The "Rule of W" in Urology: Testing Surgical Dictum

Abstract

Objective: To evaluate the timing and frequency of postoperative occurrences as described in the "Rule of W" mnemonic for modern urologic and general surgical cases.

Methods: Using data from the American College of Surgeons National Surgical Quality Improvement Program, patients who underwent a urologic or general surgery procedure and developed a postoperative pneumonia (PNA), urinary tract infection (UTI), surgical site infection, venous thromboembolic event, or myocardial infarction (MI) were included. Frequency and median days to complication were compared.

Results: A total of 445,639 general surgery and 57,963 urology patients were included. Median time to occurrence differed between the cohorts for PNA, UTI, superficial infection, organ space infection, and MI. MI occurred earliest on POD3 for both groups (P = .0438). PNA occurred second on POD4 and POD5 for general surgery and urology, respectively (P = .0034). Venous thromboembolic events occurred third with PE occurring on POD8 for both cohorts (P = .1225) and deep venous thrombosis occurring on POD10 and POD11 (P = .6879) for general surgery and urology, respectively. Wound-related complications occurred at days 9-12 for general surgery and 11-13 for urology. The final sequence yielded waves, wind, walking, water/wound for general surgery and waves, wind, walking, wound, water for urology.

Conclusion: A different chronology of postoperative events was found for urology patients than that described in the original mnemonic. UTIs and wound-related complications represent the most frequent morbidities for the urologic and general surgical patient, respectively. As patient demographics and practice patterns evolve, the "Rule of W", and other teaching tools, will need to be continually and critically reviewed.