Reporting Complications

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D. Mitropoulos (chair), W. Artibani, M. Graefen, M. Remzi, M. Rouprêt, M.C. Truss


Evidence of variations in clinical practice, together with rising costs associated with constrained resources in most health care systems over the past decade, has triggered growing interest in evaluating the quality of our surgical work [1-3]. At present, the main methods of assessing surgical results for audit and quality assurance remain mortality and morbidity [4-6]. Thus measurement of morbidity requires an accurate definition of a surgical complication. Although the incidence of postoperative complications is still the most frequently used surrogate marker of quality in surgery [1,3,7], the direct cause-and-effect relationship between surgery and complications is often difficult to assess. This uncertainty carries a risk of underreporting surgical complications, with substantial consequences.

Most published articles focus only on positive outcomes (e.g. trifecta in prostate cancer after radical

prostatectomy) [8]. There is a need to compare complications for each specific approach in a systematic, objective, and reproducible way. As yet, no definitions for complications or guidelines for reporting surgical outcomes have been universally accepted. Reporting and grading of complications in a structured fashion is only one aspect of the quality of outcome reporting. In 2002, Martin et al. proposed 10 criteria that should be met when reporting complications following surgery [9] (Table 1). Clavien and Dindo proposed a system for grading the severity of postoperative complications [10] that was subsequently revised and validated [11] (Table 2).

Table 1: Martin et al. criteria of accurate and comprehensive reporting of surgical complications [9]



Method of accruing data defined

Prospective or retrospective accrual of data are indicated

Duration of follow-up indicated

Report clarifies the time period of postoperative accrual of complications such as 30 days or same hospitalisation

Outpatient information included

Study indicates that complications first identified following discharge are included in the analysis

Definition of complications provided

Article defines at least one complication with specific inclusion criteria

Mortality rate and causes of death listed

The number of patients who died in the postoperative period of study are recorded together with cause of death

Morbidity rate and total complications indicated

The number of patients with any complication and the total number of complications are recorded

Procedure-specific complications included

Severity grade utilised

Any grading system designed to clarify severity of complications including major and minor is reported

Length-of-stay data

Median or mean length of stay indicated in the study

Risk factors included in the analysis

Evidence of risk stratification and method used indicated by study

Table 2: Clavien-Dindo grading system for the classification of surgical complications [11]



Grade I

Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic and radiological interventions. Acceptable therapeutic regimens are: drugs such as antiemetics, antipyretics, analgesics, diuretics and electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside.

Grade II

Requiring pharmacological treatment with drugs other than those allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included.

Grade III

Requiring surgical, endoscopic or radiological intervention

Grade III-a

Intervention not under general anaesthesia

Grade III-b

Intervention under general anaesthesia

Grade IV

Life-threatening complication (including CNS complications: brain haemorrhage, ischaemic stroke, subarachnoid bleeding, but excluding transient ischaemic attacks) requiring IC/ICU management

Grade IV-a

Single organ dysfunction (including dialysis)

Grade IV-b

Multi-organ dysfunction

Grade V

Death of a patient

Suffix “d”

If the patient suffers from a complication at the time of discharge the suffix “d” (for disability) is added to the respective grade of complication. This label indicates the need for a follow-up to evaluate the complication fully.

Despite these proposals, no current standard guidelines or criteria exist for reporting surgical complications in the area of urology. It appears important that the urologic community create universally accepted criteria for reporting surgical morbidity and outcomes to establish the efficacy of surgical techniques and improve the quality of patient care [12]. Adopting an integrated method of characterising and reporting surgical morbidity has the potential to improve patient care on many levels:

  • It enables better characterisation of surgical morbidity associated with various surgical techniques.
  • It allows comparison of different surgical techniques, which is important due to the relative lack (< 1%) of randomised trials in the urologic literature.
  • It allows the physician to portray more accurately to patients the risks of a procedure versus other surgical or medical options.
  • It allows better sequencing of multimodality approaches.
  • It allows earlier recognition of the pattern of complications, thereby allowing for pre-emptive changes in care in an effort to decline the incidence.
  • It allows better comparisons between individual surgeons or between institutional experiences.
  • It allows identification of quality-of-care measures for benchmarking.

The aim of our work was to 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 (currently widely used for the reporting of complications related to urologic surgical interventions); to identify shortcomings in reporting complications, and to present recommendations for the development and implementation of future reporting systems that focus on patient-centred outcomes. The panel did not take intraoperative complications into consideration, which may be addressed in a follow-up project.

1.1.Publication history

This article presents a republication of a scientific paper published in European Urology, the EAU scientific journal [13]. Prior to publication, the paper has been subjected to double blind peer review.

In the course of 2016 the authors aim to assess the usage and reproducibility of the proposed model for reporting of complications. These findings will be published upon completion of the assessment.