The NICE classification for "Ultra-radical (extensive) surgery for advanced ovarian cancer" guidance does not meaningfully predict post-operative complications: a cohort study

Research output: Contribution to journalArticlepeer-review


  • Andrew Phillips
  • Kavita Singh
  • Rachel Pounds
  • James Nevin
  • Janos Balega
  • Ahmed Elattar

Colleges, School and Institutes

External organisations

  • Department of Obstetrics and Gynaecology, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, United Kingdom.
  • Pan-Birmingham Gynaecological Cancer Centre, City Hospital, Dudley Rd, Birmingham B18 7QH, United Kingdom.
  • Pan-Birmingham Gynaecological Cancer Centre, City Hospital, Dudley Rd, Birmingham B18 7QH, United Kingdom; Institute of Cancer and Genomic Sciences, Vincent Drive, University of Birmingham, Birmingham B15 2TT, United Kingdom.


OBJECTIVE: To determine which descriptors of cytoreductive surgical extent in advanced ovarian cancer(AOC) best predict post-operative morbidity.

DESIGN: Retrospective notes review.

SETTING: A gynaecological cancer centre in the United Kingdom.

POPULATION: 608 women operated on for AOC in 114 months at a tertiary cancer centre between 16/8/07-16/2/17.

METHODS: Outcome data were analysed by six approaches to classify extent of surgery. Standard/ultra-radical surgery; standard/radical/supra-radical surgery; presence/absence of gastrointestinal resections; low/intermediate/high surgical complexity score(SCS); presence of bowel anastomoses and/or diaphragmatic surgery; and presence/absence of multiple bowel resections.

MAIN OUTCOME MEASURES: Major (grade 3-5) post-operative morbidity and mortality.

RESULTS: 43(7.1%) patients experienced major complications. Grade 5 complications occurred in 6 patients(1.0%). Patients who underwent multiple bowel resections had a relative risk(RR) of 7.73(95%CI 3.92-15.26), high SCS RR of 6.12(95%CI 3.25-11.52); diaphragmatic surgery and gastrointestinal anastomosis RR 5.57(95%CI 2.65 - 11.72); "any gastrointestinal resection" RR 4.69(95%CI 2.66-8.24); ultra-radical surgery RR 4.65(95%CI 2.26-8.79); supra-radical surgery RR 4.20(95%CI 2.35-7.51) of grade 3-5 morbidity as compared to those undergoing standard surgery as defined by NICE. No significant difference was seen in the rate of major morbidity between standard (6/59,10.2%) and ultra-radical (9/81,11.1%) surgery within the cohort who had intermediate complex surgery (p>0.05).

CONCLUSIONS: Numbers of procedures performed significantly correlates with major morbidity. The number of procedures performed better predicted major post-operative morbidity than the performance of certain "high risk" procedures. We recommend the SCS to define a higher-risk operation. NICE should re-evaluate the use of the term "ultra-radical" surgery. This article is protected by copyright. All rights reserved.


Original languageEnglish
JournalBJOG: An International Journal of Obstetrics & Gynaecology
Early online date9 Aug 2018
Publication statusE-pub ahead of print - 9 Aug 2018


  • Ovarian cancer, surgery, morbidity, ultra-radical, NICE