Year : 2013 | Volume
: 5 | Issue : 1 | Page : 23--24
Safwat E Abouhashem
Urology Department, Faculty of Medicine, Zagazig University, Egypt
Safwat E Abouhashem
Urology Department, Faculty of Medicine, Zagazig University
|How to cite this article:|
Abouhashem SE. Commentary.Urol Ann 2013;5:23-24
|How to cite this URL:|
Abouhashem SE. Commentary. Urol Ann [serial online] 2013 [cited 2020 Jan 24 ];5:23-24
Available from: http://www.urologyannals.com/text.asp?2013/5/1/23/106960
Thank you for an interesting manuscript; it clearly shows that great efforts were made to complete it. While reviewing this article earlier, I had made some comments, but have not received any reply from the author.
Again I have some comments:
There is a need to evaluate complications of the surgical approach. And these evaluations must be standardized. Patients and physicians differ greatly in understanding complications. Usually, patients report a higher frequency of complications than their physicians. , The purpose of this study was to assess postoperative complications based on Clavien-Dindo classification. I think the objective is to assess or modify Clavien-Dindo classification from urologic point of view since Clavien-Dindo is a validated system for recording post-operative complications and not intraoperative complications and quality of life.
In the manuscript, [Table 2] shows a small bowel injury in one case and its grade 3b as the complication was managed intraoperatively and, perhaps, led to longer in-patient stay. It could be argued that this is grade I complication; however, bowel injury is considered a major complication and its intraoperative repair under general anesthesia is a significant deviation from the planned procedure, justifying its inclusion as a Grade 3a event. So according to what bowel injury can it be classified?
How to grade the presence of residual fragments of stones that increase the morbidity after treatment, either by using endoscopy or extracorporeal shock wave lithotripsy (ESWL) it considered as failures not as complications. Another controversy is secondary ureteropelvic junction obstruction, which leads to loss of renal function ended by nephrectomy (grade 4a), but when secondary ureteropelvic junction obstruction is managed endoscopically (grade 3b).  Impotence is a common consequence in urologic surgery, but is it common enough to become a sequel? If the patient does not wish any treatment for his impotence, then no recording is needed and it becomes a sequel. Conservative measures such as pump devices mean a grade I complication should be recorded. Medical therapy such as Phosphodiesterase type 5 inhibitor (PDE5 inhibitors) necessitate recording grade 2 complications and surgical therapy such as penile implants indicate that grade 3b complications have occurred, so according to what do you consider impotence? Incontinence could be even more difficult to classify. Some surgeons may be tempted to treat this potentially major complication with several pads per day or a urethral catheter, which means grade I is recorded without offering surgical management (grade 3b). The Clavien-Dindo classification is validated method successfully used by some urology centers. But it does not cover all complications of urological operations; therefore, grading of intraoperative and long-term complications must be included in Uro-Clavien-Dindo classification.  Thus, Clavien-Dindo classification is not a reliable classification in urology and need some modifications. While reporting the outcomes of urologic procedures, Mitropoulos et al.  stated that, "Define the complications: The Clavien-Dindo grading system is highly recommended, improve reporting of complications. Define the method of accruing data: Retrospective, prospective. Define who collected the data: Medical doctor/nurse/data manager/other, and whether they were involved in the treatment. Indicate the duration of follow-up: 30, 60, 90, or >90 days. Include outpatient information. Include mortality data and causes of death. Include definitions of complications. Define procedure-specific complications. Use a severity grading system (avoiding the distinction minor/major); the Clavien-Dindo system is recommended. Include risk factors: American Society of Anaesthesiologists, score, Charlson score, Eastern Cooperative Oncology Group. Include readmissions and causes. Include reoperations, types, and causes, as well as the percentage of patients lost to follow-up. Finally, editors of urologic journals should demand the use of a standardized system to report complications after urologic surgery."
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