LRP were comparable for all three patient groups. Perioperative and oncologic outcomes were compared across all three groups to assess the impact of the learning curve for LRP. All surgical complications were classified using the Clavien-Dindo system (CDS). The mean age was 61.9 years (range 46-74 y). There was a significant reduction in the mean operative time (P<0.05), mean blood loss (P<0.05), mean duration of hospital stay (P<0.05), and duration of catherization (P<0.05) between the three groups as the series progressed. The two most important factors predictive of positive surgical margins at LRP were the initial prostate-specific antigen level and tumor stage at diagnosis. The overall positive margin rate was 27.7%. For pT(2) tumors, the positive margin rate was 21%, while patients with pT(3) tumors had a positive margin of 44%. For pT(2) tumors, positive margin rates decreased with increasing experience (group 1, 27% vs group 2, 17% vs group 3, 19%). The incidence of major complications--ie, grade CDS score ≤ III--was 4.6% (14/300). LRP is a safe procedure with low morbidity. As surgeons progress through the learning curve, perioperative parameters and oncologic outcomes improve. Using a carefully mentored approach, LRP can be safely introduced as a new procedure without compromising patient outcomes.

The Uro-Clavien—Dindo System—Will the Limitations of the Clavien—Dindo System for Grading Complications of Urological Surgery Allow Modification of the Classification to Encourage National Adoption within the UK?

Although quality outcome assessment is gaining widespread recognition, there is still no consensus about grading postoperative complications in urology. There have been several attempts to grade surgical complications. The Clavien—Dindo system has been standardised and validated. However there are limitations when using the system to grade urological complications. We suggest modification of the Clavien—Dindo system to include intraoperative complications. Widespread implementation of the grading system could benefit the transparent reporting of complications to demonstrate quality outcomes.

Complication rates of open transvesical prostatectomy according to the Clavien-Dindo classification system

Traditional open prostatectomies either transvesical or retropubic remains the reference standard for managing benign prostatic enlargement in some centers, especially in developing countries. The comparison of complication rates between the various types of open prostatectomies is usually a source of significant debate among urologists, most times with conflicting results. The Clavien-Dindo classification system is an excellent attempt at standardization of reporting complications associated with surgeries. We reviewed retrospectively the records of patients who had open transvesical prostatectomy (TVP) in three specialist urology centers in Anambra state, Southeast Nigeria, over a period of 5 years (January 2004-December 2009), with the aim of documenting medical and surgical complications arising from open TVP. These complications were then categorized according to the Clavien-Dindo system. A total of 362 patients had open TVP over the period under review. Of this number, 145 had documented evidence of complications. The mean age of the patients was 66.3 years (SD 9.4 years; range 49-96 years). The mean follow-up period was 27.8 months (SD 12.6 months; range 6-33 months). The overall complication rate for open TVP in this study was 40.1% (145/362). Complication rates for grades i, id, ii, iiia, and iiib were 0.8%, 0.6%, 35.1%, 0.6%, and 3.0%, respectively. Most complications of open TVP occur in the early postoperative period. Open TVP still remains a valid surgical option in contemporary environment where advanced techniques for transurethral resection of the prostate and laparoscopic prostatectomy are unavailable. Most complications occur in the early postoperative period, with bleeding requiring several units of blood transfusion accounting for the commonest complication. This should be explained to patients during the preoperative counselling.