Evaluation of laparoscopic approach in radical cystectomy from implementation to consolidation: Internal validation | Actas Urológicas Españolas (English Edition)

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The clinical guidelines recommend radical cystectomy as first treatment option in the following cases&#58; muscle-infiltrating bladder tumor &#40;T2-4 N0-x M0&#41;&#44; BCG-refractory non-muscle-infiltrating tumor&#44; recurrence after BCG and non-muscle-infiltrating tumor which cannot be treated endoscopically&#46; The guidelines of the European Association of Urology &#40;EAU&#44; 2017&#41; recognize that laparoscopic or robot-assisted approaches should be considered as research procedures due to the limited data&#46; Despite this&#44; they acknowledge that these techniques provide a shorter hospital stay&#44; fewer transfusions and less complications&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The &#8220;learning curve&#8221; refers to the period of time when a surgical procedure is slower&#44; more difficult&#44; has a greater number of complications and low efficacy&#44; due to surgeons&#8217; inexperience&#46; However&#44; a standard definition of &#8220;learning curve&#8221; has not been accepted&#46; It is often defined as the minimum number of cases required to be performed to reproduce a technique considered as standard&#46; Obviously&#44; this curve is influenced by certain surgeon-dependent parameters&#44; such as previous experience in other procedures &#40;open and minimally invasive&#41; in addition to good attitude and self-confidence&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of this study is to analyze the implementation of a laparoscopic cystectomy &#40;LRC&#41; program in one center and compare it with a consolidated and standardized open cystectomy &#40;ORC&#41; program&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0020" class="elsevierStylePara elsevierViewall">This program of laparoscopic access to cystectomy was initiated in our center in 2006 by two staffs with wide experience in open and laparoscopic surgery&#46; The data of the patients consecutively submitted to cystectomy from 2003 until 2016 &#40;712 from 1986&#8211;2016&#41; were collected from the cystectomy data base&#46; A total of 393 patients was identified&#58; 197 &#40;50&#46;1&#37;&#41; were treated with an open access between 2003 and 2016&#44; and 196 &#40;49&#46;9&#37;&#41; were operated laparoscopically between 2006 and 2016&#46; An ORC cohort was selected to be compared with an LRC cohort&#46; Thus&#44; all ORCs performed on the same period of LRC of the study were collected before the beginning of laparoscopic approach in radical cystectomy&#58; 96 patients submitted to ORC from 2003&#8211;2005 versus 196 treated only with laparoscopy from 2006 to 2016&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients in the laparoscopy group received extracorporeal urinary diversion&#44; same as in open surgery&#46; Extended lymphadenectomy was performed systematically from 2006&#59; therefore&#44; only in the LRC group&#46; The laparoscopic access in LRC was performed by the same urologists&#44; and the urinary diversion was carried out mainly by urology residents&#46; The ORC surgical team was constituted by open surgery and radical cystectomy expert surgeons and residents in similar percentages &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">No patient received neoadjuvant chemotherapy&#44; and 12&#46;5&#37; of the ORC patients had previous pelvic radiotherapy vs&#46; 5&#46;1&#37; from the LRC group &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The anesthetic risk was defined according to the classification system of the American Society of Anesthesiologists &#40;ASA&#41;&#46; Previous pathologies were scored according to the Charlson index<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and subsequently calculated with the sum of the scores&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Postoperative complications were graded with the Clavien-Dindo classification&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Patients were restaged with the 7th&#46; edition of the UICC TNM classification&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> All complications occurred within the 60 postoperative days were collected&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A retrospective cohort study was conducted between two patient groups&#58; group 1-ORC &#40;2003&#8211;2005&#41; and group 2-LRC &#40;2006&#8211;2016&#41;&#44; aiming to compare the evolution of the following parameters&#58; cystectomy operative time &#40;defined as cystectomy time&#8239;&#43;&#8239;lymphadenectomy and urinary diversion&#41;&#44; the need for transfusion&#44; resection margin status&#44; postoperative complications&#44; length of hospital stay and recurrence rates&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When retrospectively analyzing the LRC data&#44; we observe that the surgical time variable defines three periods from the beginning of our experience&#58; the first period takes place during the introduction of the laparoscopic access implementation program&#44; with heterogenous operative time among cases&#44; subsequently decreasing until its stabilization&#59; the second period has similar operative time among cases&#59; and the third period&#44; showing significantly decreased operative times &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Therefore&#44; we have established 3 subgroups in our LRC cohort&#44; defined as follows&#58; implementation &#40;2006&#8211;09&#41; &#40;LRC-I&#41;&#44; development &#40;2010&#8211;14&#41; &#40;LRC-D&#41; and consolidation &#40;2015&#8211;16&#41; &#40;LRC-C&#41; periods&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In order to meet the objective of the study&#44; the ORC group &#40;control&#41; will be compared with each LRC subgroup&#58; LRC-I &#40;2006&#8211;09&#41;&#44; LRC-D &#40;2010&#8211;14&#41; Y LRC-C &#40;2015&#8211;16&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A descriptive analysis of the variables analyzed was performed using the usual statistics for the quantitative variables &#40;median and interquartile range-IQR&#41; and qualitative variables &#40;absolute frequencies and percentages&#41;&#46; The Chi squared test has been used to compare the qualitative variables and the Anova test for the numerical variables&#46; Statistical significance was considered with p&#8239;&#60;&#8239;0&#44;05&#46; All calculations have been performed with the IBM&#174; SPSS&#174; statistics v-21 statistical package&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The baseline characteristics of the patients and the surgical approach to cystectomy are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; and those according to the defined time periods are detailed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Those patients treated laparoscopically presented significantly different characteristics when compared to the control group &#40;ORC&#41;&#58; they presented more clinically advanced tumors and greater cN&#8239;&#43;&#8239;&#44; higher ASA 3&#8211;4&#44; Charlson index &#8805;3 and increased percentage of pelvic RT&#46; In contrast&#44; the time between TUR and cystectomy was lower &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">When comparing patients treated with laparoscopic approach according to the I&#44; D and C periods&#44; we observed a higher percentage of more advanced tumors and pelvic RT in the last period &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Seven patients &#40;3&#46;4&#37;&#41; required conversion to open surgery&#58; 3&#44;6 cases in LRC-I due to anesthetic indication for intolerance to pneumoperitoneum and 2 in each of the other periods&#44; due to laparoscopic technical impossibility&#46; There were 2 incidental intraoperative lesions&#58; a hypogastric vein injury in the LRC-D and a rectal lesion in the LRC-C&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Transintestinal diversion was performed in 75 patients &#40;78&#46;1&#37;&#41; in the ORC group&#44; and in 182 &#40;92&#46;9&#37;&#41; &#40;p&#8239;&#61;&#8239;0&#44;0001&#41; from the LRC group&#46; The diversions in the ORC group were as follows&#58; transileal Bricker-type ureterostomy was performed in 66 &#40;88&#37;&#41; and bladder replacement in 9 &#40;12&#37;&#41;&#59; and 158 &#40;86&#46;8&#37;&#41; and 24 &#40;13&#46;2&#37;&#41;&#44; respectively&#44; in the LRC group &#40;p&#8239;&#61;&#8239;0&#44;80&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The intraoperative&#44; pathological variables and the postoperative complications according to the 3 periods are detailed in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 4</a> and <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; A median of 5 lymph nodes &#40;IQR 3&#8211;9&#41; was resected in ORC and 11 &#40;IQR 7&#8211;15&#41; in LRC&#46; Significantly&#44; patients undergoing laparoscopic surgery presented different characteristics than those of the ORC&#58; practically all were performed by one staff&#44; there were more intestinal diversions and fewer associated surgeries in LRC-C&#44; higher pathological stage in CLR-I&#59; CLR -C had less positive surgical margins&#44; more lymphadenectomies performed and a greater number of lymph nodes resected by procedure&#46; In addition&#44; the number of resected nodes increased in LRC-D with respect to LRC-I &#40;0&#46;0001&#41;&#44; but not between CLR-D and CLR-C &#40;P&#8239;&#61;&#8239;0&#44;25&#41;&#44; greater operative time in LRC-I and LRC-D&#44; less intraoperative transfusions in the 3 periods and post-operative in LRC-D and LRC-C&#44; lower overall complication rate in LRC-D and LRC-C &#40;basically due to the decreased number of surgical wound infections and evisceration&#41; and less serious complications &#40;Clavien&#8239;&#8805;&#8239;3&#41; in all periods&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Mortality also decreased from the beginning of the implementation period &#40;p&#8239;&#61;&#8239;0&#44;01&#41;&#44; and it presented a relevant tendency to significance &#40;p&#8239;&#61;&#8239;0&#44;09&#41; with respect to the control group in the development &#40;p&#8239;&#61;&#8239;0&#44;02&#41; and consolidation periods &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Hospital stay decreased since the onset of the program &#40;p&#8239;&#61;&#8239;0&#44;01&#41; and continued with this tendency during the following two study periods &#40;LRC-D p&#8239;&#61;&#8239;0&#44;002 and LRC-C p&#8239;&#61;&#8239;0&#44;005&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Involved surgical margins were observed in 22 patients &#40;7&#46;8&#37;&#41;&#44; 7 &#40;8&#37;&#41; in the ORC group&#44; and 15 &#40;7&#46;7&#37;&#41; in LRC&#46; The comparison of the different periods of the LRC with the ORC is detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">135 patients &#40;46&#46;2&#37;&#41; presented recurrence&#58; 53 &#40;55&#46;2&#37;&#41; in ORC and 82 &#40;41&#46;8&#37;&#41; in LRC&#46; The comparison of the different periods between LRC and ORC is detailed in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The implementation of a new surgical approach is a complicated process due to the difficulties when performing studies &#40;clinical trials&#41; that allow comparing it with the approach considered as standard&#46; This explains why the European clinical guidelines consider minimally invasive cystectomy as an experimental option despite the fact that it has been two decades since the publication of the standardized minimally invasive cystectomy&#59; first&#44; laparoscopic in 2000 by Gill<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and later&#44; robotic&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Novara<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> points out several causes that may have hindered the implementation of minimally invasive surgery in radical cystectomy&#58; the technical difficulty of cystectomy&#44; the limited prospective studies that support it against open cystectomy&#44; and the doubts that have arisen regarding the reproducibility of the technique&#46; Several authors have expressed their concerns about the effectiveness of LRC<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> during these 2 decades&#59; these apprehensions include oncological safety due to the theoretical risks of dissemination of the urothelium tumor associated with the laparoscopic pneumoperitoneum&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> All these considerations are reflected in the scarce implementation of minimally invasive cystectomy around the world&#58; only 20&#37; of all cystectomies performed in the USA in 2016 were performed as minimally invasive surgeries&#46; In 2013 in Spain&#44; only 10&#37; of all cystectomies were laparoscopic and robotic&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The validation of a new surgical technique is based on demonstrating its efficacy&#44; morbidity advantages over the standards&#44; and reproducibility&#46; Regarding an already complex surgery such as cystectomy&#44; it is precisely the technical difficulty of the laparoscopic approach&#44; and&#44; therefore&#44; its reproducibility in comparison to the open standard approach&#44; the main obstacle for its implementation in many centers&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We have established 3 periods in the analysis of our laparoscopic experience&#58; the implementation period &#40;LRC-I&#41;&#44; the development period &#40;LRC-D&#41; and the consolidation period &#40;LRC-C&#41; according to the operative time observed in cystectomy&#46; The development period was considered when a standardized operative time was observed &#40;305&#8239;min mean&#41; and the transition to the consolidation phase when the operative time decreased &#40;2633&#8239;min mean&#41;&#44; even below the standard values for open surgery &#40;270&#8239;min mean&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Other authors establish the number of cases&#47;year as a criterion in the analysis of their experience&#46; However&#44; this is only useful when there is a similar and correlative number of cases&#47;year during the study period&#46; Liss and Kader<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> review the literature on minimally invasive cystectomies and describe an average of 20 cases before obtaining an operative time of less than 6&#46;5&#8239;h and 30 cases to obtain a mean of 20 resected lymph nodes in lymphadenectomy&#46; However&#44; the authors recognize the lack of standardization tools for the learning curves and the great variability of studies&#46; In our study we opted for operative time&#44; due to the fact that the laparoscopic approach has coexisted with the open standard technique for years&#44; until we have validated the technique&#46; Therefore&#44; the number of cases&#47;year in our series is very variable and does not faithfully describe the evolution of the technique&#46; Since the beginning in 2006&#44; the comparison of LRC has been established with a proportionate and contemporary homogeneous series of ORC&#44; which represents the standard and consolidated technique in our hospital&#46; Urinary diversion has always been performed extracorporeally&#44; and it has been a constant variable for all the cystectomy groups of the study&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">For the validation of laparoscopic approach in our hospital&#44; we have considered 3 aspects that should be compared with the ORC standard&#58; the assessment of morbidity and mortality&#44; the therapeutic efficacy and the reproducibility of the technique&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">When we evaluate the morbidity of LRC&#44; we observe that the total number of complications during the implementation period &#40;LRC-I&#41; is similar to that of the ORC&#46; However&#44; during the development &#40;LRC-D&#41; and consolidation &#40;LRC-C&#41; phases&#44; there is a significant reduction of complications with respect to ORC&#46; In addition&#44; regarding all stages of LRC&#44; we observed a significant decrease of complications associated with surgical aggression &#40;wound infection&#44; abscesses and eviscerations&#41;&#46; We also observed a lower rate of intra- and postoperative transfusions since the beginning of LRC compared to the ORC&#46; These data correspond with what has been published in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> Also&#44; serious complications &#40;Clavien&#8239;&#8805;&#8239;III&#41; decreased from the beginning of the LRC experience&#44; despite the fact that during the development and consolidation &#40;LRC-D and LRC-C&#41; periods of LRC&#44; the urinary diversion &#40;considered the most frequent cause of serious complications in radical cystectomy&#41; was performed by urology trainees in more than 90&#37; of the cases&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Mortality rates must be taken with caution&#46; Although it was of 10&#37; in the control group&#44; a 5&#37; was reported for open cystectomies in the service database&#46; In the laparoscopic series &#40;lower in number&#41; the mortality rate was 2&#37; &#40;p&#8239;&#61;&#8239;0&#46;07&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Despite the fact that the patients intervened in these periods had a higher percentage of locally advanced stages &#40;which theoretically would associate a higher complication rate and bleeding&#41;&#44; there is a significant decrease regarding overall complications in the development and consolidation phases of LRC compared to ORC&#46; These data reinforce the idea that the standardization of the complete technique developed in the initial phase by a limited number of staff surgeons&#44; 2 urologists&#44; has improved the safety of the technique and promoted its learning process&#46; The mean hospital stay&#44; although subject to certain biases&#44; has also been lower with respect to ORC and in each period of the learning curve&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Regarding therapeutic efficacy&#44; we have considered the oncology quality criteria in radical cystectomy established by the Bladder Cancer Collaborative Group in 2004<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#58; surgical margins&#60; 10&#37; in pT0-2 and &#60;15&#37; in pT3-4 and 10&#8211;14 resected lymph nodes in lymphadenectomy&#46; We obtained 7&#46;7&#37; positive surgical margins and a number of lymph nodes &#40;median n&#8239;&#61;&#8239;11&#41; in our LRC series&#59; these values are considered standard in the different phases of the learning curve of LRC by the oncology guidelines&#46; We have not observed significant differences between ORC and LRC in terms of surgical margins and recurrence&#44; neither in the total series&#44; nor in the comparison among periods&#44; which supports the quality of the LRC technique since its introduction&#46; These data are comparable to the longest series regarding ORC&#44; published by Stein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Third&#44; and finally&#44; the reproducibility of the LRC technique has been made evident by the fact that&#44; at the end of the study period &#40;2010&#8211;2016&#41;&#44; 86&#37; radical cystectomies were performed with this approach&#44; practically replacing ORC&#46; In addition&#44; we have increased the number of surgeons who execute this surgical technique&#44; which internally validates reproducibility in our service&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">However&#44; we found that the learning curve of the LRC is demanding&#58; the operative time was longer compared to open surgery during the first 151 cases &#40;phases LRC-I and LRC-D&#41;&#46; This could be due to the time of extended lymphadenectomy&#44; which was performed since the beginning of LRC&#44; as opposed to ORC&#46; After the first 45 cases&#44; a reduction in the operative time was achieved&#44; reaching a mean duration of 300&#8239;min in the development phase &#40;2010&#8211;14&#41;&#46; It was only in the last two years &#40;2015&#8211;16&#41;&#44; consolidation period &#40;LRC-C&#41;&#44; when we observed a trend towards a decreased operative time of the LRC compared to the cohort of ORC &#40;270 vs&#46; 263&#8239;min media p&#8239;&#61;&#8239;0&#44;40&#41;&#44; although it probably does not reach statistical significance due to the reduced number of cases in this period &#40;LRC-C&#8239;&#61;&#8239;45&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The scarce number of cases&#44; especially in the last period of LRC&#44; as well as the retrospective design&#44; are some of the weaknesses that reduce the power of the study&#46; In addition&#44; the performance of extended lymphadenectomies was not homogenous between ORC and LRC groups&#44; as the recommendations of the clinical guidelines varied from one period of the study to the other&#44; which can undoubtedly have an impact on operative time&#44; oncological outcomes and morbidity&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In short&#44; we observed that from the implementation period of laparoscopic cystectomy &#40;LRC-I&#41; of our study&#44; there was a decrease in transfusions&#44; complications and hospital stay&#44; at the expense of longer operative time compared to the ORC&#46; During the development period &#40;LRC-D&#41;&#44; the previously described parameters improved significantly and the operative time increased&#46; In the consolidation period &#40;LRC-C&#41; the operative time was reduced and showed a tendency to a shorter time compared to the control group of open surgery&#44; maintaining the advantages regarding morbidity&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">There is a great heterogeneity of results regarding the learning curves of minimally invasive approach of radical cystectomy by different authors&#44; due to the different criteria when defining learning curve and to the fact that some studies represent the experience of more than one center&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Some authors observe that its implementation does not compromise the safety of patients&#44; although they do not describe significant advantages over ORC&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and others affirm that increased surgeon&#8217;s experience improves the quality of lymphadenectomy and reduces operative time&#44; although without improving the results of the ORC&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Based on our experience&#44; the implementation of new techniques&#47;surgical approaches in diseases with a small number of cases&#47;year&#44; should be limited to a small group of highly experienced surgeons&#44; especially at the beginning of the learning curve&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="par0175" class="elsevierStylePara elsevierViewall">Laparoscopic cystectomy versus open cystectomy improves the percentage of transfusions&#44; complications and hospital stay from its implementation phase&#44; at the expense of a longer operative time&#46; In our experience&#44; the laparoscopic approach requires a long learning curve before having a comparable&#44; and even lower&#44; operative time than open cystectomy&#46; In our center&#44; laparoscopy has been validated as a minimally invasive reference approach to radical cystectomy&#44; providing advantages in morbidity&#44; maintaining the quality criteria for cystectomy&#44; as well as demonstrating its reproducibility after a demanding learning curve&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The AEU Guidelines of 2017 consider laparoscopic and robot-assisted approaches as investigational procedures&#46; The surgical learning curve is defined as the minimum number of cases that a surgeon has to perform in order to reproduce a technique considered as standard&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to analyze&#44; within our department&#44; the implementation of a laparoscopic radical cystectomy &#40;LRC&#41; program compared with a well consolidated and standardized open radical cystectomy &#40;ORC&#41; program&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Retrospective cohort analysis of two cystectomy groups&#58; LRC &#40;n&#8239;&#61;&#8239;196&#41; &#40;20062016&#41; vs ORC &#40;n&#8239;&#61;&#8239;96&#41; &#40;2003&#8211;2005&#41;&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Comparison of the evolution over time of the following parameters&#58; operative time&#44; blood transfusion rates&#44; resection margins&#44; postoperative complications&#44; hospital stay and recurrence&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Three time periods have been defined for LRC&#58; implementation &#40;2006&#8211;09&#41; &#40;LRC-I&#41;&#44; development &#40;2010&#8211;14&#41; &#40;LRC-D&#41; and consolidation &#40;2015&#8211;16&#41; &#40;LRC-C&#41;&#59; comparing each of them with the control group &#40;ORC&#41;&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">The chi-square test was used for the comparison of the qualitative variables and the Anova test for the numerical ones&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">When compared to ORC&#44; LRC presented longer operative times in LRC-I and LRC-D periods&#46; We observed a trend toward shorter operative time than ORC in the consolidation period &#40;LRC-C&#41;&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">LRC also presented lower intraoperative transfusion rates in all periods and lower postoperative rates in CRL-D and CRL-C&#46; Overall complications in LRC-D and LRC-C were lower in LRC&#44; having fewer major complications &#40;Clavien&#8239;&#8805;&#8239;3&#41; in the 3 periods&#46; A decrease in mortality and hospital stay after the LRC-I phase was also observed&#46; These results were consolidated during the two last periods of the study&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">We have not observed significant differences between ORC and LRC when comparing surgical margins and recurrence rates&#44; neither in the total series&#44; nor in the comparison between the different periods&#46; These results endorse the oncologic safety of LRC from the beginning of the implementation process&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">When compared to ORC&#44; LRC improves perioperative transfusion rates&#44; complications and hospital stay from its implementation period&#44; maintaining oncological safety&#46; On the contrary&#44; longer operative times during implementation and development were observed&#46; However&#44; in our series&#44; we observed a trend toward shorter operative times than ORC approach in the consolidation period&#46; We have validated the laparoscopic approach for radical cystectomy in our service&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Las Guidelines de la AEU de 2017&#44; consideran el acceso laparosc&#243;pico o asistido por robot como procedimientos en investigaci&#243;n&#46; La curva de aprendizaje se define por el n&#250;mero m&#237;nimo de casos que es necesario realizar para reproducir la t&#233;cnica considerada como est&#225;ndar&#46;</p><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio es analizar en el mismo servicio&#44; la implantaci&#243;n de un programa de cistectom&#237;a laparosc&#243;pica &#40;CRL&#41;&#44; compar&#225;ndolo con un programa consolidado y estandarizado de cistectom&#237;a abierta &#40;CRA&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis de cohortes retrospectivo de dos grupos de cistectom&#237;as&#58; CRL &#40;n&#8239;&#61;&#8239;196&#41; &#40;2006&#8211;2016&#41; frente a CRA &#40;n&#8239;&#61;&#8239;96&#41; &#40;2003&#8211;2005&#41;&#46;</p><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Comparaci&#243;n de la evoluci&#243;n en el tiempo de los siguientes par&#225;metros&#58; tiempo quir&#250;rgico&#44; las necesidad de transfusi&#243;n&#44; el estado de los m&#225;rgenes quir&#250;rgicos de resecci&#243;n&#44; las complicaciones postoperatorias&#44; la duraci&#243;n de la estancia hospitalaria y las recidivas&#46;</p><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Se han definido 3 periodos de tiempo para CRL&#58; implantaci&#243;n &#40;2006&#8211;09&#41; &#40;CRLI&#41;&#44; desarrollo &#40;2010&#8211;14&#41; &#40;CRL-D&#41; y consolidaci&#243;n &#40;2015&#8211;16&#41; &#40;CRL-C&#41;&#59; compar&#225;ndose cada uno de ellos con el grupo control &#40;CRA&#41;&#46;</p><p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">Para el contraste de variables cualitativas se ha utilizado el test de la Chi cuadrado y para las variables num&#233;ricas el test de Anova&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">La CRL&#44; en comparaci&#243;n con la CRA&#44; present&#243; un mayor tiempo quir&#250;rgico en las fases de CRL-I y CRL-D&#44; observando una tendencia de menores tiempos operatorios que la CRA en el periodo de consolidaci&#243;n&#46;</p><p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">La CRL presenta adem&#225;s menor trasfusi&#243;n intraoperatoria en los 3 periodos y postoperatoria en CRL-D y CRL-C&#44; menos complicaciones totales en CRL-D y CRL-C&#44; menos complicaciones graves&#40;Clavien&#8239;&#8805;&#8239;3&#41; en las 3 fases&#59; as&#237; como una disminuci&#243;n de la mortalidad y estancia hospitalaria desde la fase de CRL-I&#44; consolid&#225;ndose esta disminuci&#243;n en los otros dos periodos de estudio&#46;</p><p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">No hemos observado diferencias significativas entre CRA y CRL en cuanto a m&#225;rgenes quir&#250;rgicos y recurrencias ni en el total de la serie ni en la comparaci&#243;n entre los distintos periodos&#44; lo que avala la seguridad de la CRL&#44; desde su inicio&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0160" class="elsevierStyleSimplePara elsevierViewall">La CRL frente a CRA mejora desde su implantaci&#243;n el porcentaje de transfusiones&#44; de complicaciones y la estancia hospitalaria&#44; con seguridad oncol&#243;gica&#44; a expensas de un mayor tiempo quir&#250;rgico en las fases de implantaci&#243;n y desarrollo&#46; Sin embargo&#44; en nuestra serie observamos una tendencia de menores tiempos quir&#250;rgicos que la CRA en el periodo de consolidaci&#243;n&#46; En nuestro servicio el abordaje laparosc&#243;pico se ha validado en el tratamiento de la cistectom&#237;a radical&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Subir&#225;-R&#237;os D&#44; et al&#46; Evaluaci&#243;n del abordaje laparosc&#243;pico en la cistectom&#237;a radical desde la implantaci&#243;n hasta su consolidaci&#243;n&#58; validaci&#243;n interna&#46; Actas Urol Esp&#46; 2020&#59;44&#58;62&#8211;70&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Percentage comparison of transfusions&#44; surgical margins condition and complications during the study period&#46; ORC &#40;open radical cystectomy&#41; &#40;2003&#8211;2005&#41; control group&#59; LRC-C laparoscopic radical cystectomy-consolidation period &#40;2015&#8211;2016&#41;&#59; LRC-D&#58; laparoscopic cystectomy-development period &#40;2010&#8211;2014&#41;&#59; LRC-I&#58; laparoscopic cystectomy-implementation period &#40;2006&#8211;2010&#41;&#46;</p>"
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                  \t\t\t\t">7 &#40;IQR 5&#8211;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;IQR 8&#8211;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;IQR 11&#8211;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ORC &#40;N&#8239;&#61;&#8239;96&#41; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LRC &#40;N&#8239;&#61;&#8239;196&#41; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69 &#40;IQR 60&#8211;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#44;5 &#40;IQR 62&#8211;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;26&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88 &#40;91&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">174 &#40;88&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;8&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;11&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;0&#44;1&#8211;4&#93;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Local stage &#40;cT&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>cTx&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;3&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>cTa-T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88 &#40;91&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">169 &#40;86&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>cT3-T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;5&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;11&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">cN&#43;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;3&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;18&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">ASA classification 3&#8211;4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;16&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78 &#40;39&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Charlson index</span>&#8239;<span class="elsevierStyleItalic">&#8805;</span>&#8239;<span class="elsevierStyleItalic">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;3&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;24&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Previous pelvic radiotherapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;12&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hydronephrosis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;26&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69 &#40;35&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Time from TUR-cystectomy &#40;median&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;IQR 2&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;IQR 2&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;044&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
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                  \t\t\t\t"><span class="elsevierStyleItalic">cN&#43;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;17&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ASA classification 3-4</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">19 &#40;20&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;22&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Previous pelvic radiotherapy</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;13&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Hydronephrosis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19 &#40;42&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Time from TUR-cystectomy &#40;median&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;IQR 3&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;IQR 2&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;IQR 2&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Mortality &#40;Clavien V&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;10&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;2&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;2&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Most frequent complications&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intestinal obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;2&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dynamic ileus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;12&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;8&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;19&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;15&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Infected surgical wound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;28&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;14&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;7&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urinary sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;8&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;17&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;11&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;8&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obstructive uropathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;2&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abdominal sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;5&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;4&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evisceration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;22&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;11&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urinary fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;7&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;5&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;5&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Intestinal fistula&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;5&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;2&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pelvic abscess&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5 &#40;5&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">1 &#40;2&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">CVC sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;8&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;3&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;2&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;17&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Postoperative transfusion</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;41&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;42&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;12&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;13&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Hospital stay</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;IQR 11&#8211;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;IQR 10&#8211;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;IQR 10&#8211;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;IQR 8&#8211;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Recurrence</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53 &#40;55&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;42&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;42&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparison between the control group &#40;open cystectomy&#41; &#40;2003&#8211;2005&#41; and the laparoscopic cystectomy groups&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:20 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Update 2016 EAU Guidelines on muscle invasive and metastatic bladder cancer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Witjes"
                            1 => "E&#46; Comp&#233;rat"
                            2 => "N&#46;C&#46; Cowan"
                            3 => "G&#46; Gakis"
                            4 => "V&#46; Hern&#225;ndez"
                            5 => "T&#46; Lebret"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.eururo.2016.06.020"
                      "Revista" => array:7 [
                        "tituloSerie" => "Eur Urol"
                        "fecha" => "2017"
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