Prospective randomised non-inferiority trial of pelvic drain placement vs no pelvic drain placement after robot-assisted radical prostatectomy

Role of pelvic drain and timing of urethral catheter removal following RARP: a systematic review and meta-analysis

OBJECTIVES

To assess the clinical value of routine pelvic drain (PD) placement and early removal of urethral catheter (UC) in patients undergoing robot-assisted radical prostatectomy (RARP), as perioperative management such as the necessity of PD or optimal timing for UC removal remains highly variable.

METHODS

Multiple databases were searched for articles published before March 2022 according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. Studies were deemed eligible if they investigated the differential rate of postoperative complications between patients with/without routine PD placement and with/without early UC removal, defined as UC removal at 2-4 days after RARP.

RESULTS

Overall, eight studies comprising 5112 patients were eligible for the analysis of PD placement, and six studies comprising 2598 patients were eligible for the analysis of UC removal. There were no differences in the rate of any complications (pooled odds ratio [OR] 0.89, 95% confidence interval [CI] 0.78-1.00), severe complications (Clavien-Dindo Grade ≥III; pooled OR 0.95, 95% CI 0.54-1.69), all and/or symptomatic lymphocele (pooled OR 0.82, 95% CI 0.50-1.33; and pooled OR 0.58, 95% CI 0.26-1.29, respectively) between patients with or without routine PD placement. Furthermore, avoiding PD placement decreased the rate of postoperative ileus (pooled OR 0.70, 95% CI 0.51-0.91). Early removal of UC resulted in an increased likelihood of urinary retention (OR 6.21, 95% CI 3.54-10.9) in retrospective, but not in prospective studies. There were no differences in anastomosis leakage and early continence rates between patients with or those without early removal of UC.

CONCLUSIONS

There is no benefit for routine PD placement after standard RARP in the published articles. Early removal of UC seems possible with the caveat of the increased risk of urinary retention, while the effect on medium-term continence is still unclear. These data may help guide the standardisation of postoperative procedures by avoiding unnecessary interventions, thereby reducing potential complications and associated costs.

The Prevalence of Lower Limb and Genital Lymphedema after Prostate Cancer Treatment: A Systematic Review

(1) Background: Secondary lymphedema is a chronic, progressive, and debilitating condition with an important impact on quality of life. Lymphedema is a frequently reported complication in oncological surgery but has not been systematically studied in the setting of prostate cancer. (2) Methods: Pubmed/MEDLINE and Embase were systematically searched to identify articles reporting on lower limb or genital lymphedema after primary treatment (surgery of radiation therapy) of the prostate and the pelvic lymph nodes in men with prostate cancer. Primary outcome was the prevalence of lower limb and genital lymphedema. (3) Results: Eighteen articles were eligible for qualitative synthesis. Risk of bias was high in all included studies, with only one study providing a prespecified definition of secondary lymphedema. Eleven studies report the prevalence of lower limb (0-14%) and genital (0-1%) lymphedema after radical prostatectomy with pelvic lymph node dissection (PLND) Seven studies report a low prevalence of lower limb (0-9%) and genital (0-8%) lymphedema after irradiation of the pelvic lymph nodes. However, in the patient subgroups that underwent pelvic irradiation after staging pelvic lymph node dissections, the prevalence of lower limb (18-29%) and genital (2-22%) lymphedema is substantially elevated. (4) Conclusion: Prostate cancer patients undergoing surgery or irradiation of the pelvic lymph nodes are at risk of developing secondary lymphedema in the lower limbs and the genital region. Patients receiving pelvic radiation after pelvic lymph node dissection have the highest prevalence of lymphedema. The lack of a uniform definition and standardized diagnostic criteria for lower limb and genital lymphedema hampers the accurate estimation of their true prevalence. Future clinicals trials are needed to specifically evaluate secondary lymphedema in patients undergoing prostate cancer treatments, to identify potential risk factors and to determine the impact on quality of life.

ROBOCOP II (ROBOtic assisted versus conventional open partial nephrectomy) randomised, controlled feasibility trial: clinical trial protocol

INTRODUCTION

Randomised controlled trials comparing robotic-assisted partial nephrectomy (RAPN) and open PN (OPN) are lacking. Therefore, we aim to report the study protocol and a trial update for a randomised controlled feasibility trial comparing RAPN versus OPN for renal neoplasms.

METHODS AND ANALYSIS

The ROBOtic assisted versus conventional Open Partial nephrectomy II trial is designed as a single-centre, randomised, open-label, feasibility trial. Participation will be offered to patients with renal neoplasms and deemed feasible for both, OPN and RAPN. We aim to enrol 50 patients within 15 months using a 1:1 allocation ratio. The primary endpoint of the trial is feasibility of recruitment and will be successful if one third of eligible patients agree to participate. Secondary endpoints include perioperative results, health-related quality of life, inflammatory response as well as surgical ergonomics of the operating team. If the primary outcome, feasibility of recruitment, is successful, the secondary results of the trial will be used for planning a confirmative phase III trial.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the local institutional review board (Ethik-Kommission II at Heidelberg University: 2020-542N). Results will be made publicly available in peer-reviewed scientific journals and presented at appropriate congresses and social media.

TRIAL REGISTRATION NUMBER

NCT04534998.

Urine leak after robotic radical prostatectomy: not all urine leaks come from the anastomosis

Radical prostatectomy is the gold standard in patients that are surgical candidates with localized prostate cancer. While most postoperative urine leaks are from vesico-urethral anastomosis, urologists must be aware that a small percentage of patients may have a urine leak from other sites that may have been inadvertently injured during the procedure. We propose a systematic workup to evaluate the source of the urinary leak as well as appropriate management of such injuries. The mid-ureter can be injured during lymph node dissection. The distal ureter is at risk of injury when performing the Montsouris approach. The posterior bladder neck dissection can at times be challenging. If not careful, one can easily cause an injury to the trigone and/or ureteral orifices. The most common site of leak is at the vesico-urethral anastomosis due to a non-watertight closure. The management of intraoperatively detected ureteral injuries require placement of a ureteral stent. The location, severity and type of injury determine the reconstruction required to fix it. Postoperatively urine leak can be frequently detected when assessing the pelvic drain, and imaging such as CT Urogram with a cystogram phase may be helpful in the diagnosis. Urine leak after robotic-assisted laparoscopic radical prostatectomy remains a rare complication, sometimes the diagnosis can be challenging, and management varies depending on the site and severity of injury.

Recommendations on robotic-assisted radical prostatectomy: a Brazilian experts' consensus

Radical prostatectomy is a commonly adopted treatment for localized/locally advanced prostate cancer in men with a life expectancy of ten years or more. Robotic-assisted radical prostatectomy (RARP) is comparable to open radical prostatectomy on cancer control and complication rates; however, new evidence suggests that RARP may have better functional outcomes, especially with respect to urinary incontinence and erectile dysfunction. Some of the surgical steps of RARP are not adequately described in published literature and, as such, may have an impact on the final outcomes of the procedure. We organized a Brazilian experts' panel to evaluate best practices in RARP. The confection of the recommendations broadly involved: selection of the experts; establishment of working groups; systematic review of the literature and elaboration of a questionnaire; and construction of the final text with the approval of all participants. The participants reviewed the publications in English from December 2019 to February 2020. A one-round Delphi technique was employed in 188 questions. Five reviewers worked on the final recommendations using consensual and non-consensual questions. We found 59.9% of questions with greater than 70% agreement that were considered consensual. Non-consensual questions were reported according to the responses. The recommendations were based on evidence-based literature and individual perceptions adapted to the Brazilian reality, although some issues remain controversial. We believe that these recommendations may help urologists involved in RARP and hope that future discussions on this surgical procedure may evolve over the ensuing years.

Advantages of using a prophylactic epidural closed drain and non-watertight dura suture in a craniotomy near the "parietal site"

Background

In neurosurgery, the necessity of having a drainage tube is controversial. Subgaleal fluid collection (SFC) often occurs, especially in a craniotomy near the "parietal site".This study aimed to reassess the benefit of using a prophylactic epidural drainage (ED) and non-watertight dura suture in a craniotomy near the parietal site.

Methods

A retrospective review was conducted on 63 consecutive patients who underwent a craniotomy near the parietal site. The patients were divided into two groups according to different period. The deal group received ED and a non-watertight dura suture (drain group, DG), the control group that did not (non-drain group, NDG). Complications and patient recovery were evaluated and analysed.

Results

Three patients (11.5%, 26) in DG and 20 patients (54.1%, 37) in NDG presented with SFC (p < 0.05). One patient (3.8%) in DG and three patients (8.1%) in NDG presented with subdural tensile hydrops (STH) (p > 0.05). Six developed an infection in NDG (four intracranial infections, one abscess, one pulmonary infection), while none in DG (p > 0.05) developed infection. Three (11.5%) cases in DG and one (2.7%) case in NDG had muscle strength that improved postoperatively (p > 0.05). Fifteen (57.7%) in DG and 14 (37.8%) in NDG had epileptic seizures less frequently postoperatively (p < 0.05). The average temperature (37.4 °C vs 37.6 °C, p > 0.05), the maximum temperature (37.9 °C vs 38.1 °C, p > 0.05) on 3 PODs, the postoperative hospital stay day (7.5 days vs 8.0 days, p > 0.05), and the postoperative medicine fee (¥29762.0 vs ¥28321.0, p > 0.05) were analysed.

Conclusion

In patients who undergo a craniotomy near the parietal site, the prophylactic use of ED and a non-watertight dura suture helps reduce SFC, infection, and control epilepsy.

A prospective comparative study of routine versus deferred pelvic drain placement after radical prostatectomy: impact on complications and opioid use

PURPOSE

To evaluate the association of post-RP drain placement with post-operative complications and opioid use at a high-volume institution.

METHODS

A prospective, comparative cohort study of patients undergoing robot-assisted or open RP was conducted. Patients for two surgeons did not routinely receive pelvic drains ("No Drain" arm), while the remainder routinely placed drains ("Drain" arm). Outcomes were evaluated at 30 days including Clavien-Dindo complications and opioid use. Intention-to-treat primary analysis and additional secondary analyses were performed using appropriate statistical tests and logistic regression.

RESULTS

Of 498 total patients, 144 (28.9%) were in the No Drain arm (all robot-assisted) and 354 (71.1%) in the Drain arm. In the No Drain arm, 19 (13.2%) intraoperatively were chosen to receive drains. There was no difference in overall or major (Clavien ≥ 3) complications between groups (p = 0.2 and 0.4, respectively). Drain deferral did not predict complications on multivariable analysis adjusted for age, BMI, comorbidities, clinical risk, surgical approach, operating time, lymphadenectomy, and number of nodes removed [OR 0.61, 95% CI 0.34-1.11, p = 0.10]; nor did it predict symptomatic fluid collection, adjusting for lymphadenectomy and nodes removed [OR 1.14, 95% CI 0.43-3.60, p = 0.8]. Drain deferral did not decrease opioid use (p = 0.5). Per protocol analysis and restriction to robot-assisted cases demonstrated similar results.

CONCLUSION

There was no difference in adverse events, complications, symptomatic collections, or opioid use with deferral of routine drain placement after RP. Experienced surgeons may safely defer drain placement in the majority of robot-assisted RP cases.

Review of the use of prophylactic drain tubes post‐robotic radical prostatectomy: Dogma or decent practice?

Objective

To assess the necessity of routine prophylactic drain tube use following robot‐assisted radical prostatectomy (RARP).

Method

We performed a literature review using the Medline, Scopus, and Web of Science databases with no restriction of language from January 1900 to January 2020. The following terms we used in the literature search: prostatectomy, radical prostatectomy, robot assisted, drainage, and drain tube.

Results

We identified six studies that examined the use of routine prophylactic drain tubes following RARP. One of these studies was a randomized study that included 189 patients, with 97 in the pelvic drain (PD) arm and 92 in the no pelvic drain (ND) arm. This non‐inferiority showed an early (90‐day) complication rate of 17.4% in the ND arm versus 26.8% in the PD arm (P < .001). Another non‐inferiority randomized control trial (RCT) showed a complication rate of 28.9% in the PD group versus 20.4% in the ND group (P = .254). Similarly, the other studies found no benefit of routine use of prophylactic drain tube after RARP.

Conclusion

Drain tubes play a role during robotic‐assisted radical prostatectomy, however, following a review of the current available literature, they can be safely omitted and we suggest that clinicians may be selective in their use.

Should a Drain Be Routinely Required After Transperitoneal Robotic Partial Nephrectomy?

Introduction: Closed drains have traditionally been placed after partial nephrectomy because of risks of bleeding and urine leak. We sought to study the safety of a nonroutine drain (NRD) approach after transperitoneal robotic partial nephrectomy (RPN). Patients and Methods: From a multi-institutional database, we have analyzed the data of 904 patients who underwent RPN. Five hundred forty-six (60.40%) patients underwent RPN by a surgeon who routinely placed drains. Three hundred fifty-eight (39.60%) patients underwent RPN by a surgeon who did not routinely placed drains. Perioperative outcomes, length of stay (LOS), and readmission rates were compared between the two groups. Baseline characteristics, perioperative, and postoperative outcomes were compared using Mann-Whitney U test, chi-square test, and Fisher's exact test. Results: Patients in the NRD group were more likely to have higher body mass index (30.10 kg/m² vs 28.07 kg/m²; P < 0.001), higher tumor size (3.0 cm vs 2.5 cm; P = 0.001), and higher renal score (8 vs 7; P < 0.001). Rate of transfusion (0.00% NRD vs 0.56% RD; P = 0.157) and overall complication (7.33% NRD vs 7.82% RD; P = 0.782) were comparable. Median hospital stay is 1 day for both groups. Readmission rate was also similar (0.55% NRD vs 1.40% RD; P = 0.279). In a multivariable analysis, NRD approach was associated with shorter length of hospital stay (incidence rate ratio [IRR] - 0.72, P < 0.001). Conclusion: An NRD approach for RPN yielded a decreased LOS and similar perioperative outcomes. Placement of surgical drains should be based on individual circumstances, and not required on a routine basis.

Surgical Strategies for Lymphocele Prevention in Minimally Invasive Radical Prostatectomy and Lymph Node Dissection: A Systematic Review

Purpose: Pelvic lymph node dissection is an important step during robotic radical prostatectomy. The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore, different strategies have been proposed to reduce its incidence. Materials and Methods: In this systematic review, EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials were searched for articles including the following interventions: transperitoneal vs extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains, and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Randomized, nonrandomized, and/or retrospective studies were included. Results: Twelve studies were included (including one ongoing randomized clinical trial). Because of heterogeneity of included studies, no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, nonrandomized studies showed a potential benefit of peritoneal reconfiguration to maximize the peritoneal surface of reabsorption. Conclusion: Lymphocele formation is a multistep and multifactorial event; high-quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence.

Prophylactic abdominal or retroperitoneal drain placement in major uro-oncological surgery: a systematic review and meta-analysis of comparative studies on radical prostatectomy, cystectomy and partial nephrectomy

PURPOSE

To systematically analyze the impact of prophylactic abdominal or retroperitoneal drain placement or omission in uro-oncologic surgery.

METHODS

This systematic review follows the Cochrane recommendations and was conducted in line with the PRISMA and the AMSTAR-II criteria. A comprehensive database search including Medline, Web-of-Science, and CENTRAL was performed based on the PICO criteria. All review steps were done by two independent reviewers. Risk of bias was assessed with the Cochrane tool for randomized trials and the Newcastle-Ottawa Scale.

RESULTS

The search identified 3427 studies of which eleven were eligible for qualitative and ten for quantitative analysis reporting on 3664 patients. Six studies addressed radical prostatectomy (RP), four studies partial nephrectomy (PN) and one study radical cystectomy. For RP a reduction in postoperative complications was found without drainage (odds ratio (OR)[95% confidence interval (CI)]: 0.62[0.44;0.87], p = 0.006), while there were no differences for re-intervention (OR[CI]: 0.72[0.39;1.33], p = 0.300), lymphocele OR[CI]: 0.60[0.22;1.60], p = 0.310), hematoma (OR[CI]: 0.68[0.18;2.53], p = 0.570) or urinary retention (OR[CI]: 0.57[0.26;1.29], p = 0.180). For partial nephrectomy no differences were found for overall complications (OR[CI]: 0.99[0.65;1.51], p = 0.960) or re-intervention (OR[CI]: 1.16[0.31;4.38], p = 0.820). For RC, there were no differences for all parameters. The overall-quality of evidence was assessed as low.

CONCLUSION

The omission of drains can be recommended for standardized RP and PN cases. However, deviations from the standard can still mandate the placement of a drain and remains surgeon preference. For RC, there is little evidence to recommend the omission of drains and future research should focus on this issue.

REVIEW REGISTRATION NUMBER (PROSPERO)

CRD42019122885.

Regular vs. selective use of closed suction drains following robot-assisted radical prostatectomy: results from a regional quality improvement collaborative

BACKGROUND

Closed suction drain (CSD) placement is common in robot-assisted radical prostatectomy (RARP). Our goal is to quantify outcomes of RARP for patients undergoing RARP by surgeons who regularly or selectively use CSDs.

METHODS

Patients undergoing RARP (4/2014-7/2017) were prospectively entered into the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry. Outcomes included length of stay (LOS) >2 days, >16-day catheterization, 30-day readmission, and clinically significant urine leak or ileus. Retrospective analysis of each adverse event was performed comparing groups using chi-square tests.

RESULTS

In all, 6746 RARPs were performed by 115 MUSIC surgeons. CSDs were used in 4451 RARP (66.0%), with wide variation in surgeon CSD use (median: 94.7%, range: 0-100%, IQR: 45-100%). The cohorts of patients treated by surgeons with regular vs. selective CSD usage were similar. CSD use pattern was not associated with rates of prolonged catheterization (4.6% vs. 3.9%, p = 0.17) or readmission (4.5% vs. 4.0%, p = 0.35) and multivariable analysis confirmed these findings (each p > 0.10). Regular CSD use was associated with LOS >2 days (8.4% vs. 6.3%, p = 0.001) and multivariable analyses indicated an odds ratio (OR) of 1.42 (95% CI: 1.12-1.79; p = 0.017) and increased likelihood of clinically significant ileus (OR: 1.64; CI: 1.14-2.35; p = 0.008).

CONCLUSIONS

Although there are specific situations in which CSDs are beneficial, e.g. anastomotic leak or observed lymphatic drainage, regular CSD use during RARP was associated with a greater likelihood of LOS >2 days and clinically significant ileus. Our data suggest that CSD should be placed selectively rather than routinely after RARP.

Is a Drain Needed After Robotic Radical Prostatectomy With or Without Pelvic Lymph Node Dissection? Results of a Single-Center Randomized Clinical Trial

Objective: To investigate by means of a randomized clinical trial the safety of no drain in the pelvic cavity after robot-assisted radical prostatectomy (RARP) with or without extended pelvic lymph node dissection (ePLND). Materials and Methods: From May to December 2016, 112 consecutive patients who underwent RARP with or without ePLND were prospectively randomized into a control group (CG) and study group (SG). In the CG, a drain was placed in the pelvic cavity at the end of surgery and removed after 24 hours. The trial was designed to assess noninferiority. The primary endpoint was evaluated as complication rates graded by the Clavien-Dindo score (CDS). Secondary endpoints included length of hospital stay (LOHS) and hospital readmission (RAD). Results and Limitations: At final analysis, 56 patients were in the CG and 54 belonged to the SG. The groups were homogenous for all preoperative and perioperative variables and did not show any difference in CDS complication rates (28.9% in the CG and 20.4% in the SG; p = 0.254), LOHS (on average 4 days in each group; p = 0.689), and RAD rates (3.6% in the CG and 3.7% in the SG; p = 0.970). Conclusions: In a modern cohort of patients who underwent RARP with or without ePLND, a single-center randomized controlled trial showed that no-drain policy is equivalent to drain after RARP in terms of CDS complication rate, LOHS, and RAD rate. The option of placing a postoperative drain for the first 24 hours could be considered in cases of difficult urethrovesical anastomosis with uncertain watertightness.

A comparison of perioperative outcome between robot-assisted and laparoscopic radical prostatectomy: experience of a single institution

PURPOSE

To compare perioperative and pathological results in different approaches of robotic or laparoscopic radical prostatectomy.

MATERIALS AND METHODS

We retrospectively reviewed 206 patients diagnosed with pros¬tate cancer (PC) from June 2016 to October 2017 in the First Affiliated Hospital of Nan¬jing Medical University. A total of 132 cases underwent robot-assisted laparoscopic radical prostatectomy (RLRP) including 54 patients on transperitoneal robot-assisted laparoscopic radical prostatectomy (Tp-RLRP) and 78 on extraperitoneal robot-assisted laparoscopic radical prostatectomy (Ep-RLRP). Meanwhile, 74 patients performed with extraperitoneal laparoscopic radical prostatectomy (Ep-LPR) were also included. Peri¬operative and pathological data were compared among these groups.

RESULTS

All operations were completed without conversion. There was no signifi¬cant difference in basic and pathological characteristics of patients between each two groups. In Tp-RLRP vs. Ep-RLRP: Significant differences were found in the comparison in to¬tal operation time [235.98 ± 59.16 vs. 180.45 ± 50.27 min, P = 0.00], estimated blood loss (EBL) [399.07 ± 519.57 vs. 254.49 ± 308.05 mL, P = 0.0473], postoperative pelvic drainage time [5.37 ± 2.33 vs. 4.24 ± 3.08 d, P = 0.0237] and postoperative length of stay [8.15 ± 3.30 vs. 6.49 ± 3.49 d, P = 0.0068] while no significant differences were detected in other variables. In Ep-RLRP vs. Ep-LPR: Longer total operation time was observed in Ep-RLRP when compared to Ep-LPR [180.45 ± 50.27 vs. 143.80 ± 33.13 min, P = 0.000]. No significant differences were observed in other variables.

CONCLUSION

In RLRP, Ep-RLRP was proved a safe and effective approach based on the perioperative results compared to Tp-RLRP. Ep-RLRP and Ep-LPR provides equivalent perioperative and pathological outcomes.

Risk factors, complications and management of lymphocele formation after radical prostatectomy: A mini-review

Lymphocele formation is the most common adverse event of pelvic lymphadenectomy during radical prostatectomy for prostate cancer. Previous studies failed to favor one surgical technique over the other in terms of minimizing its rate. Data on risk factors for its development are still conflicting and warranting further research. In this mini-review, we aimed to scrutinize available evidence on these aspects and outline current achievements in lymphocele prevention approaches.

Enhanced Recovery After Surgery: Urology

Enhanced recovery after surgery programs were developed as a type of standardized evidence-based perioperative care protocols. The necessity and benefit of clinical care pathways is not a new phenomenon in urology and have been a big part of the evolution of care for urology patients, especially in terms of urologic oncology. This article discusses the key components of evidence-based perioperative care in key urologic procedures. These protocols have been shown to decrease length of stay, decrease complications, and reduce cost.

Body mass index is an independent predictor of Clavien-Dindo grade 3 complications in patients undergoing robot assisted radical prostatectomy with extensive pelvic lymph node dissection

Robot assisted radical prostatectomy (RARP) with extensive pelvic lymph node dissection (ePLND) is an effective procedure for treating and staging prostate cancer; however, high grade complications represent a critical issue. To investigate clinical factors associated with the risk of Clavien-Dindo grade 3 complications in patients undergoing RARP with ePLND. The study included 211 consecutive patients who were operated in a period running from June 2013 to March 2017. Factors associated with grade 3 complications were evaluated by the logistic regression model. Receiver operating characteristic curves and area under the curve (AUC) were used to assess the risk model. Of the 211 patients included in the study, 55 (26.1%) had complications, which were classified Clavien grade one in 36 cases (17.1%), two in 7 (3.3%), 3a in 9 (4.3%) and 3b in 3 (1.4%). Higher median measurements of body mass index (BMI) were detected in grade 3 subjects (27.6 kg/m²) when compared to grade 0-2 cases (25 kg/m²) and the difference was significant (P = 0.015). BMI increased the risk of high grade complications (odds ratio, OR 1.184; P = 0.047) with a fair discrimination power (AUC 0.709). It generated a risk curve by the model, which stratified patients in low (BMI < 26 kg/m²; probability risk less than 5%), intermediate (26 ≤ BMI (kg/m²) ≤ 30; risk between 5 and 10%), and high (BMI > 30 kg/m²; risk between 10 and 20%) risk classes for grade 3 complications. BMI is an independent predictor of grade 3 complications, which are increased by 18.4% for each unit rise. Patients may be stratified preoperatively by BMI into grade 3 risk categories, which include low (normal weight), intermediate (overweight), and high (obese) risk cases.