AUA 2017: The Comprehensive Complication Index (CCI) is superior to the Clavien-Dindo grading system in predicting length of stay and hospital readmission following radical nephroureterectomy

Boston, MA ( The Clavien-Dindo classification system is a commonly used tool to classify procedural complications by severity. As it has validated in numerous prior studies, it has become the standard to assess complication rates after major operations. However, it is limited by the fact that it rates complications on an individual basis. This classification grades complications according to the most severe complication or events judged to be relevant, and as a result, less severe complications and the total number of complications are not reported.

The Comprehensive Complication Index (CCI) was an alternative developed in the general surgery literature (Slankamenac K 2013) to capture the cumulative nature of multiple complications on a 0-100 scale – it should be noted that the scores are based on Clavien-Dindo classification. The authors of this multi-institutional study translate it into the GU literature by looking at its utility following radical nephroureterectomy (RNU). Specifically, they assess its ability to predict hospital length of stay (LOS) and readmission as compared to the Clavien-Dindo classification.

This was a retrospective chart review of 532 consecutive patents who underwent RNU at 7 academic medical centers between 2005-2015. Both classification systems were used to grade complications within 30 days of RNU. 377 men and 219 women with a median age of 71, BMI of 27, and Charlson comorbidy score of 4 were included. 60% had an ASA score > 2, 22% were ECOG > 2, and 59% had baseline CKD stage III or greater. Median LOS following RNU was 6.0 days (range, 1-37) and readmission within 30 days occurred in 45 (7%) patients. RNU was completed in a minimally invasive fashion in 75% of patients.

Overall, 136 patients (23%) experienced a post-operative complication with 91 having a single complication, while 45 had between 2-6 complications. 44 (7%) patients had Clavien III or greater complications, and the median CCI for those patients experiencing a complication was 20.9 (range, 8.7-100). High complication rate cohorts: the upper quartile of CCI (> 75th %) and major CD complications (grade III+) were associated with higher Charlson score, ECOG > 2, and CKD stage > III (p for all < 0.05). However, only the upper quartile of CCI was associated with LOS (8.9 vs. 5.4 days, p<0.01) and hospital readmission (OR 3.2, p =0.02) after RNU whilst major CD complications were not (LOS 7.4 vs. 5.6 days, p=0.14; Readmission OR 1.4, p=0.21).

Based on this, the authors conclude that the CCI was superior to the Clavien-Dindo classification in predicting perioperative outcomes, likely due to its cumulative nature.

While the appeal of this new tool is evident, more work needs to be done to establish its superiority. However, it does seem to be a promising carryover from the general surgery literature, where it is more established.

Likely to be used primarily for future studies to help quantify perioperative morbidity, we did discuss that it also helps staff (residents and practicing urologists) understand that each small complication likely affects outcomes just as much as the single major complication.

1. Slankamenac K., Graf R., Barkun J., Puhan M.A., Clavien P.A. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013;258:1–7.

Presented by: Scott Geiger, MD

Co-Authors: Neil Kocher, Dan Ilinsky, Evanguelos Xylinas, Peter Chang, Lauren Dewey, Andrew A. Wagner, Firas Petros, Surena F. Matin, Conrad Tobert, Chad Tracy, Patard Pierre-Marie,

Written By: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto
Twitter: @tchandra_uromd

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA