Pelvic lymph node dissection in prostate cancer: laparoscopy is not dead | Actas Urológicas Españolas (English Edition)

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minimally invasive techniques &#40;laparoscopic and robot-assisted&#41; have emerged in order to reduce perioperative morbidities&#46; Schuessler and colleagues developed the laparoscopic radical prostatectomy in 1992&#59; it was standardized by Gaston in 1997&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In May 2000&#44; Binder et al&#46; reported the first Laparoscopic Radical Prostatectomy &#40;LRP&#41; assisted by a master-slave robotic system &#40;Da Vinci&#41;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Since&#44; numerous authors have reported pros and cons for each surgical technique&#44; and guidelines still discuss all approaches &#40;i&#46;e&#46;&#44; open&#44; laparoscopic or robotic&#41; as acceptable treatment options&#46; Although there are many studies comparing open&#44; laparoscopic and robotic approaches for prostatectomy&#44; only a few articles compare pelvic lymph node dissection approaches&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This article will present the surgical technique of laparoscopic pelvic lymph node dissection &#40;PLND&#41;&#59; explain the complications of PLND&#59; and offer a qualitative review of literature comparing open&#44; laparoscopic and robotic PLND&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Evidence acquisition</span><p id="par0025" class="elsevierStylePara elsevierViewall">A comprehensive and exhaustive review of the literature was performed using MEDLINE via PubMed and Google Scholar&#46; We considered all papers that addressed comparison between open&#44; laparoscopic&#44; and&#47;or robotic pelvic lymph node dissection&#46; Only studies published in French and English from 1990 until 1 June 2019 were considered suitable for the study&#46; The following keywords were used along with Boolean operators&#58; &#34;pelvic lymph node dissection&#34;&#44; &#34;prostatectomy&#34;&#44; &#34;laparoscopic lymphadenectomy&#34;&#44; &#34;robot-assisted lymphadenectomy&#34;&#44; &#34;open lymphadenectomy&#34;&#46; The following search strategy was used on Medline via PubMed&#58; &#40;&#34;pelvic lymph node dissection&#34;&#41; OR &#40;&#34;pelvic lymphadenectomy&#34;&#41; AND &#40;&#34;french&#34;&#91;Language&#93; OR english&#91;Language&#93;&#41; AND &#40;&#34;1990&#34;&#91;Date - Publication&#93; &#58; &#34;3000&#34;&#91;Date - Publication&#93;&#41; AND prostatectomy&#91;Title&#93;&#41;&#46; The search query was conducted on 15 June 2019&#46; After removal of duplicates&#44; all of the studies were evaluated by two independent reviewers &#40;E&#46;H&#46; and A&#46;S&#46;&#41; and selected on the basis of their titles and abstracts&#46; Editorials&#44; commentaries&#44; case reports&#44; case series and abstracts were excluded&#46; Manuscripts evaluating or comparing the extent of lymph node dissection in radical prostatectomy were also excluded&#46; Full-text articles were then obtained and read&#46; References were manually checked for any other relevant studies&#46; We hereby describe the detailed article triage technique&#46; Of the 591 initial papers identified&#44; after title screening and elimination of redundant articles&#44; 55 articles remained&#46; After reading the abstract&#44; the authors excluded 43 additional articles&#46; Handsearching and searching the references of note-worthy articles added 17 articles&#44; leaving 29 articles for review&#46; A flow chart depicting this process is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">For each article&#44; the following parameters were collected when applicable&#58; number of patients&#44; operation time&#44; complications rate&#44; lymph node yield&#44; positive lymph node percentage&#44; blood loss&#44; hemoglobin decrease&#44; post-operative analgesic&#44; mean hospital stay&#44; average return to normal activities&#44; oral intake&#44; obturator nerve injury&#44; drain and lymphocele&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Evidence synthesis</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Pelvic lymph node dissection in prostate cancer&#58; boundaries and guidelines</span><p id="par0035" class="elsevierStylePara elsevierViewall">Numerous studies have reported the variable lymphatic drainage of the prostate gland&#44; thus justifying the importance of the extended pelvic lymph node dissection&#46; The lymphatic chains are the internal iliac&#44; obturator&#44; external iliac and presacral regions&#46; Thus&#44; the anatomical landmarks of the extended pelvic lymph node dissection include the nodes located over the external iliac artery and vein&#44; the nodes within the obturator fossa located superiorly and inferiorly to the obturator nerve and the nodes medial and lateral to the internal iliac artery&#46; This technique results in 94&#37; of patients appropriately staged&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Cf&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Given the poor outcome of all available imaging modalities&#44; PLND remains the most accurate staging method&#46; Moreover&#44; PLND is performed in patients with aggressive prostate cancer&#46; This is determined by nomograms such as the Briganti nomogram that predict lymph node positivity in patients undergoing ePLND&#46; Based on the European Association of Urology &#40;EAU&#41; guidelines&#44; PLND should not be performed in patients with low risk prostate cancer but is mandatory in patients with high-risk prostate cancer&#59; in patients with intermediate risk&#44; PLND should only be performed in those with a risk of lymph node metastasis &#62;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The National Comprehensive Cancer Network &#40;NCCN&#41; recommends PLND when the risk of nodal involvement is &#62;2&#37; by nomograms&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleItalic">A risk of nodal metastases over 5&#37;&#40;Briganti nomogram or Roach formula</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleItalic">which has been shown to be almost as accurate as the nomogram&#41; is an indication to perform nodal sampling by an extended nodal dissection&#46;</span> It&#8217;s important to note the trend of omitting the PLND&#44; which occurs up to five times more often with minimally invasive surgery than open surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleItalic">Moreover&#44; there is still insufficient quality evidence supporting oncological effectiveness of sentinel node biopsy for nodal staging&#46; Sentinel node biopsy is therefore still considered an experimental nodal staging procedure&#46;</span></p></span></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Complications of PLND</span><p id="par0045" class="elsevierStylePara elsevierViewall">PLND is not an innocuous procedure&#44; and its benefits and disadvantages should be weighed&#46; Intraoperative complications include ureteral and vascular injury and obturator nerve lesion&#46; Post-operative complications include lymphocele&#44; lymphedema and venous thromboembolism&#46; Parkin and colleagues found a major and minor complication rate of 5&#37; and 17&#37; respectively based on the Clavien-Dindo Classification&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> We will cite the most important complications&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Lymphocele</span><p id="par0050" class="elsevierStylePara elsevierViewall">The most common complication of PLND is lymphocele&#44; caused by lymphatic drainage disruption and accumulation of lymph fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Parkin and colleagues stated that the lymphocele rate was 3&#46;3&#37;&#46; Other studies suggest that asymptomatic lymphocele appears in 27&#37;&#8211;61&#37; of patients<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> while clinically detected lymphocele after open pelvic lymph node dissection &#40;OPLND&#41; ranges from 4&#46;7&#37; to 14&#46;8&#37;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Briganti et al&#46; report a 10&#46;3&#37; rate of lymphocele in extended lymphadenectomies vs&#46; 4&#46;6&#37; for transperitoneal laparoscopic PLND &#40;LPLND&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Therefore&#44; higher rates of symptomatic lymphoceles may be attributable to the extraperitoneal approach and thus the use of the laparoscopic transperitoneal approach appears to be protective against lymphocele&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Nevertheless&#44; the more extended the PLND is&#44; the higher the probability of lymphocele occurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Not every lymphocele should be treated&#46; In fact&#44; lymphoceles should only be treated if symptomatic &#40;urinary tract compression and irritation&#41; or in case of secondary complications &#40;superinfection&#44; ileus or deep venous thrombosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The main reason for symptomatic lymphocele formation is failure of the peritoneum to reabsorb leaked lymph&#46; Many lymphoceles resolve with conservative treatment&#46; 70&#37; of lymphoceles were absorbed within 50 days postoperatively&#46; If they persist after 3 months&#44; the infection rate approaches 60&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> It should be noted that anticoagulant use may increase the risk of lymphocele formation by 6&#46;7 times&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Treatment options for symptomatic lymphoceles include percutaneous drainage&#44; sclerotherapy&#44; and when these options fail laparoscopic marsupialization should be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Stolzenburg<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> described a technique of bilateral peritoneal fenestration after extraperitoneal PLND that significantly decreases the occurrence of asymptomatic and clinically significant lymphocele formation Lebeis et al&#46; described a surgical technique to prevent lymphocele formation by rotating&#44; interposing and fixating the ipsilateral peritoneal flap on the bladder itself&#44; which resulted in 0&#37; lymphocele formation in 77 patients&#46; Results from a randomized controlled trial are awaited&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Venous thromboembolism &#40;VTE&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">VTE is a major cause of mortality after radical prostatectomy &#40;RP&#41;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and is known to be multifactorial&#46; It has been discovered that lymphocele is one cause of VTE&#46; Heinzer et al&#46; reported that routine drainage of pelvic lymphoceles after open RP with bilateral PLND reduced the rate of VTE from 6&#46;2&#37; to 2&#46;1&#37; &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;049&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In a retrospective study on 773 patients who underwent RP&#44; Eiffler et al&#46; showed that an additional PLND &#40;in 60&#37; of patients&#41; was associated with more cases of VTE &#40;1&#46;5&#37;&#41; compared to RP alone &#40;0&#37;&#41;&#46; BMI was the most important differentiating factor among patients who had VTE and those who did not&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The authors went further&#44; performing a meta-analysis showing that realizing PLND doubled the risk of VTE&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Administration of antithrombotic prophylaxis reduced VTE by 40&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Vascular injury</span><p id="par0095" class="elsevierStylePara elsevierViewall">Injuries to the major vessels are uncommon during pelvic lymph node dissection&#46; When necessary&#44; experienced surgeons can use laparoscopic surgical clamps to repair injuries laparoscopically&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Obturator nerve injury</span><p id="par0100" class="elsevierStylePara elsevierViewall">Obturator nerve injury is an important but rare complication of pelvic lymph node dissection&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Obturator nerve injury is usually the consequence of inadvertent clip placement&#44; electrofulguration and complete or incomplete transection&#46; These lesions are most often located in the obturator fossa and are often diagnosed and repaired during the operation&#46; Laparoscopic magnification seems to allow precise nerve repair compared to the open technique&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Open&#44; laparoscopic or robot-assisted PLND</span><p id="par0105" class="elsevierStylePara elsevierViewall">It is important to mention that most of the articles concerning PLND in the treatment of prostate cancer target its extent&#44; limits&#44; staging and possible therapeutic role&#46; Studies evaluating the pathological aspects and complications of PLND are rare&#44; as are comparative studies on PLND and open&#44; laparoscopic and robot-assisted techniques&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Study characteristics</span><p id="par0110" class="elsevierStylePara elsevierViewall">In this study&#44; eight articles were found adequate for review&#46; They were considered eligible because they were comparative and evaluated pathological aspects&#44; perioperative variables and complications of pelvic lymph node dissection&#46; Four studies compared laparoscopic and open lymph node dissection&#44; three compared open&#44; laparoscopic and robotic pelvic lymph node dissection and only one compared laparoscopic and robotic PLND&#46; The age range was comparable with a mean age of 65 without any further details about patients&#8217; comorbidities except for BMI&#44; which was mentioned in two studies&#44; and obesity percentage&#44; which was mentioned in one&#46; Manuscripts excluded from this review were those that were not comparative&#44; those evaluating PLND in patients with conditions other than prostate cancer&#44; those evaluating the extent and benefit of PLND and those written in languages other than French and English&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Study results</span><p id="par0115" class="elsevierStylePara elsevierViewall">Laparoscopic lymph node dissection was initially described by Schuessler and Winfield in 1991&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Kerbl et al&#46; &#40;1993&#41; compared 30 patients who underwent laparoscopic lymph node dissection to 16 patients who underwent open surgery&#46; The main outcomes included operation time&#44; which was doubled in laparoscopic surgery &#40;199&#46;41 vs&#46; 102&#46;4&#8239;min in ORP&#41;&#44; and complication rate&#44; which was significantly higher in laparoscopic surgery with 13&#46;3 vs&#46; 0&#37;&#46; However&#44; laparoscopy showed lower blood loss rates&#44; less post-operative analgesic use &#40;1&#46;55 vs&#46; 47&#8239;mg&#46;&#41;&#44; a lower mean hospital stay &#40;1&#46;7 vs&#46; 5&#46;37 days&#41; and a lower average number of days it took patients to return to normal activities &#40;4&#46;94 vs&#46; 42&#46;9 days&#41;&#46; A thorough assessment of the complication rate denotes the importance of the learning curve in laparoscopy&#59; in fact&#44; major complications occurred only in the first 12 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Lezin et al&#46; &#40;1997&#41; compared LPLND to mini-laparotomy in 44 patients&#46; They evaluated operative time&#44; which was significantly shorter with mini-lap &#40;a mean of 1&#46;2&#8239;h vs&#46; a mean of 2&#46;9&#8239;h&#41;&#46; The mean initial hospital stay was 1 day for mini-lap and 1&#46;6 days for lap&#59; the complication rate was 9&#46;1&#37; for mini-lap and 31&#46;8&#37; for lap&#46; Lymph node invasion was noted in 45&#37; of mini-lap patients and 27&#37; of lap patients&#46; The authors found two advantages of mini-lap&#58; it is more cost-effective and has less morbidity than laparoscopic technique&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Solberg et al&#46; &#40;2003&#41; compared the frequency of lymphocele formation in 132 patients who underwent PLND&#44; concluding that LPLND was associated with a statistically significant lower frequency of lymphocele formation compared to OPLND &#40;61&#37; of patients in the OPLND group vs&#46; 38&#37; of patients in the LPLND group&#41;&#46; Nevertheless&#44; only three patients developed clinically significant lymphoceles&#44; all of them in the OPLND group&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">A retrospective comparative analysis by Bodin et al&#46; &#40;2011&#41; on 115 patients who underwent LPLND and 36 patients who underwent OPLND showed no significant statistical difference when it came to vascular lesions &#40;7 vs&#46; 3&#37;&#41;&#44; obturator nerve lesion &#40;1 vs&#46; 0&#41;&#44; drainage &#40;3 vs&#46; 2&#46;5 days&#41;&#44; and hospital stay &#40;4&#46;5 vs&#46; 4&#46;8 days&#41; in laparoscopic vs&#46; open PLND&#46; Nevertheless&#44; blood loss &#40;12&#46;09 vs&#46; 105&#46;6&#8239;cm<span class="elsevierStyleSup">3</span>&#41; was less in laparoscopic surgery but the intervention duration &#40;132 vs&#46; 103&#46;7&#8239;min&#46;&#41; and lymph node number &#40;5&#46;73 vs&#46; 7&#46;2&#41; favored the open technique&#46; In order to eliminate the learning curve effect&#44; the 36 patients who underwent open surgery were compared to the last 36 patients in the laparoscopy group&#59; no difference was found between those two groups&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In a retrospective study&#44; Silberstein and colleagues &#40;2012&#41; compared the lymph node yield in the three surgical approaches&#46; The mean number of lymph nodes was not significantly different among the three approaches &#40;ORP 20&#44; LRP 19&#44; Robot Assisted Laparoscopic Prostatectomy &#40;RALP&#41; 16&#41;&#46; Regarding lymphocele rate&#44; it was low in all three groups&#58; 1&#47;126&#44; 1&#37; in the ORP group&#59; 2&#47;77&#44; 3&#37; in the LRP group&#59; and 4&#47;120&#44; 3&#37; in the RALP group&#46; No nerve injury was reported in any of the groups&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44; 28</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In a matched-paired analysis of 140 patients who underwent laparoscopic and robot-assisted PLND&#44; Albissini and colleagues reported that the number of lymph nodes extracted was higher in the robotic approach&#58; 18 &#40;14&#8211;23&#41; compared to 12 &#40;10&#8211;14&#41; in laparoscopic procedures&#46; Nevertheless&#44; laparoscopy showed a lower operation time &#40;205 vs&#46; 245&#8239;min&#46;&#41; and less blood loss &#40;200 vs&#46; 300&#8239;mL&#41; compared to the robotic approach&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Luciani et al&#46; compared the surgical outcomes of radical prostatectomy &#40;RP&#41; performed with three different approaches&#58; open&#44; laparoscopic-assisted and robot-assisted&#46; The median number of the lymph nodes removed was 9 in open prostatectomy&#44; 10 in LRP&#44; and 20 in RARP groups&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Van Huele et al&#46; &#40;2018&#41; compared minimally invasive PLND &#40;laparoscopic and robotic- assisted techniques&#41; to open surgery&#46; The authors compared 219 cases of PLND &#40;50 done with open surgery&#44; 96 laparoscopically and 73 with robot assistance&#41;&#46; The operation time was longer in minimally invasive PLND &#40;130 vs&#46; 102&#8239;min&#46;&#41; with no significant difference between minimally invasive techniques&#46; These techniques showed a lower complication rate &#40;4&#46;3 vs&#46; 22&#37;&#41;&#44; a higher lymph node yield &#40;15 vs&#46; 11&#46;5&#41;&#44; a lower hemoglobin decrease &#40;1&#46;19 vs&#46; 1&#46;63&#8239;g&#46;&#41; and a lower mean hospital stay &#40;2 vs&#46; 5 days&#41; compared to open surgery&#46; Moreover&#44; when comparing laparoscopic technique results to robotic-assisted results&#44; significant difference was only noted in lymph node &#40;LN&#41; number&#44; with 14&#8239;LN in laparoscopy and 18&#46;5 in robotic-assisted&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Although no randomized clinical trials are available&#44; data from prospective cohort studies comparing survival of pN&#8239;&#43;&#8239;patients show that RP may have a survival benefit over abandonment of RP in node-positive cases&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> As a consequence&#44; there is no role for performing a frozen section examination of suspicious LNs as cited by the EAU 2019 guidelines&#46; It is also important to mention some concepts about salvage lymph node dissection&#46; Novel imaging modalities improve the early detection of nodal metastases and the surgical management of &#40;recurrent&#41; nodal metastases in the pelvis has been the topic of several retrospective analyses&#46; The majority of treated patients showed BCR but clinical recurrence-free and CSS 10-year survival over 70&#37; has been reported&#46; Neither the template nor the real value of nodal salvage dissection is available&#46; It must&#44; however&#44; be remembered that the imaging modalities under-evaluate the real nodal involvement&#46; Biochemical recurrence rates were found to be dependent on PSA&#44; depending on surgery&#44; location and number of positive nodes&#46; Addition of RT to the lymphatic template after salvage LND may improve the BCR rate&#46; The real efficacy of this salvage procedure remains unproven&#44; as is its impact on the patient&#8217;s survival&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Cost effectiveness</span><p id="par0165" class="elsevierStylePara elsevierViewall">The expense of the various PLND surgical approaches is rarely compared or discussed in the literature&#46; However&#44; the authors did compare the cost-effectiveness of ORP&#44; LRP&#44; and RALP&#46; Bolenz et al&#46; criticized the increasing use of RALP without objective proof of its cost-effectiveness&#44; insisting on the necessity of an economic and cost-effectiveness assessment before worldwide adoption and replacement of standard techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> The LAPPRO trial &#40;2018&#41; done in Sweden found a lower cost of ORP compared to RALP&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> In a study done in the United States&#44; Bolenz et al&#46; &#40;2010&#41; found that direct cost of the procedure was higher for RALP &#40;&#36;6752&#41; compared to LRP &#40;&#36;5687&#41; or ORP &#40;&#36;4437&#41;&#59; this difference was primarily due to the surgical supply and the operating room cost&#46; Moreover&#44; RALP increased the overall cost by &#36;2698 per patient&#44; due to the cost of purchase and robot maintenance with an average of 126 patients per year&#59; its effect on the burden of prostate cancer care is therefore quite substantial&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the results of the review&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0175" class="elsevierStylePara elsevierViewall">With the low but increasing rate of publication in this area&#44; the overall methodological quality of the evidence identified through this qualitative literature review remains low &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Minimally invasive vs&#46; open approach</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Perioperative outcomes</span><p id="par0180" class="elsevierStylePara elsevierViewall">This review clearly reveals the benefit of minimally invasive surgery in both laparoscopy and robot-assisted over open surgery in PLND in prostate cancer&#46; Although the operative time of the laparoscopic groups was longer than that of the open groups&#44; the laparoscopic groups had less intraoperative blood loss and shorter postoperative hospital stays than the open group&#46; A possible explanation is that during laparoscopy&#44; the positive abdominal pressure due to pneumoperitoneum reduces bleeding&#46; Another explanation is that laparoscopy offers a clear surgical field and magnification of the narrow and deep pelvic cavity&#44; allowing secured accurate hemostasis and a clear&#44; detailed view of the anatomy&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Oncologic outcomes</span><p id="par0185" class="elsevierStylePara elsevierViewall">The pathological parameters evaluating the quality of laparoscopic PLND in prostate cancer included the number of lymph nodes extracted&#46; Although some early studies<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> favored the open technique showing more lymph node yield&#44; Van Huele et al&#46; reported a higher lymph node count with minimally invasive techniques with no difference between robot-assisted and conventional laparoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Surgical skill improvement could explain the increasing number of lymph nodes removed with time&#46; Moreover&#44; most of the surgeons performing PLND with a minimally invasive technique have a transperitoneal approach&#46; This gives them closer access to blood vessels&#44; allowing them to extract a greater number of lymph nodes&#46; Conversely&#44; surgeons are limited by their extraperitoneal approach in open PLND&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Laparoscopic vs&#46; robot-assisted approach</span><p id="par0190" class="elsevierStylePara elsevierViewall">The data shows comparable results between laparoscopic and robot-assisted techniques in mean hospital stay&#44; blood loss and lymph node yield&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Laparoscopic PLND takes less time than the robot-assisted technique&#44; as shown by Albissini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> This is explained by lengthy set-up times for robotic procedures&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The most striking drawback of robotics is the cost&#44; with a cost analysis in favor of standard laparoscopy&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In this review&#44; a clear benefit of minimally invasive techniques over open surgery exists&#46; But with the growing popularity of the robotic approach&#44; a question remains&#58; is robotic better than conventional laparoscopy&#63; The superiority of the robot-assisted approach has been proven in some types of complicated surgery in various surgical fields including partial nephrectomy in urology&#46; However&#44; conventional laparoscopy showed comparable outcomes to robotic surgery in less complicated surgeries like radical nephrectomy&#44; adrenalectomy and pyeloplasty&#46; Pelvic lymph node dissection appears to fall in the category of less complex surgeries&#59; considering oncological outcome&#44; perioperative outcome and complication rate&#44; robot assistance shows no benefits compared to conventional laparoscopy&#46; Additionally&#44; laparoscopy had a clear financial benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Limitations</span><p id="par0205" class="elsevierStylePara elsevierViewall">This review has some limitations&#46; First&#44; all included studies are non-RCT&#58; they are either retrospective studies&#44; cohort studies or matched pair analyses&#46; Second&#44; there is a great degree of heterogeneity in the patient selection in each study and the expertise and qualification of the surgeons&#44; which may alter the results&#46; The included literature is limited to studies published in English or French&#59; this may have caused a selection bias in this review&#46;</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conclusion</span><p id="par0210" class="elsevierStylePara elsevierViewall">Laparoscopic pelvic lymph node dissection in prostate cancer is a minimally invasive procedure with short operative time&#44; minimal blood loss&#44; low level of pain&#44; short hospital stay and an acceptable cost&#46; In terms of perioperative outcomes and complications&#44; it is superior to the open surgical approach and comparable to the robot-assisted technique&#44; but it is more cost-effective than the latter&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conflict of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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                  "identificador" => "sec0020"
                  "titulo" => "Pelvic lymph node dissection in prostate cancer&#58; boundaries and guidelines"
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          "titulo" => "Complications of PLND"
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            0 => array:2 [
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              "titulo" => "Lymphocele"
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            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Venous thromboembolism &#40;VTE&#41;"
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              "titulo" => "Vascular injury"
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              "titulo" => "Obturator nerve injury"
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          "titulo" => "Open&#44; laparoscopic or robot-assisted PLND"
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              "identificador" => "sec0055"
              "titulo" => "Study characteristics"
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              "titulo" => "Study results"
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          "titulo" => "Cost effectiveness"
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          "titulo" => "Discussion"
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              "identificador" => "sec0075"
              "titulo" => "Minimally invasive vs&#46; open approach"
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                  "identificador" => "sec0080"
                  "titulo" => "Perioperative outcomes"
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                  "titulo" => "Oncologic outcomes"
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              "titulo" => "Laparoscopic vs&#46; robot-assisted approach"
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              "titulo" => "Limitations"
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          "titulo" => "Conclusion"
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    "fechaRecibido" => "2020-04-03"
    "fechaAceptado" => "2020-06-30"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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            0 => "Pelvic lymph node dissection"
            1 => "Prostate cancer"
            2 => "Laparoscopy"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Disecci&#243;n de ganglios linf&#225;ticos p&#233;lvicos"
            1 => "C&#225;ncer de pr&#243;stata"
            2 => "Laparoscopia"
          ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Context</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pelvic lymph node dissection &#40;PLND&#41; in localized prostate cancer is feasible through an open&#44; laparoscopic or robot-assisted approach&#46; Data comparing the three approaches is sparse&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">To perform a review in order to compare the effectiveness of the different PLND approaches&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Acquisition of evidence</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A search was performed including the following words&#58; &#40;&#34;pelvic lymph node dissection&#34;&#41; OR &#40;&#34;pelvic lymphadenectomy&#34;&#41; AND &#40;&#34;french&#34;&#91;Language&#93; OR english&#91;Language&#93;&#41; AND &#40;&#34;1990&#34;&#91;Date - Publication&#93;&#58; &#34;3000&#34;&#91;Date - Publication&#93;&#41; AND prostatectomy&#91;Title&#93;&#41;&#46; Twenty-nine articles were finally included in the qualitative synthesis&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Evidence Synthesis</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic pelvic lymph node dissection in prostate cancer is a minimally invasive procedure with a relatively short operative time&#44; minimal blood loss&#44; lower level of pain&#44; shorter hospital stay&#44; and fewer perioperative complications when compared to an open approach&#46; This technique is more cost-effective than a robot-assisted approach&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Concerning the treatment of localized prostate cancer&#44; laparoscopic pelvic lymph node dissection should be learned and applied by urologists&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Context"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Acquisition of evidence"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Evidence Synthesis"
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            "identificador" => "abst0025"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Contexto</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La disecci&#243;n de los ganglios linf&#225;ticos p&#233;lvicos &#40;DGLP&#41; en el c&#225;ncer de pr&#243;stata localizado es viable mediante un abordaje abierto&#44; laparosc&#243;pico o asistido por robot&#46; La informaci&#243;n sobre la comparaci&#243;n de los tres enfoques es escasa&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Realizar una revisi&#243;n para comparar la efectividad de los diferentes enfoques de DGLP&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Adquisici&#243;n de la evidencia</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; una b&#250;squeda incluyendo las siguientes palabras&#58; &#40;&#34;disecci&#243;n de ganglios linf&#225;ticos p&#233;lvicos&#34;&#41; o &#40;&#34;linfadenectom&#237;a p&#233;lvica&#34;&#41; y &#40;&#34;franc&#233;s&#34; &#91;Idioma&#93; o ingl&#233;s &#91;Idioma&#93;&#41; y &#40;&#34;1990&#34; &#91;Fecha - Publicaci&#243;n&#93;&#58; &#34;3000&#34; &#91;Fecha - Publicaci&#243;n&#93;&#41; y prostatectom&#237;a &#91;T&#237;tulo&#93;&#41;&#46; Finalmente&#44; se incluyeron 29 art&#237;culos en la s&#237;ntesis cualitativa&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">S&#237;ntesis de la evidencia</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Al compararla con un abordaje abierto&#44; la linfadenectom&#237;a p&#233;lvica laparosc&#243;pica en el c&#225;ncer de pr&#243;stata es un procedimiento m&#237;nimamente invasivo con un tiempo operatorio relativamente corto&#44; un sangrado m&#237;nimo&#44; un nivel m&#225;s bajo de dolor&#44; una estancia hospitalaria m&#225;s corta y menos complicaciones perioperatorias&#46; Esta t&#233;cnica es m&#225;s rentable que el abordaje asistido por robot&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusi&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La linfadenectom&#237;a p&#233;lvica laparosc&#243;pica debe ser conocida e implementada por los ur&#243;logos para el tratamiento del c&#225;ncer de pr&#243;stata localizado&#46;</p></span>"
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            "identificador" => "abst0030"
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            "identificador" => "abst0035"
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            "identificador" => "abst0040"
            "titulo" => "Adquisici&#243;n de la evidencia"
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            "identificador" => "abst0045"
            "titulo" => "S&#237;ntesis de la evidencia"
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            "titulo" => "Conclusi&#243;n"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Semaan A&#44; El Helou E&#44; Abi Tayeh G&#44; Mjaess G&#44; Abi Chebel J&#44; Sarkis J&#46; Disecci&#243;n de los ganglios linf&#225;ticos p&#233;lvicos en el c&#225;ncer de pr&#243;stata&#58; la laparoscopia no ha muerto&#46; Actas Urol Esp&#46; 2020&#59;44&#58;682&#8211;691&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flow chart of the review&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Boundaries of pelvic lymph node dissection subdivided into different regions&#46; Limited PLND&#58; I&#46; Standard PLND&#58; I and II&#46; Extended PLND&#58; I&#44; II and IV&#46;</p>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">126 O 78&#8239;L 136 R&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">&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">61&#37; O 37&#37; L&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">Albissini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&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">70&#8239;L 70 R&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">205 v&#47;s 245&#8239;min&#46;&#8239;L&#47;R&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&#47;7&#8239;L v&#47;s 1&#46;5&#47;7 R&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 v&#47;s 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">&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">200 v&#47;s 300&#8239;mL L&#47; R&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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \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">1&#47;70 1&#47;70&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">Luciani et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&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">100 O 100&#8239;L 100R&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
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                  \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">9 v&#47;s10 v&#47;s 20 &#40; O-<span class="elsevierStyleSmallCaps">l</span>-R&#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><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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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  " 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">Van Huele et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&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">50 O 96&#8239;L 73R&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">130 v&#47;s 102&#40;MI&#47;O&#41; No dif &#40;L&#47;R&#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&#46;3 v&#47;s 22&#37; &#40;MI&#47; O&#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><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">- 1&#46;19 v&#47;s -1&#46;63&#8239;g&#47;d &#40;MI&#47; O&#41; No dif &#40;L&#47;R&#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><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 v&#47;s 5d &#40;MI&#47;O&#41; No dif &#40;L&#47;R&#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><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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\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></tbody></table>
                  """
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        "etiqueta" => "Table 2"
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        "detalles" => array:1 [
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            "detalle" => "Table "
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            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">First Author&#47; Year&nbsp;\t\t\t\t\t\t\n
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                  \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">Study Type&nbsp;\t\t\t\t\t\t\n
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                  \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">Total Patients&nbsp;\t\t\t\t\t\t\n
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                  \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">Laparoscopic&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Open&nbsp;\t\t\t\t\t\t\n
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                  \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">Robotic&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean age L&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean Age O&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean Age R&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age range L&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age Range O&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age Range R&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comorbidities&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BMI&nbsp;\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">Kerbl et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&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">Retrospective&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">46&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">30&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&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
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                  \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\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">Lezin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&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">Retrospective&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
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                  \t\t\t\t">44&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">22&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
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                  \t\t\t\t">66&#46;5&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
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                  \t\t\t\t">67&#46;4&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
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                  \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
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \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">Bodin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&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">Retrospective&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">151&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">115&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
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                  \t\t\t\t">36&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
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                  \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">66&#46;16&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">64&#46;1&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
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                  \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
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                  \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">Obese 16&#37;L 11&#37;O&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">Silberstein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&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">Retrospective&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">330&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&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">126&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
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                  \t\t\t\t">126&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
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                  \t\t\t\t">62&#46;1&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
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                  \t\t\t\t">61&#46;6&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
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                  \t\t\t\t">63&#46;3&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
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                  \t\t\t\t">56&#46;1&#8722;68&#46;2&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">55&#46;9&#8722;65&#46;3&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">57&#46;6&#8722;67&#46;7&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">Solberg et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&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">Retrospective&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">132&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
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                  \t\t\t\t">38&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
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                  \t\t\t\t">94&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
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                  \t\t\t\t">&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
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                  \t\t\t\t">65&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
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                  \t\t\t\t">65&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">56&#8722;74&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">50&#8722;70&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">Albissini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&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">Retrospective Matched pair analysis&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">140&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
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                  \t\t\t\t">70&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
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                  \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
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                  \t\t\t\t">70&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">61&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
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                  \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
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                  \t\t\t\t">66&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">56&#8722;66&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">26&#46;6&#8239;L 26&#46;9R&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Retrospective&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26&#46;7&#8239;L 27&#46;1 O 25&#46;6 R&nbsp;\t\t\t\t\t\t\n
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