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Sezer, E. Kandemir, M. Savun, A. Erbin, M.F. Akbulut, M. Binbay" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Sezer" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Kandemir" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Savun" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Erbin" ] 4 => array:2 [ "nombre" => "M.F." "apellidos" => "Akbulut" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Binbay" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357862200141X?idApp=UINPBA00004N" "url" => "/21735786/0000004700000003/v3_202310271253/S217357862200141X/v3_202310271253/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Evolution and current status of the management of functional and pelvic floor pathology in the hospitals of the Community of Madrid" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "187" "paginaFinal" => "192" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "L.M. Quintana Franco, R. González López, H. Garde García, J.M. Díez Rodríguez, C. González Enguita" "autores" => array:5 [ 0 => array:4 [ "nombre" => "L.M." "apellidos" => "Quintana Franco" "email" => array:1 [ 0 => "luis.quintana@quironsalud.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "González López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "H." "apellidos" => "Garde García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.M." "apellidos" => "Díez Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "C." "apellidos" => "González Enguita" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estado actual y evolución del manejo de la patología funcional y del suelo pélvico en los hospitales de la Comunidad de Madrid" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Functional Urology is a subspecialty within Urology that addresses a wide range of pathologies including urinary and fecal incontinence, pelvic organ prolapse, sensory function changes and voiding alterations, defecatory dysfunction, female sexual disorders, and chronic pelvic pain syndrome. The incidence of pelvic floor dysfunction (PFD) is currently growing in our setting due to the aging and higher obesity rates of population.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Among the characteristics of PFD is the multidisciplinary nature of its management. Traditionally, it has been carried out in a compartmentalized and independent manner by each department involved, with the consequent delay in health care, repeated consultations, and the economic expense that this entails. Moreover, the results derived from this individualistic approach are less satisfactory as only one area of the pathology is being treated.</p><p id="par0010" class="elsevierStylePara elsevierViewall">To alleviate this deficit, multidisciplinary committees or units are becoming increasingly frequent. In the case of pelvic floor dysfunction, these committees include urologists, general surgeons, rehabilitation physicians and gynecologists.</p><p id="par0015" class="elsevierStylePara elsevierViewall">For an adequate management of these patients, Urologists who treat PFD should have specific training in the fields of Neurourology and Urogynecology, as well as in specific diagnostic and surgical techniques. However, the means available in each center are variable, and this may limit optimal physicians’ training and their management of PFD.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The main objective of the study is to verify and describe the possible clinical variability in the management of functional and pelvic floor pathology in the urology departments of the public health centers of the Community of Madrid in the year 2021. We will review the different diagnostic methods, indications, and surgical techniques used in the treatment of these conditions.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Secondarily, we will analyze the resources currently available in the centers of the Autonomous Community, understood as human, material and technical resources, education level and experience of each department.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">Observational, descriptive, cross-sectional study conducted in September 2021, using an anonymous, self-administered questionnaire for data collection, addressed to Urology specialists (Annex 1). The questionnaire was sent to the 26 public hospitals of the Community of Madrid that have a urology department. We used the Microsoft® Office Forms platform and we obtained 17 responses.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This questionnaire is based on the one carried out by Díez Rodríguez et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in 2011. This questionnaire obtained data from 18 urology departments in the Community of Madrid. The data obtained in the two surveys have been compared for those variables in which the same question was asked. We do not have all the results obtained in that survey, so the comparison between those results and the current ones has only been possible for certain variables.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The variables under study are grouped under the following headings: characteristics of each healthcare center, structure of the Pelvic Floor Unit (PFU), female stress urinary incontinence (FSUI), urgency urinary incontinence (UUI), male stress urinary incontinence (MSUI), pelvic organ prolapse (POP), bladder pain syndrome (BPS), pudendal neuropathy and pelvic floor rehabilitation.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Quantitative variables are expressed as median<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>interquartile range. Qualitative variables are expressed as absolute values and percentages.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Healthcare center characteristics</span><p id="par0050" class="elsevierStylePara elsevierViewall">More than half of the centers surveyed<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> serve a population of >250.000 inhabitants and another 6 centers a population of >100.000 inhabitants. The median number of urologists in each department was 10<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–16</span></a> with two of them dedicated to PFD. The number of specific Functional Urology consultations and interventions per month ranged from 5-15 for most centers (59% and 53% respectively); in two centers the number of consultations per month was >15, and four centers perform >15 procedures per month. The volume of urodynamic studies (UDS) was >20 per month for most centers (53%), but only 5 centers perform video urodynamics and 2 carry out ambulatory urodynamics.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Structure of the Pelvic Floor Unit</span><p id="par0055" class="elsevierStylePara elsevierViewall">There is a structured PFU in 8 (47%) of the centers surveyed. There is no PFU in 8 (47%) but they collaborate through interconsultation between specialists; only 1 center did not have an established structure. This is a notable increase with respect to 2011, when 50%<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> of the centers did not have a PFU or an interconsultation system, and only 5 centers (28%) had a structured PFU.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The specialties forming the different PFUs were Urology,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Rehabilitation,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Gynecology,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Coloproctology,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Pain Unit,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Digestive,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Radiology<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and Clinical Psychology.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding the pathologies assessed according to the availability of a PFU, pudendal nerve pathology (87.5% vs. 22.2%) and middle and posterior compartment prolapse (100% vs. 66.7%) are treated more frequently in established PFUs, with no differences in the rest of the PFD.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Female stress urinary incontinence</span><p id="par0070" class="elsevierStylePara elsevierViewall">In relation to 2011, the initial assessment of FSUI showed a greater use of voiding diary (15 vs. 10) and quality of life questionnaires (12 vs. 8), as well as a decrease in the use of UDS (7 vs. 12), voiding cystourethrography (5 vs. 9) or cystoscopy (5 vs. 8).</p><p id="par0075" class="elsevierStylePara elsevierViewall">The surgical techniques used for the correction of FSUI and their indications are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Of note, in centers with established PFUs, injectable agents (100% vs. 22.2%), mini-sling (62.5% vs. 22.2%), and the retropubic approach for TVT placement (62.5% vs. 11.1%), adjustable TVT (50% vs. 0%) and REMEEX (100% vs. 22.2%) were used more frequently. There are no major differences in the use of artificial urinary sphincter between both groups (75% vs. 66.7%).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Urge urinary incontinence</span><p id="par0085" class="elsevierStylePara elsevierViewall">In the initial treatment of UUI, most centers apply hygiene and dietary measures,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> voiding reeducation techniques<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and pharmacological treatment<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> in >50% of cases. PF rehabilitation by Kegel exercises is indicated in <50% cases in 9 of the centers surveyed. When indicated, only 4 centers make referrals to Rehabilitation for targeted treatment in the majority of cases.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In cases of overactive bladder refractory to pharmacological treatment, the applicable techniques were intravesical botulinum toxin injection,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> glycosaminoglycan instillation,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> posterior tibial nerve neuromodulation (PTNM),<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> sacral nerve root neuromodulation (SRNM)<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and augmentation enterocystoplasty.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">When differentiating between centers with and without established PFU, centers with PFU have less tendency to use intravesical instillations (50% vs. 77.8%) and more use of PTNM (87.5% vs. 33.3%) and SRNM (75% vs. 11.1%).</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Male stress urinary incontinence</span><p id="par0100" class="elsevierStylePara elsevierViewall">Among the conservative treatment options, the indication of self or guided rehabilitation is indicated in >50% of cases in only 11 of the 17 centers: the same proportion as pharmacological treatment. The use of clamps for urethral occlusion is indicated in <25% of cases in the vast majority of centers<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>; only one center employs it in >50% of cases.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The surgical techniques applied by the different centers were AMS-800 artificial urinary sphincter (AUS),<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> ATOMS device,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> ADVANCE sling,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> ZSI 375 AUS,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> VIRTUE sling,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> male Reemex<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and the use of injectable agents.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Compared to 2011, this represents an increased use of slings and adjustable devices by 150% (25 vs. 10 including all devices) and 67% in the use of AUS (20 vs. 12). The use of injectable agents has been reduced by half (2 vs. 4).</p><p id="par0110" class="elsevierStylePara elsevierViewall">In centers with established PFU there is a greater use of ATOMS devices (100% vs. 44.4%) and the ZSI-375 artificial urinary sphincter (62.5% vs. 11.1%), with no differences in the use of other devices. All the centers that use the ZSI-375 AUS also use the AMS-800 with the exception of one of them.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Pelvic organ prolapse</span><p id="par0115" class="elsevierStylePara elsevierViewall">The most widely used classification for the description of prolapse is still the Baden–Walker classification<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> over the POP-Q (11 centers). Ten centers administer quality of life questionnaires, the most commonly used being the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), Pelvic Floor Distress Inventory (PFDI-20) and pelvic organ prolapse/Urinary Sexual Incontinence Questionnaire (PISQ-12).</p><p id="par0120" class="elsevierStylePara elsevierViewall">Regarding surgical techniques, all centers perform sacrocolpopexy by laparoscopic<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> or robotic<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> approach. In the vaginal approach, there are 10 centers performing vaginoplasty without mesh placement and 7 with mesh placement. Compared to 2011, this represents a doubling of centers performing sacrocolpopexy (17 vs. 8), a 150% increase in the use of vaginoplasty without mesh (10 vs. 4) and a 42% decrease in the use of vaginal mesh (7 vs. 12). Among the centers that use vaginal mesh placement, this technique is the first-line treatment mainly in anterior compartment prolapse with associated lateral defect<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and in triple compartment prolapse in patients with uterus<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and hysterectomized.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In this section, there are no significant differences between centers with and without PFU in the use of vaginal mesh placement (50% vs. 44.4%) or laparoscopic sacrocolpopexy (100% vs. 88.9%).</p><p id="par0130" class="elsevierStylePara elsevierViewall">In relation to occult SUI revealed at prolapse repositioning, there is a different attitude compared to 2011, with observation and deferred treatment currently being the most preferred option (11 vs. 7 in 2011) before associating an anti-incontinence technique in the same surgical procedure (6 vs. 11 in 2011).</p><p id="par0135" class="elsevierStylePara elsevierViewall">In cases with an indication for hysterectomy associated with POP repair, 65%<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> of the respondents referred the patient to gynecology for treatment, and hysterectomy was performed by urologists in only 2 (12%) centers. It should be noted that in the remaining 4 (23%) centers a joint intervention with a gynecologist is performed.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Bladder pain syndrome</span><p id="par0140" class="elsevierStylePara elsevierViewall">In the initial treatment of BPS, the most frequent options (>50% of cases) applied by the departments in the survey were pharmacological treatment,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> hygienic-dietary measures and voiding reeducation,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> instillations of glycosaminoglycans<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and pelvic floor rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> For cases of BPS refractory to previous therapies, the most widespread option among all units was bladder hydrodistention<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>ulcer fulguration<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>botulinum toxin injection into the bladder trigone.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Regarding random bladder biopsies, 35%<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> of the respondents take biopsies in all cases, while 65%<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> only take them in case of suspicious lesions or compatible with Hunner’s ulcers.</p><p id="par0145" class="elsevierStylePara elsevierViewall">When conservative therapies fail and radical treatment is considered, cystectomy with urinary diversion is a more widespread option than augmentation enterocystoplasty (12 vs. 9).</p><p id="par0150" class="elsevierStylePara elsevierViewall">As with UUI, for the treatment of refractory BPS in centers with PFU, there is a more widespread use of PTNM (62.5% vs. 33.3%) and SRNM (87.5% vs. 22.2%). There are no major differences in the use of the remaining therapies.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Pudendal neuropathy</span><p id="par0155" class="elsevierStylePara elsevierViewall">Among the therapeutic options employed for this pathology, pharmacological treatment,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> lifestyle changes, including postural changes<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and pelvic floor rehabilitation,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> were the most frequently used by the respondents. Transvaginal or transperineal pudendal nerve block was the most commonly used invasive therapy,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> while NMTP,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> NMRS,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> radiofrequency<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> or surgical nerve release<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> were less frequently used options.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Pelvic floor rehabilitation</span><p id="par0160" class="elsevierStylePara elsevierViewall">Thirteen (76%) of the centers that responded the survey have PFD specialist rehabilitators, with a median of 2 specialists per center. The median time to receive rehabilitation treatment after referral is 4 months.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,4,5,17–20</span></a> Referral to rehabilitation in >50% of cases for the pathologies previously described follows this distribution: FSUI,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> pudendal neuropathy,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> MSUI,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> female UUI,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> PPS<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and male UUI.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">The creation of multidisciplinary committees emerged in the 1990s in the United Kingdom for the management of oncologic pathology.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Subsequently, other multidisciplinary committees have been developed, including PFUs, which have essential specialists in Urology, Gynecology, Coloproctology and Rehabilitation; and a variable number of additional services depending on the center. Today, PFUs are the reference framework for the management of urinary incontinence and POP according to NICE guidelines.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The literature on the provision of means for the management of PFD and the multidisciplinary approach to these pathologies is scarce. Pandeva et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> highlight the importance of the PFU for the management of complex cases, exposing that, in 20% of the cases presented, the committee recommended a change in the initial management plan.</p><p id="par0175" class="elsevierStylePara elsevierViewall">In Spain, López-Salazar et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> published the 5-year experience of the PFU at the Hospital de Galdakao-Usansolo, emphasizing that there was an improvement in the quality of care of patients with complex pathology. As the survey reflects, more and more centers in the Community of Madrid have a PFU or an interconsultation system between departments for the management of these pathologies, which are becoming increasingly frequent. For example, pudendal neuralgia is more frequently treated in centers with an established PFU. Due to the diagnostic and therapeutic complexity of this pathology, patients actually benefit from a multidisciplinary approach.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">It is estimated that 1 in 4 women will develop some form of PFD in her lifetime.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> One of the growing risk factors in our environment is obesity. It is estimated that by 2030, 2.16 billion people will be overweight and 1.12 billion will be obese.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The sole correction of this factor has been shown to be very effective in the treatment of incontinence, with the mean weekly number of incontinence episodes decreasing by 47% with a weight loss between 3%–5% from baseline weight.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore, hygienic-dietary measures and lifestyle changes are one of the main conservative measures chosen by physicians, as shown in the survey.</p><p id="par0185" class="elsevierStylePara elsevierViewall">On the other hand, the option of pelvic floor rehabilitation has been a less frequent measure among the respondents. Pelvic floor exercises have been shown to be effective in reducing the symptomatology of various PFD, being superior to other exercises such as hypopressive gymnastics.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Strengthening the pelvic floor musculature is one of the conservative therapies included in the main treatment guidelines for the management of urinary incontinence and POP in its early stages.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8,18</span></a> It can be assumed that the current delay in receiving rehabilitation treatment in many of the centers surveyed may be the cause of this resource being underused.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Transobturator tape (TOT) continues to be the most widely used technique for surgical correction of FSUI. However, the use of injectable and mini-sling agents is more widespread in centers with PFUs. The use of these alternatives to conventional TOT has increased in recent years following the complications that have arisen with the use of vaginal mesh placement. It should be recalled that in 2011 the Food & Drug Administration (FDA) issued a statement warning against the use of vaginal mesh for POP correction.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Although it did not directly allude to the use of mesh for the correction of SUI as the source of the problem, in many countries, mainly in the English-speaking countries, the use of alternatives to synthetic sling, such as autologous fascia, has been promoted.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Injectable agents are less effective than slings for the correction of SUI, but they may be an interesting alternative in patients who wish to minimize the complications of surgery or synthetic mesh.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Mini-slings, on the other hand, are an interesting alternative with increasing evidence of their long-term efficacy.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Another aspect to highlight in this section is that centers with PFUs use the retropubic approach more frequently than centers without an established PFU. On the other hand, the high number of centers offering artificial urinary sphincter (AUS) placement as a treatment for FSUI is striking given its surgical complexity.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> It is possible that this option has gained weight due to the complications derived from the mesh.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Together with the previous section, we can conclude that centers with PFUs have more tools for the treatment of FSUI.</p><p id="par0205" class="elsevierStylePara elsevierViewall">As for MSUI, a notable increase in the use of slings for the management of this pathology has occurred in the last 10 years. This is supported by the recently published results of Abrams et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> demonstrating the non-inferiority of slings to AUS. However, for patients with a pad test >250<span class="elsevierStyleHsp" style=""></span>g and following radiotherapy, the results were more favorable for the sphincter group. Furthermore, the rate of revision surgery over time is high, with series reaching 43% at 10 years and 59% at 15 years.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">In our setting, the most widely used sling in centers with PFU is the ATOMS. Its effectiveness in curing and improving incontinence is 67% and 90%, respectively, after adjustment according to the meta-analysis performed by Esquinas et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> However, although the possibility of postoperative adjustments is an interesting aspect, it should be remembered that fixed slings, such as the ADVANCE system, have not yet been shown to be superior to adjustable slings.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Perhaps the most interesting data are those obtained in relation to POP management. After the initial FDA warning in 2011, several subsequent analyses were performed resulting in the prohibition of the marketing of meshes for rectocele correction in 2018 and concluded in April 2019 with anterior and middle compartment meshes.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Although the use of mesh placement for anterior and apical POP correction is not banned in our environment, it has significantly decreased. This is seen in the change in trend toward mesh free vaginal surgery reported in the survey with respect to the one conducted in 2011. However, in centers where transvaginal mesh placement is still used, whether there is a PFU or not is irrelevant.</p><p id="par0225" class="elsevierStylePara elsevierViewall">The other major change is the establishment of laparoscopic/robotic sacrocolpopexy as the most widespread option for POP repair, which is performed in practically all centers participating in the survey, regardless of whether or not they have a PFU.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusion</span><p id="par0230" class="elsevierStylePara elsevierViewall">The management of PFD through multidisciplinary committees allows optimal treatment of patients and is probably the reference framework to be followed. Surgical options in the treatment of both male and female SUI are increasing, with the use of adjustable devices in MSUI on the rise. Laparoscopic/robotic sacrocolpopexy has become the gold standard treatment for POP. There is a tendency to defer treatment of occult SUI with POP correction with respect to 10 years ago.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1999099" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1713385" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1999098" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1713386" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Healthcare center characteristics" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Structure of the Pelvic Floor Unit" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Female stress urinary incontinence" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Urge urinary incontinence" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Male stress urinary incontinence" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Pelvic organ prolapse" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Bladder pain syndrome" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Pudendal neuropathy" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Pelvic floor rehabilitation" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusion" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-09-22" "fechaAceptado" => "2022-12-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1713385" "palabras" => array:3 [ 0 => "Functional Urology" 1 => "Pelvic Floor Units" 2 => "Madrid" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1713386" "palabras" => array:3 [ 0 => "Urología funcional" 1 => "Unidades de Suelo Pélvico" 2 => "Madrid" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pelvic floor dysfunction (PFD) includes a large number of pathologies subjected to a significantly varied management, depending on the hospitals’ resources and educational levels of their professionals. The aim of this study is to determine and describe the clinical variability in the management of PFD in the urology departments of the public health centers of the Community of Madrid, as well as the resources currently available in these centers.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The survey was carried out in September 2021 and was addressed to physicians specialized in functional urology in the public hospitals of the Community of Madrid. This survey is based on the one performed in 2011 by Díez et al. for the same purpose. The characteristics of the healthcare services provided in the different centers and the management of the main functional pathologies of the pelvic floor were analyzed. The results were compared with those of the 2011 survey for equivalent questions.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The number of Pelvic Floor Units (PFUs) has remarkably increased in the last 10 years. The use of adjustable devices in the treatment of male SUI has become widespread in the centers included in the survey. Laparoscopic/robotic sacrocolpopexy has become the gold standard treatment for pelvic organ prolapse (POP).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Multidisciplinary PFUs represent the reference framework for the management of PFD. Variability in the management of urinary incontinence, POP, bladder pain syndrome and pudendal nerve neuropathy is recognized.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las disfunciones del suelo pélvico (DSP) incluyen un amplio número de patologías sujetas a una alta variabilidad en su manejo según los medios y capacitación de los centros y sus profesionales. El objetivo del estudio es constatar y describir la variabilidad clínica en el manejo de las DSP en los servicios de Urología de los centros sanitarios públicos de la Comunidad de Madrid, así como la dotación de medios disponibles en la actualidad en dichos centros.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Encuesta realizada en septiembre de 2021 dirigida a facultativos especialistas en Urología Funcional de los hospitales públicos de la Comunidad de Madrid. Esta se basa en una encuesta realizada en 2011 por Díez et al. con la misma finalidad. Se analizaron las características asistenciales de los distintos centros y el manejo de las principales patologías funcionales del suelo pélvico. Se compararon los resultados con los de la encuesta de 2011 para las preguntas equiparables.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El número de Unidades de Suelo Pélvico (USP) ha aumentado notablemente en los últimos 10 años. El uso de dispositivos ajustables en el tratamiento de la IUE masculina se ha extendido en los centros encuestados. La colposacropexia laparoscópica/robótica se ha convertido en el tratamiento de referencia del prolapso de órganos pélvicos (POP).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Las USP multidisciplinares son el modelo a seguir para el manejo de las DSP. Se constata la variabilidad en el manejo de la incontinencia urinaria, POP, el síndrome de dolor vesical y la neuropatía del nervio pudendo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0240" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0080" ] ] ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \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 \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Surgical techniques employed in your unit \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 \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">First-line surgical techniques \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 \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Surgical techniques after treatment failure/relapse after primary technique \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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">Injectable agents \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 \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 \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 \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">Open retropubic colposuspension \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 \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 \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 \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">Laparoscopic/robotic colposuspension \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 \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 \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 \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">Outside-in TOT \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 \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 \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 " rowspan="2" align="left" valign="middle">4</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">Inside-out TOT \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 \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 \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">Adjustable TOT \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 \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 \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 \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">TVT \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 \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 \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 \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">Adjustable TVT \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 \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 \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 " rowspan="2" align="left" valign="middle">5</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">Reemex \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 \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 \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">Mini-sling \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 \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 \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 \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">Artificial urinary sphincter \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 \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 \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 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3319372.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Surgical treatment for female stress urinary incontinence.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 368745 ] ] ] "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" => "Global burden of obesity in 2005 and projections to 2030" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T. 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