Abstract
1. PULS is an organ injury scale and, as such, a classification system of intraoperative lesions/injuries, whereas the Clavien-Dindo classification describes postoperative complications. Therefore, assigning PULS grades to Clavien grades is difficult.
2. Clavien and Dindo themselves proposed the following definition of a surgical complication: Any deviation from the ideal postoperative course that is not inherent in the procedure and does not comprise a failure to cure. 1 We are aware that the term “inherent to the procedure” refers to sequelae of a procedure, such as the inability to walk after an amputation, rather than incidents that inevitably occur with a certain procedure, such as minor ureteral lesions during ureteroscopy (URS). Nevertheless, there is general agreement among endourologists that short-term Double-J stent placement for minor lesions, such as PULS grades 1 and 2, should be seen as an integral part of the procedure. Subsequent removal of that stent forms part of the normal postoperative course, too, rather than a necessary intervention after the development of a postoperative complication.
3. Our recommendations for the length of postoperative stent placement are preliminary, because data from randomized trials are lacking. It is possible that the duration of stent placement for PULS grade 2 lesions will be reduced in future, allowing removal by the attached thread without cystoscopy.
Our aim is to standardize reporting of ureteral lesions after URS with PULS as a simple tool for clinical decision-making. Taking into account the above arguments, we suggest the following: PULS grades 0 (no lesion), 1 (superficial mucosal lesion), and 2 (submucosal lesions) should be described as “uncomplicated URS.” In our opinion, these minor lesions should not be assigned to a Clavien-Dindo grading at all, because this would clearly overrate the severity of those lesions and certainly does not reflect the impression of most endourologists.