Introduction

To examine postoperative complications in a contemporary series of patients after radical cystectomy (RC) using the comprehensive complication index (CoCI), a new extension of the Clavien-Dindo-Classification (CDC), that integrates not only the most severe but all events with their respective severity.

Methods

Using the CoCI, we assessed the 90-day postoperative clinical course of 804 bladder cancer patients who underwent open RC and urinary diversion (ileal conduit n = 510, ileal neobladder n = 294) between June 2003 and December 2015 at a single institution. All Martin criteria for standardized reporting of complications were met. The CoCI is calculated as the sum of all CDC events that are weighted for their severity. The final formula yields a continuous scale to rank the severity of any combination of complications from 0 to 100 in a single patient. Cut-off of the CoCI was set at 26.2%, the equivalent of a single CDC IIIa complication, to assess major complications. Uni- and multivariable analyses for prediction of complications were carried out; covariables included body mass index, Charlson Comorbidity Index (CCI), age, sex, American Society of Anesthesiologists Score (ASA), neoadjuvant chemotherapy, prior abdominal or pelvic surgery, clinically localized tumor and urinary diversion type.

Results

The 90-day rates for overall (CDC I-V) and high-grade complications (CDC III-V), as well as mortality (CDC V), were 58.8, 21.8 and 3.7%, respectively. The median CoCI was 20.9 (IQR 0-29.6) with a CoCI≥26.2 in 29.2% of the study population. Patients that received an ileal neobladder had a significantly lower CoCI, 8.7% (IQR 0-22.6), compared to those that received ileal conduit, 20.9% (IQR 0-33.7, P=0.013). Independent risk factors for overall complications were BMI≥30 (OR 1.75), female gender (OR 1.66) and ASA≥3 (OR 1.47). Risk factors for a CoCI≥26.2 were BMI≥30 (OR 1.52), CCI≥3 (OR 1.63) and ASA≥3 (OR 1.72, all P<0.05).

Conclusions

RC is associated with significant morbidity; nevertheless, the majority of complications are minor. CCI, ASA and BMI might help to identify patients at risk for major complications after radical cystectomy. The comprehensive complication index gives detailed and acurate information on the individual burden of complications.

Funding

none