Ten senior urologists were interrogated to develop a predictive model based on factors from which they could anticipate complex transurethral resection of bladder tumours (TURBT). Complexity was defined by consensus. Panel members then used a five-point Likert scale to grade those factors that, in their opinion, drove complexity. Consensual factors were highlighted through two Delphi rounds. Respective contributions to complexity were quantitated by the median values of their scores. Multivariate analysis with complexity as a dependent variable tested their independence in clinical scenarios obtained by random allocation of the factors. The consensus definition of complexity was "any TURBT/En-bloc dissection that results in incomplete resection and/or prolonged surgery (>1 h) and/or significant (Clavien-Dindo ≥ 3) perioperative complications". Logistic regression highlighted five domains as independent predictors: patient's history, tumour number, location, and size and access to the bladder. Receiver operating characteristic (ROC) analysis confirmed good discrimination (AUC = 0.92). The sum of the scores of the five domains adjusted to their regression coefficients or Bladder Complexity Score yielded comparable performance (AUC = 0.91, C-statistics, p = 0.94) and good calibration. As a whole, preoperative factors identified by expert judgement were organized to quantitate the risk of a complex TURBT, a crucial requisite to personalise patient information, adapt human and technical resources to individual situations and address TURBT variability in clinical trials.

Department of Urology 2nd Faculty of Medicine Charles University Teaching Hospital Motol 15006 Prague Czech Republic

Department of Urology Fundacio Puigvert 08025 Barcelona Spain

Department of Urology Hôpital Cochin APHP 75014 Paris France

Department of Urology Hôpital Edouard Herriot 69437 Lyon France

Department of Urology Institut Universitaire du Cancer 31059 Toulouse CEDEX 9 France

Department of Urology Radboud UMC 6525 GA Nijmegen The Netherlands

Department of Urology Royal Surrey County Hospital Surrey Guildford GU2 7RF UK

St Josef Klinik für Urologie Caritas Krankenhaus 93053 Regensburg Germany

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