Beilan J et al, 2014: The Postoperative Morbidity Index: a quantitative weighing of postoperative complications applied to urological procedures
Beilan J, Strakosha R, Palacios DA, Rosser CJ
Clinical and Translational Program, University of Hawaii Cancer Center, 701 Ilalo St, Honolulu, HI 96814, USA
BACKGROUND: The reporting of post-operative complications in the urological field is lacking of a uniform quantitative measure to assess severity, which is essential in the analysis of surgical outcomes. The purpose of this study was to evaluate the feasibility of estimating quantitative severity weighing of post-operative complications after common urologic procedures.
METHODS: Using a large healthcare system's quality database, complications were identified in eleven common urologic procedures (e.g., insertion or replacement of inflatable penile prosthesis, nephroureterectomy, partial nephrectomy, percutaneous nephrostomy tube placement, radical cystectomy, radical prostatectomy, renal/ureteral/bladder extracorporeal shockwave lithotripsy (ESWL), transurethral destruction of bladder lesion, transurethral prostatectomy, transurethral removal of ureteral obstruction, and ureteral catheterization) from January 1, 2011 to December 31, 2011. Complications were classified by the Expanded Accordion Severity Grading System, which was then quantified by validated severity weighting scores. The Postoperative Morbidity Index (PMI) for each procedure was calculated where an index of 0 would indicate no complication in any patient and an index of 1 would indicate that all patients died.
RESULTS: This study included 654 procedures of which 148 (22%) had one or more complications. As would be expected, a more complex procedure like radical cystectomy possessed a higher PMI (0.267), while a simpler procedure like percutaneous nephrostomy tube placement possessed a lower PMI (0.011). The PMI of the additional nine procedures fell within the range of these PMIs. These PMIs could be used to compare surgeons, hospitals or procedures.
CONCLUSIONS: Quantitative severity weighing of post-operative complications for urologic procedures is feasible and may provide exceptionally informative data related to outcomes.
BMC Urol. 2014 Jan 3;14:1. doi: 10.1186/1471-2490-14-1.PMID:24383457 [PubMed - in process]. PMCID:PMC3893398. FREE ARTICLE
A standardized and validated system for recording complications is indeed highly desirable. For the individual patient it is important to know what in this regard can be expected from a specific surgical procedure. Although it stands to reason that the occurrence and severity of complications are directly related to the type of surgery, it is definitely of interest to compare the pattern of complications when alternative procedures for one specific pathological condition are considered.
The authors of this report used a postoperative morbidity index (PMI) based on the Accordion Severity Grading System. Different procedures carried out in 654 patients with stone disease were analysed. Of interest for this group of patients were ESWL, transurethral removal of ureteral obstruction (=URS?), ureteral catheterization and insertion of a percutaneous nephrostomy catheter. For ESWL 33 out of 36 patients had severity grade 0; complications thus were observed in 8.3% of the patients. For patients treated with URS 120 of 159 patients were referred to grade 0 and the rate of complications was accordingly 24.5%. The corresponding complication rates for percutaneous nephrostomy and ureteral catheterization were 6.0 and 15.1%, respectively.
A comparison between these four procedures expressed as weighted severity grades are shown in the Figure.
In the URS group 7.5% of the patients had complications of grade 4. This should be compared with 2.8% in the ESWL treated patients. It is important to emphasize, however, that the grade of complication depends on how generously general anaesthesia was used for managing complications. Unfortunately there were no PNL or open surgical procedures included in this report.
It is highly important to analyse different treatment options in view of their complications and that information should be included when the final result is considered. But whether PMI or Clavien score should be used in this regard remains to be determined.