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ORIGINAL ARTICLE
Year : 2012  |  Volume : 15  |  Issue : 1  |  Page : 34-37

Complication rates of open transvesical prostatectomy according to the Clavien-Dindo classification system


1 Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, P.M.B, Nnewi, Anambra State, Nigeria
2 Department of Anaesthesia, Nnamdi Azikiwe University Teaching Hospital, P.M.B, Nnewi, Anambra State, Nigeria

Date of Acceptance11-May-2011
Date of Web Publication20-Mar-2012

Correspondence Address:
C K Oranusi
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, P.M.B. 5025, Nnewi, Anambra State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1119-3077.94094

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   Abstract 

Background: Traditional open prostatectomies either transvesical or retropubic remains the reference standard for managing benign prostatic enlargement in some centers, especially in developing countries. The comparison of complication rates between the various types of open prostatectomies is usually a source of significant debate among urologists, most times with conflicting results. The Clavien-Dindo classification system is an excellent attempt at standardization of reporting complications associated with surgeries.
Materials and Methods: We reviewed retrospectively the records of patients who had open transvesical prostatectomy (TVP) in three specialist urology centers in Anambra state, Southeast Nigeria, over a period of 5 years (January 2004-December 2009), with the aim of documenting medical and surgical complications arising from open TVP. These complications were then categorized according to the Clavien-Dindo system.
Results: A total of 362 patients had open TVP over the period under review. Of this number, 145 had documented evidence of complications. The mean age of the patients was 66.3 years (SD 9.4 years; range 49-96 years). The mean follow-up period was 27.8 months (SD 12.6 months; range 6-33 months). The overall complication rate for open TVP in this study was 40.1% (145/362). Complication rates for grades i, id, ii, iiia, and iiib were 0.8%, 0.6%, 35.1%, 0.6%, and 3.0%, respectively. Most complications of open TVP occur in the early postoperative period.
Conclusion: Open TVP still remains a valid surgical option in contemporary environment where advanced techniques for transurethral resection of the prostate and laparoscopic prostatectomy are unavailable. Most complications occur in the early postoperative period, with bleeding requiring several units of blood transfusion accounting for the commonest complication. This should be explained to patients during the preoperative counselling.

Keywords: Classification, postoperative complications, reference standard, suprapubic prostatectomy


How to cite this article:
Oranusi C K, Nwofor A, Oranusi I O. Complication rates of open transvesical prostatectomy according to the Clavien-Dindo classification system. Niger J Clin Pract 2012;15:34-7

How to cite this URL:
Oranusi C K, Nwofor A, Oranusi I O. Complication rates of open transvesical prostatectomy according to the Clavien-Dindo classification system. Niger J Clin Pract [serial online] 2012 [cited 2020 Feb 29];15:34-7. Available from: http://www.njcponline.com/text.asp?2012/15/1/34/94094


   Introduction Top


Transurethral resection of the prostate (TURP) still remains the gold standard for the surgical management of benign prostatic enlargement (BPE) in the developed nations. [1] Traditional open prostatectomies either transvesical or retropubic remains the reference standard for managing BPE in some centers, especially in developing countries. [2] Although TURP is increasingly becoming available in our environment, more time is required for proper assessment and comparison with the open procedure.

The comparison of complication rates between the various types of open prostatectomies is usually a source of significant debate among urologists, most times with conflicting results. Within a particular surgical procedure, there is also a need for constant evaluation of surgical techniques through their complication rates. These biases and surgical audit of surgeries can be overcome by using a valid and reliable classification system in reporting complications.

The classification system of Clavien et al.[3] is an excellent attempt at standardization of reporting complications associated with surgeries. The Clavien classification system was first reported in 1992 and was initially used for complications associated with cholecystectomy. [3]

In this study, we applied the revised Clavien classification system as published by Dindo et al.[4] in 2004 to objectively assess complication rates associated with open TVP.


   Materials and Methods Top


We reviewed retrospectively the records of patients who had open TVP in three specialist urology centers in Anambra state, Southeast Nigeria, over a period of 5 years (January 2004-December 2009), with the aim of documenting medical and surgical complications arising from open TVP. All the data were analyzed by the same author to ensure strict inclusion criteria. Consent for the study was obtained from the hospital ethical committee.

Complications were defined at onset of data collection and categorized as immediate, early, or late complications. Immediate complications were defined as complications occurring at the time of surgery; early when within the first 30 days after surgery; and late when beyond 30 days after surgery. Complications were graded according to the Clavien classification system. All the patients were followed up at regular intervals at the out-patient clinic. Those with complications were followed up at more frequent intervals.


   Results Top


A total of 362 patients had open TVP over the period under review. Of this number, 145 had documented evidence of complications. The mean age of the patients was 66.3 years (SD 9.4 years; range 49-96 years). All the patients were followed up after discharge for a mean period of 27.8 months (SD 12.6 months; range 6-33) months. The overall complication rate for open TVP in this study was 40.1% (145/362). [Table 1] shows the complications commonly associated with open TVP according to the revised Clavien classification system. Immediate complications are rare and mainly due to intraoperative bleeding 10 (2.8%), requiring several units of blood during surgery. The early complication rate was 34.5% (125/362), with postoperative bleeding 65 (18%), requiring several units of blood transfusion, accounted for the commonest cause of morbidity. Severe bleeding resulted in clot retention in 5 (1.4%). This necessitated reoperation in early postoperative period. Other complications in this group include wound infection 25 (6.9%), urinary tract infection 12 (3.3%), epididymo-orchitis 15 (4.1%), and vesico-cutaneous fistula 3 (0.8%). The late complication rate was 10 (2.8%). The most common complication was post-prostatectomy urethral stricture 5 (1.4%). This required institution of suprapubic cystostomy and a delayed repair. The other complications in this group included incontinence 2 (0.6%). This was transient and resolved on Kegel's exercises, incisional herna in 1 (0.3%) treated with surgical repair. Complication rates for grades i, id, ii, iiia, and iiib were 0.8%, 0.6%, 35.1%, 0.6%, and 3.0%, respectively.
Table 1: Complications of transvesical prostatectomy according to the Clavien classification system

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   Discussion Top


Apart from physical outcome of surgery, surgical techniques require constant evaluation through their complication rates. This requires a valid, reliable, and standardized system that can be easily reproducible among surgeons and researchers. This will serve as an objective means of comparing experience between surgeons and reducing negative outcomes after surgery.

Although initially introduced for reporting negative outcomes after cholecystectomy, the original Clavien classification system consisted of four severity grades. [3] The recent modification by Dindo et al. in 2004 [4] emphasized on the risk and invasiveness of the method used to treat the complications. The Clavien classification system has been applied in reporting complication rates following open radical retropubic prostatectomy [5] and its surrogates laparoscopic radical prostatectomy [6] and robotic assisted radical prostatectomy. [7] While some reports show some significant advantage over the other in terms of complications, some report showed no significant advantage in terms of complication rates. [8] This shows the complexity and incoherence associated with the present classification system.

Open TVP still remains a veritable procedure in developing countries and in some developed countries especially for large sized prostates. [2],[9] The literature is devoid of studies using the Clavien-Dindo system to stratify complications following open TVP. Our study represents an attempt to use the Clavien-Dindo system to stratify complications associated with open TVP. Varkarakis et al.[9] (n=232) reported long-term complications of open TVP as bladder neck contraction 3.3% (5), urethral stricture 0.6% (1), and meatal stenosis 1.3% (2). Gratzke et al.[10] reported an overall complication rate of 17.3% (n=902). The most common complication in their study was bleeding in 33 (3.7%). Shi [11] in a study on 571 patients who had open prostatectomy reported complications of severe hemorrhage in 21 (3.7%), bladder neck or posterior urethral stricture in 10 (1.7%), and temporary incontinence in 21 (3.7%). These results vary widely with results noted in our study. This study observed an overall complication rate of open TVP of 40.1%. Complication rates for grades i, id, ii, iiia, and iiib were 0.8%, 0.6%, 35.1%, 0.6%, and 3.0%, respectively. Most complications of open TVP occur in the early postoperative period as seen in our study and that of Gratzke et al.[10] and the most significant of this was bleeding in 18.0% and 3.7%, respectively.

This study and indeed most studies in the literature using this classification system have some limitations. These limitations may account for the varying results of complication rates associated with these studies. First, our study was retrospective. Such studies are often froth with biases which can skew results of the study especially in reporting of negative outcomes by different surgeons. Second, the patients were not operated by the same surgeon. Surgeons experience is a predictor of the severity of complications. [12] Third, all the patients in the study do not share similar characteristics in terms of comorbidities, body mass index, and prostate size. These are factors which can impact on the outcome of surgery.

The Clavien-Dindo classification system provides an excellent platform in an attempt to produce a veritable system under which complication rates following surgery can be compared. However, the system has its shortcomings as noted by Constantinos et al.; [13] it cannot evaluate the long-term aspects of the patients' quality of life, and it does not include the comorbidity of the patient, which is a stronger predictor than age of almost all categories of early complications. Again the system does not focus on the major events that test the surgical technique and ability, and whose presentation will reflect on the patients' quality of life after surgery.

Finally, incoherencies noted in the reporting of negative outcomes after surgery can also impact seriously on studies like this. The import of this is that some physicians may underreport complications or not document any at all after surgery. It is also the opinion of the authors that anaesthetic complications such as cardiac and respiratory complications should be included in future classification systems as the presence or absence of these complications also impact seriously on the final outcome of individual surgery. The Clavien-Dindo system provides the necessary building block upon which future attempts at objectively assessing complications following surgery can be made, putting into consideration these recommendations.

In conclusion, open TVP still remains a valid surgical option in contemporary environments where advanced techniques for TURP and laparoscopic prostatectomy are unavailable. Most complications occur in the early postoperative period, with bleeding requiring several units of blood transfusion accounting for the commonest complication. This should be explained to patients during the preoperative counselling. The Clavien-Dindo classification system promises to be a good system for assessing complications following prostatectomy.

 
   References Top

1.AUA Practice Guidelines Committee. AUA Guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol 2003;170:530-47.  Back to cited text no. 1
[PUBMED]    
2.Evans CM. UROLINK in sub-Saharan Africa. BJU Int 2002;89:6-10.  Back to cited text no. 2
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3.Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 1992;111:518-26.  Back to cited text no. 3
[PUBMED]    
4.Dindo D, Dermartines N, Clavien PA. Classification of surgical complications. A new proposal with evaluation in a cohort of 63336 patients and results of a survey. Ann Surg 2004;240:205-13.  Back to cited text no. 4
    
5.Loppenberg B, Noldus J, Holz A, Palisaar RJ. Reporting complications after open radical retropubic prostatectomy using the Martin criteria. J Urol 2010;184:944-8.  Back to cited text no. 5
    
6.Rabbani F, Yunis LH, Pinochet R, Nogueira L, Vora KC, Eastham JA, et al. Comprehensive standardized report of complications of retropubic and laparoscopic radical prostatectomy. Eur Urol 2010;57:371-86.  Back to cited text no. 6
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7.Jeong J, Choi EY, Kim IY. Clavien classification of complications after the initial series of robot-assisted radical prostatectomy: The cancer institute of Jersey/Robert Wood Johnson medical school experience. J Endourol 2010;24:1457-61.  Back to cited text no. 7
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8.Artibani W, Grosso G, Novara G, Pecoraro G, Sidoti O, Sarti A, et al. Is laparoscopic radical prostatectomy better than traditional retropubic radical prostatectomy? An analysis of peri-operative morbidity in two comtemporary series in Italy. Eur Urol 2003;44:401-6.  Back to cited text no. 8
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9.Varkarakis I, Kyriakakis Z, Delis A, Protogerous V, Deliveliotis C. Long-term results of open transvesical prostatectomy from contemporary series of patients. Urology 2004;64:306-10.  Back to cited text no. 9
    
10.Gratzke C, Schlenker B, Seitz M, Karl A, Hermanek P, Lack N, et al. Complications and early post-operative outcome after open prostatectomy in patients with Benign Prostatic Enlargement: Results of a prospective multicenter study. J Urol 2007;117:1419-22.  Back to cited text no. 10
    
11.Shi SF. Major complications after open prostatectomy: Management and prevention. Zhonghua Wai Ke Za Zhi. 1992;30:551-3, 572.  Back to cited text no. 11
    
12.Hu JC, Elkin EP, Pasta DJ, Lubeck DP, Kattan MW, Carroll PR, et al. Predicting quality of life after radical prostatectomy. Results from CaPSURE. J Urol 2004;171:703-8; discussion 707-8.  Back to cited text no. 12
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13.Constantinides CA, Tyritzis SI, Skolarikos A, Liatsikos E, Zervas A, Deliveliotis C. Short- and long-term complications of open radical prostatectomy according to the Clavien classification system. BJU Int 2009;103:336-40.  Back to cited text no. 13
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    Tables

  [Table 1]


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