Title: Radical Total Pelvic Exenteration with Concomitant Right Nephrectomy in the Management of Recurrent Endometrioid Ovarian Adenocarcinoma: A Case Report and Literature ReviewAuthors: Raghavskandhan Ramachandran1, Sabina Nistor2, William Gietzmann3, Nicholas Symons4, Hooman Soleymani Majd2, 5Word Count: 2220Authors:Medical Sciences Division, University of Oxford, Oxford, United KingdomDepartment of Gynaecology Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United KingdomDepartment of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, United KingdomDepartment of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United KingdomNuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United KingdomCorresponding Author Details:Hooman Soleymani Majd, MDAddress: Department of Gynaecology Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Old Rd, Headington, Oxford, United Kingdom, OX3 7LETelephone: 07958285604Email: [email protected]: 0000-0003-3293-5321There are no conflicts of interest.No funding was received for this case report.The patient has given consent for the writing of this case report and the inclusion of surgical images.

Objective: To describe a suggested version of the Clavien-Dindo morbidity classification specific to obstetrics and employ it to build a cumulative morbidity score which fully reflects the ‘patient experience’. To demonstrate the utility of this novel system in a cohort of women with Placenta Accreta Spectrum (PAS).   Design: Delphi consensus and retrospective application of the resulting scores to morbidity from PAS surgery.   Setting: UK Tertiary referral centre for PAS.   Population: Women who had caesarean hysterectomy for PAS.   Methods: The Clavien-Dindo classification was modified to reflect obstetric procedures and a quantitative morbidity measure, the Soleymani and Collins Obstetric Morbidity Score (SaCOMS), was developed based on this. Both were then validated using a Delphi consensus of experts in PAS and retrospectively applied to a cohort of 54 women with PAS.   Main Outcome measures: Delphi consensus of >80%, binary outcome of adverse event or not and quantitative values from the SaCOMS.   Results: Clinicians with expertise in PAS believe that the Modified Obstetric Clavien-Dindo classification system and the novel SaCOMS tool can improve assessment of maternal morbidity, and better reflect the ‘patient experience’. Application to the PAS cohort demonstrates that surgery by gynae-oncological surgeons may be associated with decreased incidence and cumulative morbidity outcomes for women with PAS, especially those with the most severe presentation.     Conclusions: This study presents a clinically useful obstetric-specific classification system for surgical morbidity. SaCOMS also provides a quantitative reflection of the full patient- journey experienced as a result of surgical complications enabling a more patient-centred representation of morbidity.