The comprehensive complication index is more sensitive than the Clavien–Dindo classification for grading complications in elderly patients after radical cystectomy and pelvic lymph node dissection: Implementing the European Association of Urology guideline

Impact of lymph-node dissection during radical cystectomy for non-muscle-invasive bladder cancer: Japanese multicenter retrospective study

BACKGROUND

There is no definitive consensus on the necessity and impact of lymph-node dissection during radical cystectomy for non-muscle-invasive bladder cancer (NMIBC). This study aimed to evaluate the prognostic significance of lymph-node dissection in NMIBC and identify preoperative factors influencing non-urinary tract recurrence-free survival (NUTRFS).

METHODS

We retrospectively analyzed data for 2674 cases of bladder cancer treated with radical cystectomy between January 2013 and December 2019 from a multicenter Japanese database; 410 patients were preoperatively diagnosed with NMIBC. Patients were divided into lymph-node dissection and non-lymph-node dissection groups, and NUTRFS and overall survival were compared as endpoints. Univariate and multivariate analyses were performed to determine NUTRFS prognostic factors.

RESULTS

Lymph-node dissection was performed in 374/410 patients and not in 36/410. Compared with the lymph-node dissection group, the non-lymph-node dissection group was older, and had a lower proportion of a performance status of 0 and a higher proportion of clinical stage < T1 disease. The pathological lymph-node positivity rate in the lymph-node dissection group was 6.9%. However, lymph-node dissection did not provide a statistically significant prolonged survival. Results remained consistent after propensity score matching. Multivariate analysis revealed poor performance status and bladder neck tumors as independent risk factors for NUTRFS. Lymph-node dissection was not a significant prognostic factor in preoperatively diagnosed NMIBC.

CONCLUSIONS

Routine lymph-node dissection may be unnecessary for all NMIBC cases; however, our findings suggest that this should be considered for NMIBC involving the bladder neck.

Estimating the Morbidity of Robot-Assisted Radical Cystectomy Using the Comprehensive Complication Index: Data from the Asian Robot-Assisted Radical Cystectomy Consortium

Background/Objectives: The Clavien-Dindo classification (CDC) grades the most severe post-operative complication and may not comprehensively reflect cumulative surgical morbidity. Our objective was to investigate the potential incremental role of the comprehensive complication index (CCI) over the CDC in defining the quality of robot-assisted radical cystectomy (RARC). Methods: Data were extracted from the Asian RARC Consortium database. Complications were classified using the CCI (CCI = 0, CCI < 75th and ≥75th percentile) and CDC. Adverse peri-operative outcomes such as length of stay >14 days (LOS > 14 days), estimated blood loss >350 mL (EBL > 350 mL), time to solid food intake >4 days (TFI > 4 days) and 30-day readmission rates were analyzed. The area under the curve (AUC) of the receiver operating characteristic (ROC) curves for CCI and CDC were compared for the various adverse outcomes. Results: The peri-operative complication rate was 44.4%, comprising 11.6% with severe complications (CDC ≥ III). The mean CCI was 10.2 (±13.5) while median CCI was 0 (IQR 0-21). There were 7.6% of patients with >one perioperative complication. On adjusted analysis, CCI ≥ 75th percentile was significantly associated with greater LOS (>14 days) (OR 2.21, 95% CI 1.47-3.31, p < 0.001) compared to when CCI = 0. There were no significant differences in the AUC between CDC and CCI in predicting LOS > 14 days, TFI > 4 days, 30-day readmission or EBL > 350 mL. Conclusions: In our multi-institutional cohort, the CCI did not provide additional discrimination over CDC, and this is likely related to the limited number of complications that occurred per individual in the Asian RARC cohort. Hence, the perceived advantages of CCI over CDC are contextual.

The incidence and classification of intraoperative adverse events in urological surgery: a systematic review

PURPOSE

To perform a systematic review (SR) to examine the application of classification systems (CS) used to report intraoperative adverse events (iAEs) in urological surgery and to evaluate the crude incidence and type of iAEs.

MATERIALS AND METHODS

This review was published via PROSPERO (CRD42024549954) and conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). MEDLINE, Embase, and the Cochrane CENTRAL were searched using a predefined PICO framework: (P) patients with benign and malignant urological diseases, (I) all types of urological surgery, (C) none/any, (O) intraoperative complications classified with grading systems. Retrospective and prospective studies published between January 2019 and June 2024 were included.

RESULTS

The search yielded 1,570 abstracts, 1,043 full-text articles were assessed for eligibility, of which 325 studies reported iAEs (54 used iAE-CS, 64 used Clavien-Dindo Classification and 207 used free-text descriptions). Of the 54 studies (15,298 patients) that used an iAE-CS, the three most used systems were the EAUiaiC (54%), SATAVA (26%), and the modified SATAVA (7%). The overall incidence of iAE was 14% (2,153/15,225 patients). On a study level, the crude incidence of iAE was between 0 and 100% (median 7%, IQR: 3-13%). The misapplication of the Clavien-Dindo system to describe iAEs was high (n = 64 studies).

CONCLUSIONS

The use of iAE-CS is scarce, and there is a lack of universal consensus on a CS to describe iAEs. iAE are poorly reported in urological studies. Urologists should report all perioperative complications to improve transparency and surgical and hospital processes.

Assessing the effectiveness of continuous glucose monitoring compared with conventional monitoring in enhancing surgical outcomes for patients with diabetes: protocol for a multicentre, parallel-arm, randomised, pragmatic trial in China

INTRODUCTION

The Comprehensive Complication Index (CCI) is an internationally recognised indicator of postoperative complications. During the perioperative period, patients with diabetes mellitus (DM) or impaired glucose tolerance (IGT) may experience a significant increase in the CCI associated with glucose-related complications and increased mortality. Continuous glucose monitoring (CGM) offers advantages such as portability, accuracy, real-time monitoring and rich information. However, few large-scale studies have investigated the effectiveness and safety of CGM in reducing CCI during major surgeries.

METHODS AND ANALYSIS

This study is a multicentre, parallel-arm, randomised pragmatic trial to investigate whether CGM improves clinical outcomes in patients with type 1 or type 2 DM or IGT undergoing major surgery relative to conventional monitoring. This study is planned to be conducted in 50 secondary or tertiary hospitals in China. Eligible patients aged 18 years or older with DM or IGT undergoing elective major surgery will be recruited during a baseline screening period of 3 days before surgery. Eligible patients will be randomly assigned to receive CGM or conventional monitoring in a 1:1 ratio. The primary endpoint measure is the CCI score within 30 postoperative days. The margin of superiority is -12.0. A total of 10 168 participants will achieve 90% power to detect a clinically important difference of -13.0 between the means in the primary outcome. This trial includes multiple statistical analysis steps. For the primary outcome, a covariance model will be used to compare the difference in CCI within 30 days postoperatively between the two groups after adjusting for baseline and centre effects.

ETHICS AND DISSEMINATION

This trial has been approved by the Ethics Committee of Beijing Tsinghua Changgung Hospital (No. 23684-0-02) and its corresponding branch centres. Informed consent will be obtained from all subjects involved in the study. The primary trial results will be submitted for publication to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT06331923.

Perfusate Liver Arginase 1 Levels After End-Ischemic Machine Perfusion Are Associated with Early Allograft Dysfunction

Background/Objectives: The rising use of liver grafts from donation after circulatory death (DCD) has been enabled by advances in normothermic regional perfusion (NRP) and machine perfusion (MP) technologies. We aimed to identify predictive biomarkers in DCD grafts subjected to NRP, followed by randomization to either normothermic machine perfusion (NMP) or dual hypothermic oxygenated perfusion (D-HOPE). Methods: Among 57 DCD donors, 32 liver grafts were transplanted, and recipients were monitored for one week post-transplant. Biomarkers linked with oxidative stress, hepatic injury, mitochondrial dysfunction, inflammation, regeneration, and autophagy were measured during NRP, end-ischemic MP, and one week post-transplant. Results: Arginase-1 (ARG-1) levels were consistently higher in discarded grafts and in recipients who later developed early allograft dysfunction (EAD). Specifically, ARG-1 levels at the end of MP correlated with markers of hepatic injury. Receiver operating characteristic analysis indicated that ARG-1 at the end of MP had a good predictive accuracy for EAD (AUC = 0.713; p = 0.02). Lipid peroxidation (TBARS) elevated at the start of NRP, declined over time, with higher levels in D-HOPE than in NMP, suggesting a more oxidative environment in D-HOPE. Metabolites like flavin mononucleotide (FMN) and NADH exhibited significant disparities between perfusion types, due to differences in perfusate compositions. Inflammatory biomarkers rose during NRP and NMP but normalized post-transplantation. Regenerative markers, including osteopontin and hepatocyte growth factor, increased during NRP and NMP and normalized post-transplant. Conclusions: ARG-1 demonstrates strong potential as an early biomarker for assessing liver graft viability during perfusion, supporting timely and effective decision-making in transplantation.

Correlation analysis of preoperative renal insufficiency with major complications in patients who received a radical cystectomy and pelvic lymph node dissection: results of a retrospective observational analysis from a single center

Objective

The aim of this study was to explore the factors affecting the major complications and the impacts of preoperative renal function on the incidence of complications in radical cystectomy procedures.

Methods

A retrospective review of 705 patients who received radical cystectomy between 2006 and 2021 was conducted. The 90-day complications of patients after a radical cystectomy were reported and the Clavien-Dindo classification (CDC) was used for grading complications. The clinical characteristics and preoperative outcomes were compared among patients with different preoperative renal functions. A logistic regression analysis of all patients was used to identify the risk factors associated with the major complications. Spearman's correlation analysis was used to examine the relationship between the classification of renal insufficiency and the CDC. In order to reduce the selection bias, one-to-one propensity score matching was performed, and the comparison of complications after matching was carried out for the sensitivity analysis.

Results

Within 90 days post-surgery, 71% of patients experienced complications, with 4.8% of them being major. Patients with preoperative renal insufficiency had a higher CDC and had a higher rate of major complications (16.7% vs 3.7%, p < 0.001). There was a linear relationship between preoperative serum creatinine and complications. Spearman's correlation analysis showed a slightly positive correlation between the classification of renal insufficiency and the CDC (r=0.094, p = 0.013). Preoperative renal insufficiency was a risk factor for major complications (OR = 6.805 [95%CI: 2.706-17.112]; p < 0.001). After matching, the patients in the preoperative renal insufficiency group had a higher CDC and a higher incidence of major complications (16.9% vs 1.7%, p = 0.004).

Conclusions

In our cohort, patients with preoperative renal insufficiency exhibited a higher incidence of complications following a radical cystectomy, and renal insufficiency was a significant risk factor for major complications.

Effect of regional block technique on postoperative high-grade complications according to Clavien-Dindo classification in elderly patients with thoracic and abdominal cancer: a retrospective propensity score matching analysis

Background

Postoperative complications have an influence on postoperative rehabilitation, length of hospital stay and hospitalization expenses in elderly patients, especially those with higher Clavien-Dindo (C-D) classification. Patients with cancers often experience more serious postoperative complications after surgery. Different anesthesia methods can affect the postoperative outcomes of cancer patients. Regional block techniques have been recommended in guidelines for enhanced recovery after surgery. However, the relationship between regional blocks and high-grade postoperative complications remains unclear, thus, the study explored the relationship between regional block techniques and high-grade postoperative complications graded by C-D classification in elderly patients with thoracic and abdominal cancer.

Method

Retrospective enrollment of eligible elderly patients admitted to Peking University People's Hospital between January 2018 and March 2022 was conducted. Propensity score matching (PSM) and univariate and multivariate regression analyses were used to analyze the potential benefits of regional blocks for elderly patients in real world practice.

Results

A total of 2769 patients were enrolled in this study, including 568 who underwent colorectal resection, 2201 who underwent video-assisted thoracoscopic pneumonectomy. Among them, 2033 patients received regional block, while 736 patients did not. Statistical analysis indicated that regional blocks could reduce the incidence of postoperative complications of C-D classification Grade II or higher, with an Odds ratio (OR) of 0.742, 95% Confidence interval (CI) (0.552 to 0.996) (P = 0.047).

Conclusion

Regional block is associated with a reduction in the occurrence of postoperative complications graded by C-D classification in elderly patients with thoracic and abdominal cancer. The application of regional blocks can lower the risk of high-risk complications and mortality.

Evaluation of comprehensive complication index versus Clavien-Dindo classification in prediction of overall survival after radical cystectomy

PURPOSE

We aimed to evaluate the benefits of Comprehensive Complication Index (CCI) compared with the Clavien-Dindo Classification (CDC) in the reporting of radical cystectomy (RC) complications.

MATERIALS AND METHODS

We retrospectively analyzed post-operative complications of 251 consecutive RC patients between 2009 and 2021. Patient demographics and causes of mortality were noted. Oncologic outcomes included the recurrence, time to recurrence, cause of all deaths, and time to death. Each complication was graded with CDC and, corresponding and cumulative CCI calculated for each patient.

RESULTS

A total of 211 patients are included. Median patient age and follow-up time were 65 (IQR 60-70) years and 20 (IQR 9 - 53) months, respectively. The five-year recurrence and death rates were 39.3% (83/211) and 59.7% (126/211), respectively. Post-operative 521 complications were recorded. Patients with experienced any complication were 69.6% (147/211) and 45.0% (95/211) had > 1 complications. Thirty (14.2%) patients ended up with a cumulative CCI score that corresponded to a higher CDC grade. Severe complications calculated with CDC increased from 18.5% to 19.9% (p < 0.001) with cumulative CCI. Female gender, positive lymph node, and positive surgical margin, presence of severe CDC complication, and CCI score were significant independent predictive factors for overall survival (OS). The contribution of CCI to the multivariable model was 1.8% higher than CDC.

CONCLUSIONS

Cumulative morbidity reporting improved with the use of CCI compared to CDC. Both CDC and CCI are significant predictive factors for OS independent of oncologic predictive factors. Reporting the cumulative burden of complications with CCI is more predictive on oncologic survival than reporting complications with CDC.