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