Validation of the Clavien–Dindo Grading System in Urology by the European Association of Urology Guidelines Ad Hoc Panel

doi:10.1016/j.euf.2017.02.014

European Urology Focus

Volume 4, Issue 4, July 2018, Pages 608-613

https://doi.org/10.1016/j.euf.2017.02.014 Get rights and content

Abstract

Context

Since 2012 uniformed reporting of complications after urological procedures has been advocated by the European Association of Urology (EAU) guidelines. The Clavien–Dindo grading system was recommended to report the outcomes of urologic procedures.

Objective

To validate the Clavien–Dindo grading system in urology.

Design, setting, and participants

Members of the EAU working group compiled a list of case scenarios including those with minor and major complications. A survey was administered online via Survey Monkey to the members of EAU committees for the appropriate grading according to the Clavien–Dindo classification of surgical complications. Scenarios with intraoperative complications were intentionally included to assess respondents’ awareness of the Clavien–Dindo applicability.

Outcome measurements and statistical analysis

Survey data collected were used to calculate agreement rates and to estimate the overall inter-rater agreement on all cases using Fleiss’ kappa (κ). Differences in agreement rates for each scenario among groups with different criteria about the system were estimated using the chi-square test.

Results and limitations

Evaluable responses were received from 81 out of 174 invited raters (46.5%). Of them 56.9% believed that the Clavien–Dindo system was adequate for grading postoperative complications. The agreement rate was over a score of ≥80% in nine cases, 60–79% in 10 cases, 40–59% in 14 cases, and <40% in two cases. Interestingly, the agreement rate on the nonapplicability of the Clavien–Dindo system was quite low, ranging from 27.5% to 67.2% (κ = 0.147). Being a resident rather than a specialist affected only the distribution of agreement rates in case 1 (ie, score IIIb: 83.3% vs 94.1%). Being an academic or having affiliation did not have any impact on the distribution of agreement rates in all cases but one.

Conclusions

The Clavien–Dindo classification is a standardised approach to grade and report postoperative complications in urology and should be used systematically. However, it does not apply for intraoperative complications, and there is a need for an additional tool.

Patient summary

A rigorous methodology is mandatory when surgeons report about complications after surgery. In this study, the European Association of Urology Guidelines Panel has validated the use of the Clavien–Dindo grading system in urology.

Introduction

A well-known evaluation criterion of surgical procedures is the presence or absence of postoperative complications. In order to compare different surgical procedures or to compare results or surgical quality regarding a specific procedure between institutions or surgeons, it is imperative to have a structured registration and reporting system of the number and severity of complications. Guidelines for reporting postoperative complications have been proposed by a European Association of Urology (EAU) Guideline Group on complication reporting [1]. Adherence to these guidelines regarding structured reporting has now been implemented as recommendations in the author instructions for publications on postoperative complications in European Urology and BJU International [2], [3].

Severity of a complication is often more important for the clinical course in individual patients than the presence or number of complications per se. Thus, grading of complications according to severity is needed in order to give an accurate impression of the complications related to a specific procedure.

In 1992, Clavien et al [4] proposed a classification of complications of surgery based on experience and analyses from 650 patients undergoing cholecystectomy. This grading system was originally based on five different levels of complications stratified according to the invasiveness of intervention and clinical impact of the complication. The Clavien classification was later revised after validation on other surgical procedures with further subclassification of grade 3 and 4 complications into levels 3a, 3b, 4a, and 4b [5]. The revised system is often referred to as the Clavien–Dindo classification, and has gained popularity as the preferred grading system in surgery because of the simple concept and proven reproducibility. In the field of urology, its usage increased from 21% in 2010 [1] to 50% in 2012 [6]. However, in urology, the Clavien–Dindo classification has never been evaluated properly before implementation. The CROES group validated it for percutaneous nephrolithotomy and proposed specific grades for the procedure-related complications [7]. Other studies focused on the interobserver variability and revealed low reliability, especially in transurethral procedures or minor complications [7], [8], [9]. A need for a clarification or even customisation of the Clavien–Dindo classification for urological procedures has therefore been raised [10], [11], [12]. The purpose of the present study was to officially validate the Clavien–Dindo classification in urology.

Section snippets

Methods

Members of the Ad hoc Working Group on Reporting Complications in the Literature, a guideline panel for the European Association Urology, compiled a list of 35 case scenarios (Appendix A). The survey was administered online via Survey Monkey. The survey mailed to the members of EAU committees and offices for the appropriate grading according to the Clavien–Dindo classification of surgical complications. The case scenarios pertained to minor and major complications of different urological

Results

Complete responses were received from 81 out of 174 invited raters (46.5%). The vast majority of raters were certified urologists (87.4%), were academics or with academic affiliation (89.7%), declared familiarity with the Clavien–Dindo classification (92%), and were actually using this classification to grade complications (81%). While 56.9% believed that the Clavien–Dindo system is adequate for grading the severity of postoperative complications of urological procedures, 36.2% felt quite

Discussion

Transparent, consistent, and accurate reporting of surgical complications and outcomes in a standardised fashion is mandatory to improve patient care. The Clavien–Dindo classification of surgical complications has widely been accepted as a tool to grade surgical complications. Its simplicity, reproducibility, and logical architecture make it a compelling tool for quality assessment. This classification has since been used in general surgery, orthopaedics, and head and neck surgery [15], [16],

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Use of Clavien–Dindo classification in reporting and grading complications after urological surgical procedures: analysis of 2010 to 2012
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Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy
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Interobserver variability of Clavien–Dindo scoring in urology
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^†: Chairman, Ad Hoc EAU Guidelines Panel.

^‡: Member, Ad Hoc EAU Guidelines Panel.

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Review – EducationValidation of the Clavien–Dindo Grading System in Urology by the European Association of Urology Guidelines Ad Hoc Panel

Abstract

Context

Objective

Design, setting, and participants

Outcome measurements and statistical analysis

Results and limitations

Conclusions

Patient summary

Introduction

Section snippets

Methods

Results

Discussion

Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU Guidelines Panel assessment and recommendations

Eur Urol

Proposed classification of complications of surgery with examples of utility in cholecystectomy

Surgery

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey

Ann Surg

Use of Clavien–Dindo classification in reporting and grading complications after urological surgical procedures: analysis of 2010 to 2012

J Urol

Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy

Eur Urol

Clavien classification in urology: is there concordance among post-graduate trainees and attending urologists?

Can Urol Assoc J

Interobserver variability of Clavien–Dindo scoring in urology

Int J Urol

Review – Education
Validation of the Clavien–Dindo Grading System in Urology by the European Association of Urology Guidelines Ad Hoc Panel